The dilemma

A GP called the MDU advice line after a patient asked for regular blood tests to monitor the safety of a medication they bought online.

The patient had an autoimmune skin condition and read positive reviews of a topical treatment on an online forum. The treatment wasn't available via the NHS for the condition and was prohibitively expensive to buy in the UK, so the patient bought the medication from an overseas pharmacy website.

The treatment needed monitoring and the patient asked the GP to carry out regular blood tests to check his blood count and lipids. The GP was unsure whether to agree.

Background risks

It's understandable for patients with hard-to-treat conditions that aren't responding to standard medication to consider novel therapies. However, buying medicines from an overseas website can raise safety concerns. The NHS website warns about the risks, which include the possibility of medicines being counterfeit, out of date, or diluted.

Patients who obtain medication without getting medical advice may also receive treatment that's ineffective at best, and at worst, results in dangerous side effects.

There are also risks involved for the doctor being asked to facilitate this course of action by arranging monitoring. These are some of the questions to consider.

Do you have the expertise needed?

Is monitoring a patient within the scope of your expertise and knowledge. The GMC's 'Good medical practice' (2024) says, "You must recognise and work within the limits of your competence."

If a medication is not one routinely used in the UK, then you might not be as familiar with its use and requirements for monitoring.

GMC guidance states, "'You must treat patients with kindness, courtesy and respect. This doesn't mean agreeing to every request…" This is especially true if doing so might not be in the patient's best interests.

Will the monitoring be approved by NHS commissioners?

Funding is another issue. For NHS patients, liaise with your service's commissioning body about whether blood tests are available to monitor privately sourced medication. Keep a record of this discussion and the outcome.

Does the patient understand the risks and benefits?

You have a duty to make sure patients understand the risks and benefits of treatments. Discuss these with the patient, pointing out the risks of taking medication bought overseas.

You might not be able to have a detailed discussion about the treatment the patient obtained, but you can discuss whether conventional treatments have been properly explored. If the patient feels current treatments aren't effective, consider if it would be appropriate to arrange a specialist referral.

The patient may decide to stop taking the treatment as a result. But if they decide to continue, you need to consider the safest option for them and the available options for care.

Can you safely monitor the medication given the risks?

Be open with the patient about the limits of your knowledge of the medication, and why it might not be in their interests for you to monitor it. You'll need to take this into account when deciding whether to engage with monitoring.

If you decide to decline the request to monitor, you should explain why you feel it is not in the patient's best interests, along with your reasons. Give clear advice on why they should stop using the medication.

Despite discussing the inherent risks of using the treatment, there will be other situations where he patient is clear they'll continue doing so. In certain cases, you may decide that monitoring for safety-critical side effects would help to mitigate the risk of harm to the patient.

If you decide to carry out the blood tests, you'll also need to have a clear agreement in place with the patient for how this will work in practice. For example, which tests are needed, and at what intervals? How will the results be relayed to the patient? You also need to agree that the patient will stop using the drug if the results are a cause for concern.

Have you managed patient expectations?

Managing patient expectations about any monitoring at the outset will stand you in good stead.

For example, depending on the medication and condition, you may opt to restrict testing to those parameters that highlight side effects, rather than issues such as dosing.

If this is the case, clearly explain it to the patient so they understand that this approach isn't looking at how effective the treatment is, and that you won't be using the results to advise on dosing. If side effects occur, you can again advise the patient to stop taking the medication.

Check the patient understands the risks involved, and that you can justify the decisions you make.

Have you recorded the discussion and got advice?

Careful records of your discussion with the patient will be needed for their continuing care. They'll also help if you're asked to justify your approach later.

Consider summarising the conversation for the patient in writing, as this can demonstrate they were involved and fully informed. You could also ask them to sign a copy for your records, to confirm they understand and agree to stop the medication if you advise them to do so.

It can be helpful to not make these decisions in isolation. Discuss this in your practice or department, as well as with your commissioning body.

Given the complexity of decision around these requests, MDU members can contact us for specific advice.

Monitoring medication bought online

Dr Ellie Mein

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