NATURAL THERAPIES—WHEN IGNORANCE IS NOT BLISS!! (2007)

To the Editor: A 72-year-old Caucasian man with history of hypertension, dyslipidemia, depression, gastroesophageal reflux disease, and mild obesity presented to the hospital with intractable singultus (hiccups) for approximately 9 days, associated with anorexia and epigastric pain. He had presented to his primary care provider the day before admission and was given prochlorperazine without relief. His daily medications were metoprolol, furosemide, fluvastatin, gemfibrozil, paroxetine, and omeprazole. A thorough history revealed that he had added 2 tablespoons daily of acetic acid (household vinegar) to his routine for the previous 2 weeks after reading an article in a health magazine that indicated that vinegar helps decrease food intake (by promoting satiety) and lowers cholesterol. Physical examination was unremarkable except for mild epigastric tenderness. Computerized tomography of the abdomen with oral and intravenous contrast was suggestive of acute pancreatitis, and amylase and lipase levels were elevated, at 876 and 1,187 U/L, respectively. Other laboratory parameters were normal. Brain imaging and endoscopy were negative, and furosemide and paroxetine were discontinued on admission. The patient received nothing by mouth and was maintained with intravenous fluids for 2 days. He experienced complete resolution of the pancreatitis and the hiccups. Vinegar has a long history in medicine, including use by the father of modern medicine, Hippocrates, as an agent to fight acute infections and chronic coughs. Some modern studies support antimicrobial effects with food preparation; others claim it is a nematocyst inhibitor and protective in stings by some jellyfish. Recently, vinegar has been identified as an antiglycemic in subjects with and without glucose intolerance. In addition, it has been shown to increase satiety in healthy patients.1 There have been various adverse effects of vinegar described in the literature. Some of these include corrosive injury to the esophagus,2 hypokalemia associated with hyperreninemia and osteoporosis,3 chemical burns to the dermis of an infant,4 and one documented case of pancreatitis with 150 mL ingestion of 24% acetic acid.5 Furosemide6 and possibly paroxetine7 can cause pancreatitis as an adverse effect, but neither of the two has been known to be associated with hiccups. These had been part of the patient's medication regimen for many years without causing any adverse effects. It was therefore concluded that the most likely cause of the patient's pancreatitis and hiccups was the recent daily intake of vinegar. In the patient's attempt to follow a homeopathic therapy to address his dyslipidemia and mild obesity, he offers an interesting vignette regarding today's “informed” patient population. A simple Internet search on “homeopathic” and “cholesterol” will yield 596,000 results,8 a virtual treasure trove for the dyslipidemic! The danger of polypharmacy in any patient is a constant threat, even when only one physician is prescribing medications; the current reality consists of multiple subspecialists, in addition to patients themselves, who administer medications, herbs, and other natural products for the promotion of health. Most subspecialists communicate medication changes or recommendations to the primary care physician, but not all patients relay new herbs or natural products they are taking to their physician. This complacency may be born out of confidence that something natural cannot be dangerous to one's health. (Perhaps we have overlooked Socrates and the verdict of death by drinking hemlock.) Companies in the business of selling natural products use marketing techniques that advertise them as safe and, more importantly, effective. This and the ever-increasing cost of prescription medications for patients has created a huge market that can offer relatively inexpensive natural alternatives for various conditions including diabetes mellitus, dyslipidemia, osteoarthritis, and digestive disorders. There may be claims of “clinical effectiveness” followed by fine print to speak to a physician before starting the supplement, but the low price and large print of the advertisement do their marketing intent in persuading consumers. Additionally, unlike prescription medications, which must disclose adverse effects on the labeling, there is resistance to similar disclosures for alternative and complementary medicine in spite of Food and Drug Administration current recommendations.9 This case highlights the dangers of initiating medications (prescription or otherwise) without consulting a physician (that is in the absence of a direct patient–physician relationship).10 We would also like to stress the importance of updating patients' medication lists (including nonprescription and homeopathic medications) at every visit to ensure the continued safe delivery of quality health care. Financial Disclosure: None. Author Contributions: Nicholas Varvarelis and Hicham Khallafi: management of case, review of literature, preparation of manuscript. Binu Pappachen: management of case. Mahesh Krishnamurthy: management of case, review of literature, preparation and analysis of manuscript. Sponsor's Role: None.