The Pharmaceutical Journal
Vol 268 No 7188 p339
9 March 2002

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Hypertension

Pharmacists, who are also patients, describe in their own words what it is like to have to take a medicine for life

Living with hypertension: it is different at the receiving end

I retired about five years ago in reasonably good health, but not especially fit, after more than 40 years primarily in community practice. I had been full of enthusiasm for patient packs, patient records, compliance aids, patient specific leaflets and providing advice to homes and generally welcomed training for pharmacists and dispensing staff.

It was not long before I had to see my GP. A bit of hypertension, but 40mg of propranolol a day should sort it out. Certainly it helped the symptoms but it played havoc with my golf. On any moderate incline I would arrive at the top with a huge oxygen debt, out of puff, and with a pulse stuck at 55 per minute and very slow recovery. I soon became convinced that what exercise I took was being substantially undone by my lack of ability to attain anything near perspiration level.

I was also beginning to notice a loss of concentration. Should we consider the possibility of stopping the propranolol? My doctor agreed, but the hypertension returned. It was decided to see if 2.5mg bendroflumethiazide would be better. It was. Blood pressure was controlled with negligible diuresis and exercise produced a faster pulse.

A much needed three-week holiday abroad seemed to help. Ten days later I suffered a bout of sickness immediately following a meal out. Food poisoning was suspected. When I became mentally confused my wife insisted on going to hospital. The diagnosis was Chlamydia pneumococcii on the lung; there was no pain. A week of amoxicillin 500mg tds and erythromycin 500mg bd cured the infection. My U&Es caused considerable concern. The bendroflumethiazide was stopped and I was dosed on potassium supplement. Within 10 days I was able to go home — weak, but looking forward to recovery. Blood pressure and U&Es were to be monitored and control reintroduced with care. The eczema was gone. Was this due to antibiotics or stopping the bendroflumethiazide which it had substantially predated? Was the acute dehydration, the infection or the bendroflumethiazide responsible for the upset to my U&Es?

Stroke

A week later I suffered a stroke and four days later was back in hospital. Blood pressure was horrifying at 200/120. This did not surprise the doctors who considered raised pressure to be normal and possibly even beneficial after stroke. It would not be treated until 14 days had elapsed from the stroke. Then bendroflumethiazide was reintroduced. My cholesterol was checked and found to be 7.7. Atorvastatin 5mg and aspirin 75mg were started. First class physiotherapy enabled my discharge after about a fortnight, and within six weeks I was substantially better and allowed to drive again. Cholesterol fell rapidly to 3.7. U&Es remained satisfactory.

At that time the consultant had me back for review. She was concerned that my blood pressure was still a little on the high side and added amlodipine 5mg daily. Within days my ankles became swollen each evening, though less so if I was able to manage reasonable exercise like walking. Within six months the swelling became unbearable. I am in the habit of wearing slippers in the house. After a morning at home it was almost impossible to put shoes on to go out, and the pressure caused quite severe pain.

Time for a rethink

Once again it was time for a rethink. Both bendroflumethiazide and amlodipine were stopped. Lisinopril 10mg od was carefully introduced with no initial problem. It took about four days for the "amlodipine ankles" to clear fully .

As a pharmacist I have been quite upset to be involved in returning packs of discontinued medicines for destruction as waste. I have also in the past referred to patients' immediate experience of compliance aids failing to avoid confusion. The real annoyance has been the difficulty of synchronising calendar packs, problems with rebalancing prescribed quantities on repeat prescription and the stopping and starting of medicines mid period — and my doctor limits repeats to 56 days. Even if he kept to 28 days it could be difficult. To cap it all some medicines come in calendar packs and others do not. Some calendars go once round the foil, some go left to right in two single weeks, some manage four weeks in five rows, and some put the calendar on the push side, and some on the eject side.

There is such a lack of consistency that one is forced to question whether the industry has any interest in compliance at all, except possibly in a rather selfish way with their own product. The certainty is that life for any partially confused patient taking five or six different medicines will not be simplified by the current plethora of "systems". In my experience by far the simplest is the 14-day, once round the pack, with all the information on the push side of the pack. Enteric aspirin with the print on one side and press the other, coupled with five- and six-day rows each starting on one of five different days, is potentially very confusing. And then atorvastatin and bendroflumethiazide came in 10s and 14s with no calendar to rely on. How lucky for me that all regular medication has been just once a day, morning or evening.

Perhaps the most salutary lesson for me has been that of side effects. I simply did not expect to find any, or at least only transient ones. That has proven far from the case. Fortunately I have sufficient knowledge to manage to recognise problems and to sort them out with my GP and pharmacist friends. How many patients stop their therapy or tolerate unnecessary effects?