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Getting to the Heart of the Matter After Recall of Drugs

Weight loss: Patients using fen-phen, Redux were left with a passel of questions. The bottom line: See a doctor.


Last week the Food and Drug Administration asked the manufacturers of the popular diet drugs fenfluramine and Redux to withdraw their products, citing "an unacceptable risk" of heart valve problems. The agency also advised consumers to stop taking the drugs and to contact their doctors.

Users of fen-phen (a combination of fenfluramine, sold as Pondimin, and the drug phentermine) and Redux faced many unanswered questions. Among them:

Question: Which is better, to taper off or to quit these drugs cold turkey?

Answer: "I think it's better to taper off over a week or so," says Dr. Richard L. Atkinson, professor of medicine and nutritional sciences at the University of Wisconsin, Madison, and president of the American Obesity Assn. But he hastens to add: If you've already quit cold turkey, don't start up again.

Adds Dr. Morton Maxwell, clinical professor of medicine and director of the University Obesity Center at the UCLA School of Medicine: "In the literature, it has been reported that in some patients after stopping fenfluramine [abruptly] they can become mildly depressed for a week or so." But, he says, many patients in the UCLA program, for example, have forgotten to bring the drug on vacation with them and have not had serious problems.

Q: What kind of physical exam and other tests do I need?

A: Your doctor should take a thorough medical history and conduct a physical with an emphasis on examining the heart and lungs, says Dr. Richard Kerber, professor of medicine and director of the echocardiography lab at the University of Iowa, Iowa City, and president of the American Society of Echocardiography.

Your doctor should listen to your heart with a stethoscope as you lie down, bend over and possibly assume other positions, says Kerber.

If there is any suspicion of heart valve problems, your physician should order an echocardiogram, a diagnostic procedure that uses high-frequency sound waves, or ultrasound, to take moving pictures of the heart.

If your doctor does not think an echocardiogram is needed, you should return for follow-up exams at intervals to be decided based on medical history and other factors, says Atkinson.

Q: If there is heart valve damage, won't I have symptoms?

A: "Not necessarily," says Dr. Jack Crary, an interventional cardiologist at MeritCare Medical Center in Fargo, N.D., and a coauthor of the study published last month in the New England Journal of Medicine that aroused wide-spread concern about fenfluramine's effect on the heart. Some people have no symptoms, he says; others have shortness of breath or chest pain. If there's any doubt, "the best way to detect [problems] is with an echocardiogram."

(The FDA's action was spurred in part by its analysis of 291 patients, in which 30% had abnormal echocardiograms, even though they had no symptoms. In most, the problem was a so-called leaky valve.)

Q: What does an echocardiogram involve?

A: Before the test, no special preparations such as fasting are normally required, according to the American Society of Echocardiography. During the test, you'll be asked to disrobe from the waist up so a transducer--a small, hand-held device--can be placed on the chest wall or upper abdomen in order to direct sound waves to the heart and produce pictures of it. The images appear on a TV-like screen and are recorded on videotape as well as on special paper.

An electrocardiogram is also routinely done during an echocardiogram because it is useful for timing the events in the heart.

The echocardiogram can measure the size of each of the heart's four chambers and can study the appearance and motion of the heart valves. It can also determine how forcefully the heart muscle contracts to move blood into the chambers and to the lungs and the rest of the body.

It takes about 45 minutes to do a complete echocardiogram, Kerber says. "If your doctor thinks one is necessary, I would advise a complete exam [rather than a limited one]."

But sometimes a physician may opt to do a limited study, Kerber says, if there is already an initial, or baseline, echocardiogram for comparison.

Q: What does an echocardiogram cost?

A: In the Los Angeles metropolitan area, the test can cost as much as $1,500.

Q: Is the cost likely to be covered by my health insurance policy or health maintenance organization plan?

A: Plans vary.

At Kaiser Permanente, for example, "an echocardiogram considered necessary by a Kaiser Permanente physician is a covered benefit," says Kathleen Barco, a spokeswoman, although some members may have to make a small co-payment.

"Coverage for HMO members [who need an echocardiogram] will be decided on an individual basis," according to Rhonda Seaton of Blue Cross of California. Those Blue Cross members who have a PPO and need an echocardiogram would be covered for it "just as any other service." For instance, if they normally pay a deductible and 20% of the cost, the same would be true for the echocardiogram.

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