If the man hadn’t come into the hospital, Komolafe said the consequences could have been serious. “In these instances, we are most concerned about complications from rapid depletion of fluid and electrolytes. This can lead to various complications including acute kidney injury, low potassium levels, which predispose to abnormal heart rhythms, and low blood sodium levels, which can cause mental status alterations, including coma, when severe.”

Before coming to the hospital, the man had been having bowel movements every 20 to 30 minutes. After he arrived, the care team gave him IV hydration, potassium replacement and anti-diarrheal medication. Over the course of a few days, his kidney function improved and his dehydration eased. He went home on the fourth day. Doctors encouraged him to see a primary care doctor to establish care and help with his weight loss concerns.

Komolafe decided to write about the case in the journal Annals of Internal Medicine: Clinical Cases to try to help others. “It was an unusual clinical presentation of complications that could arise from a group of medications that are currently in the mainstream. It really was a bare-bones report not focused on the scientific aspects of the medication but more on the public health benefit.”

He has this takeaway for the public. “Basically, it’s a message of caution that highlights the potential dangers from the use of non-prescribed medications, especially since many of these can be sourced via direct-to-consumer channels. Sometimes, the composition of these agents can be unpredictable,” Komolafe said.

“The right medicine taken in the wrong way or dose can become a poison. Patients should be encouraged to discuss any medication questions that they may have with their health care providers. Finally, patients and/or their caregivers should adopt unique strategies that ensure that the risk of double dosing on medications is considerably reduced.”