A Case History: Neuropathy
Here at Caring Medical we often take care of patients who are also seeing other physicians, usually specialists, at the same time. Therefore we have the opportunity of seeing first hand the level of medical care that is given "out there". In a recent case, I was consulted about the development of symptoms of numbness and tingling in the upper extremities. She had recently seen an internist at my recommendation because of the unrelated problem of high blood pressure, and he had questioned whether perhaps the developing "neuropathy" might be related to the new arthritis drug (Arava) she had begun several months before, prescribed by her rheumatologist. At the internist's suggestion, she returned to the doctor that had prescribed the Arava, and was told that the medication was not causing her symptoms. She did feel the need to order an EMG/NCV test. This is a very painful test which involves sticking needles in muscles and running in electric current to determine if nerve transmission is blocked in any way.
This test was not done initially because the patient held off. However at the next follow up visit with the internist, when he heard that the first rheumatologist had not seen a connection with the drug, he urged her to see another high ranking University Medical Center rheumatologist for a second opinion. She did so, but against her better judgment, because he had not "taken her seriously" when she had seen him once before.
He recommended she get the NCV test done, and it came back positive. He told her she had evidence of nerve damage, asked if she had gotten any benefit from taking the drug (the answer was yes, some decreased pain), made no statement about whether the drug was causing the problem or not, advised her to continue taking the drug, and did nothing about treating the neuropathy or referring her for treatment.
Now the patient consulted me. She said simply, "I have developed these nerve symptoms, what should I do?"
Want to know what I did? I searched "Arava" and "neuropathy" on the internet and found several references to the fact that although no cases of neuropathy were described in the pre-release FDA studies (strange, isn't it?), 80 patients and then over 100 patients in the second study after the drug was approved were described as having developed a neuropathy from the drug.
Furthermore, the second study had been detailed enough to conclude that the chances of these symptoms becoming irreversible increases after they have been present for over 30 days. The patient had been symptomatic for about 45 days when I spoke to her. This investigation lead quickly to my conclusion :
GET OFF THE DRUG!
It took only about 5 minutes of my time. I am not the head of a major University Rheumatology department. But I offered this patient something she did not get from her rheumatologist: I cared. I listened, I took her seriously, and I tried to help her. In uncovering the truth, she now knows exactly what to do.
What went wrong here?
If you are going to see standard orthodox medical doctors, you must be aware of their predilection to use pharmaceuticals. Not infrequently, they will also use fairly newly released drugs without a lot of real world experience behind them. Very frequently they will be careless or uninformed when it comes to identifying adverse drug effects, and managing them properly with prompt discontinuation of the drug. It often seems from the patient reports that I hear, that once a doctor prescribes a drug, he is loathe to admit the occurrence of side effects. As in this case, for whatever the reasons, sometimes drugs are approved by the FDA on the basis of drug company sponsored studies, and yet once approved, "new" adverse effects start to show up. Finally, medical care "out there" often lacks both the medical expertise and the caring. The doctor who prescribed the Arava for my patient, and the one who gave a second opinion, were giving the patient the same answer. And they were both wrong! Was the consultant (and the prescribing doctor) conspiring to conceal the first doctor's error by not saying anything? Or were they so uninformed that they had not read that the drug in question had been reported to have the very side effect the patient was complaining about? And if they hadn't heard about the neuropathies being reported after the drug's release, what stopped them from taking the patient's new symptoms seriously at once, and simply entering two words into their search engines: "Arava" and "neuropathy" and finding the answer?
And I have another question? What would make them order a painful EMG/NCV test before just looking up the possible connection? The patient was giving a clear and trustworthy account of the development of a peripheral neuropathy. She did not need to have an EMG/NCV test in order for them to make the correct management decision: the drug causes neuropathy, you have developed neuropathy, get off the drug! Both of these doctors were in the process of making a bad situation worse, and they put the patient through the pain and expense of an elaborate and unnecssary medical examination. The research clearly suggested that neuropathies occured with Arava, and that the symptoms became progressively more irreversible the longer the delay in discontinuation of the drug. If the patient's neuropathic symptoms do not now resolve, I believe that she has a rational and valid basis for a malpractice suit. And if that happens, the real and immediate cause would have to be the doctors not CARING. No one expects doctors, even specialists, to know everything. But everyone expects them to act in a caring and responsible way. If the behavior of these physicians, and the unanswered questions disturb you, then you can understand why so many of our patients avoid standard medicine and orthodox practitioners and come to Caring Medical for treatment.
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