Part of “Talk About Your Medicine” Month
I was pleased to be asked to write a short blog contributing to the “Talk About Your Medicine” month in order to increase patient awareness of how their medications work and being part of their healthcare treatment plans. In medical training, we frequently use patients as “case presentations” to open discussion about evaluation and treatment plans. The timing was right, with a patient I saw the other day, to use a perfect example of how important it is to understand how your medications work for their purpose in addition to understanding benefits versus risks and important side-effects that may actually hinder other aspects of healthful living. There are thousands of examples, but I think the case I will discuss has some common components that play a role in much of what I preach, lifestyle as medicine.
“Joe” was a 45 year old male referred to me for difficulty losing weight and low testosterone. This is a very common reason for referral to endocrinology. Part of his evaluation was already done by his primary care doctor, so I already knew that he had recently diagnosed sleep apnea, low morning testosterone with other hormones (from pituitary) suggesting central hypogonadism (brain not sending hormones to testicles appropriately), and some criteria for metabolic syndrome (abdominal obesity with elevated triglycerides/low HDL cholesterol, high blood pressure and pre-diabetes) which makes him at high risk of progressing to type 2 diabetes and cardiovascular disease. The key to his past medical history, though, was that he just started gaining weight a couple of years ago after he had multiple left knee surgeries following an injury. At that time, he also started down a path of requiring a variety of medications. Now, I completed a thorough workup to confirm low testosterone and be sure there was no abnormality in other hormones from his pituitary (brain), but I was confident that his abdominal obesity, sleep apnea, and low testosterone were all intertwined, as they often are, and making each other worse. He was already being treated for his sleep apnea (which can result from obesity, make obesity worse, and cause problems such as low testosterone) and actually felt well overall. The key is that he was now on several medications also hindering his efforts.
His pain medications included opiates like oxycodone, which can actually cause lower testosterone by making the pituitary hormones lower, and gabapentin at very high doses, which hinders ability to lose weight. He had also been started on atenolol (beta-blocker) during that time frame, due to the elevated blood pressure that accompanied his weight gain, and is also a hindrance to weight loss along with tending to decrease energy and possibly mood.
We discussed the role these medications were playing with his physiology from his hypothalamus (controls appetite/metabolism/sleep and pituitary hormones) to his fat cells themselves. He was very engaged and motivated to optimize his lifestyle (diet, exercise, and sleep) but acknowledged his limitations due to pain and pain medication requirements. He will speak with his pain physician to try changing his medications to those that may have fewer adverse effects but this will be a big hurdle and we may need to just deal with those. But he will be discussing the blood pressure medication and his depression medication with his primary doctor and likely will be able to switch to more weight-friendly medications to help lose the weight which is putting him at risk. After his completed work-up, we may have to discuss the cardiometabolic benefits versus risks of testosterone replacement therapy if he is unable to decrease his pain medication requirements despite not having significant symptoms associated with low testosterone.
This is just a small example of how we, as physicians, want our patients to understand all the aspects (both good and bad) of the medications they need and be engaged in optimizing their individual regimens. So take this opportunity to learn about your medications and discuss them with your physician to optimize your health.