Letter. Are we moving towards direct‐to‐consumer medication?

Abstract

Sir, We recently saw a patient admitted with ketoacidosis after injecting GLP-1 analogue which she was able to buy over the internet. This illustrates the serious risks of taking medication without proper medical oversight. A 37-year-old patient with no previous medical history came to hospital with history of vomiting and feeling generally unwell for four days. She had been drinking fluids, but not able to keep food down over this period. The day prior to admission she had taken a dose of semaglutide 1mg which she was able to buy online from a UK based website – this was marketed as ‘skinny pen plus’. She was dehydrated; otherwise clinical examination was unremarkable. Venous blood gas showed significant acidosis with pH of 7.22 (7.35–7.45), bicarbonate of 12.8mmol/L (22–26) and normal lactate of 1.5mmol/L (0.6–2.5). Blood glucose was 3.7mmol/L with blood ketone of 6.8mmol/L. She had mild acute kidney injury with creatinine of 79μmol/L (baseline creatinine 47μmol/L). A diagnosis of starvation ketoacidosis was made and she was treated with intravenous dextrose and crystalloids. She improved clinically and all biochemical abnormalities resolved over the next 48 hours. She was discharged and advised not to take any further doses of semaglutide. On visiting this particular website, it is surprisingly easy to buy GLP-1 analogues. The website identifies them as ‘skinny pen’ and clients are able to choose either a daily or weekly preparation based on preference and cost. After making the choice the customer is required to fill out a medical questionnaire, following which the medication arrives by post. The website mentions that ‘an experienced medical team will assess suitability for medication based on information provided and the drug is dispensed from a UK based pharmacy’. This patient did not have a phone or video consultation and did not receive any information other than the leaflet along with the drug. It is of note that GLP-1 analogues are currently not licensed in the UK as treatment for weight management. It is well known that they induce significant weight loss; however, the licence is for treatment of type 2 diabetes.1 A search of the internet revealed at least half a dozen other websites offering similar prescriptions. GLP-1 analogues commonly cause gastrointestinal side effects and in about 5% of cases this can be serious enough to discontinue the drug.2 As there is no contact with a health care professional, it is unclear how much information is given to patients buying the drug online. Clearly this patient did not know what to expect and when to seek help. It is likely that we will be encountering more of such cases with potential harm to some patients. This practice is blurring the boundary line of ‘Direct-to-Consumer Pharmaceutical Advertising’ which is common practice in the USA, but not allowed in the UK. All online pharmacies in the UK are regulated by the General Pharmaceutical Council; however, the NHS advises caution when ordering online drugs.3 Regulations about online consultations and prescriptions may need to be reviewed to ensure safe and appropriate use of GLP-1 analogues.