Talk to slide Background reading PBS lipid-modifying drug-eligibility criteria have changed to facilitate treatment according to risk of future cardiovascular events. The PBAC accepted that the benefits of lipid-modifying drugs increase proportionally with absolute risk, and that treating people at greatest risk will maximise health benefits and cost–effectiveness. For people who are at highest absolute risk of a major cardiovascular event, statin or fibrate therapy is PBS subsidised regardless of cholesterol concentrations. For people at lower cardiovascular risk, cholesterol thresholds remain part of the criteria for PBS-subsidised prescribing of statins and fibrates. Diet and lifestyle measures are important in the management of cardiovascular risk, even when lipid-modifying therapy is used. At the time of publication, ezetimibe preparations (Ezetrol and Vytorin) continue to be authority items
Talk to slide Background reading Insulin glargine is a long-acting insulin analogue that can be used in type 1 and 2 diabetes mellitus. Insulin glargine has similar efficacy to that of isophane insulin in controlling blood glucose. Insulin glargine can reduce the overall incidence of hypoglycaemia, mostly at night, compared with isophane insulin. The risk of severe hypoglycaemia is similar to that with isophane insulin. Inform patients that insulin glargine is a clear, not a cloudy, solution. It should not be confused with clear short- or rapid-acting insulins. Insulin glargine can be given once daily, which may be more convenient for patients or carers who need to inject intermediate-acting insulin more than once daily. If switching from twice-daily isophane insulin to insulin glargine, use an initial dose that is 20% less than the total previous dose of isophane insulin, and titrate upwards if needed.
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Talk to slide – Background reading Amlodipine with atorvastatin (Caduet) is a fixed-dose combination preparation pairing drugs to treat different indications concurrently — hypertension or angina, and dyslipidaemia. Do not initiate antihypertensive, anti-angina and/or statin therapy with the combination preparation. Establish the effective and tolerated dose of each component as single drugs before changing to the combined preparation. Before prescribing, ask ‘Would these be the drugs of choice as individual agents?’ A combination preparation can cost patients less but this should not be the primary consideration. For patients responding well to therapy with other drugs there is no reason to change to this fixed-dose combination. Do not prescribe Caduet unless the patient has previously tolerated amlodipine 5 mg daily. There is no dose strength of Caduet equivalent to amlodipine 2.5 mg — this is the recommended starting dose in frail, small or elderly people, or in those at risk of hypotension. Be aware of the potential for confusion that may arise with the differently named medicine and its eight different dose combinations. Explain to the person being treated which medicines are being replaced by Caduet and tell them to discard any unneeded medicines.
Talk to slide Background reading Choose any of the available statins when initiating treatment to reduce low-density lipoprotein–cholesterol (LDL-C) level; there is no clinical outcome evidence to suggest that one statin is better than another. If existing treatment with a statin achieves target LDL-C level, there is no need to switch to another statin, including rosuvastatin. Rosuvastatin may have a place for patients who cannot achieve target LDL-C levels. Higher doses of rosuvastatin (20–40 mg) achieve reductions in LDL-C that are not possible with most recommended doses of other statins. Start with 5 mg and titrate when necessary to achieve treatment goals (usual dose 5– 20 mg once daily). Daily doses above 20 mg should be used with caution. The full adverse-effect profile for rosuvastatin is not yet known; however rosuvastatin toxicity appears to be similar to other statins.
Talk to slide Background reading Oral morphine is preferred when an opioid is required for severe chronic pain, because of its familiarity, availability and the ease of dose adjustment. Reserve fentanyl patches for use in opioid-tolerant patients with chronic pain and established opioid needs who cannot take oral morphine, for example, in severe renal impairment. Fentanyl patches might also be useful when oral opioids cannot be used because of vomiting or difficulty swallowing. Do not use fentanyl patches in opioid-naïve patients with non-cancer pain because of the potential for serious adverse effects. Fentanyl patches have a delayed onset and prolonged duration of action; adverse opioid effects may be difficult to control. Monitor serious adverse effects carefully for 24 hours after removal of the patch, as serum concentrations decline slowly. Advise patients to replace patches every 72 hours and no earlier. Ensure that patients and carers know about the safe use and disposal of fentanyl patches.
Talk to slide Background reading Alendronate with cholecalciferol (vitamin D3) contains cholecalciferol 2800 units in a weekly dose, equivalent to 400 units daily. This dose of vitamin D3 is: inadequate for sole treatment of vitamin D deficiency inadequate for preventing deficiency in high-risk groups the recommended dose to prevent deficiency in the presence of inadequate sunlight exposure in people aged 51–70 years who are not vitamin-D deficient. Assess the risk of vitamin D deficiency in people with osteoporosis and a fracture. The major source of vitamin D is sunlight exposure; institutionalised or housebound elderly people have the highest risk of deficiency. Vitamin D supplementation does not benefit people with normal vitamin D status — there is no reason to switch such patients from alendronate to the combination product. The combination product could be prescribed in addition to vitamin D3 1000-unit supplements to reduce individual cost for patients needing > 3000 units weekly and a bisphosphonate. There is no evidence that this combined formulation will reduce the risk of fracture compared with alendronate alone; this was not the basis of PBS listing. Vitamin D3 alone does not reduce fracture risk in people with an existing fracture (secondary prevention). It may have some effect in primary prevention when given with calcium; however, the evidence for this was mostly with a higher vitamin D dose (700–800 units daily).
Palliative care medicines
Think Clinical ServicesPALLIATIVE CARE Last Updated: January 2009 1
What is Palliative Care?The goal of palliative care is to achieve the best possible quality of life for patients and their families and friends.Palliative care: - provides relief from pain and other distressing symptoms - affirms life and regards dying as a normal process - intends neither to hasten nor postpone death Think Clinical Services 2 2
What is Palliative Care?- offers a support system to help patients live as actively as possible- offers a support system to help the family and carers cope during the patient’s illness - avoids futile interventions.The patient should have a central role in decision-making. Think Clinical Services 3 3
PBS ListingA new and separate section has been introduced in the Schedule of Pharmaceutical Benefits for palliative care medications. For the purposes of prescribing under the Palliative Care Section of the PBS, a palliative care patient is defined as:a patient with an active, progressive, far-advanced disease for whom the prognosis is limited and the focus of care is the quality of life.Authority required for all palliative care listings(up to 4 months supply) Think Clinical Services 4 4
Palliative Care SectionThe Palliative Care Section adds to the medicines that were already available on the PBS (such as opioid analgesics) for use in patients typically with malignant neoplasia.The following medicines are listings in the Palliative Care Section: • Carmellose mouth spray (Aquae) as a saliva substitute. • Clonazepam 500 micrograms and 2 mg tablets (Paxam, Rivotril); 2.5 mg/mL oral liquid (Rivotril) for preventing epilepsy. Think Clinical Services 5 5
Palliative Care SectionNew Palliative Medicines.• Hyoscine butylbromide 20 mg/mL inj (Buscopan) for colicky pain.• Paracetamol 500 mg suppositories (Panadol) for analgesia.• Promethazine hydrochloride 10 mg and 25 mg tablets; 5 mg/5 mL elixir (Phenergan) for nausea and vomiting. 6
LaxativesA number of laxative products are included in the new Palliative Care Section. These include: • Bisacodyl 5 mg tablets and 10 mg in 5 mL enemas (Bisalax); 10 mg suppositories (Durolax, Fleet Laxative Suppositories, Petrus Bisacodyl Suppositories) • Docusate sodium with bisacodyl 100 mg/10 mg suppositories (Coloxyl) Think Clinical Services 7 7
LaxativesLaxatives• Glycerol suppositories 700 mg (for infants), 1.4 g (for children), 2.8 g (for adults) (Petrus)• Sorbitol, sodium citrate and sodium lauryl sulfoacetate enemas (Microlax)• Sterculia with frangula bark granules (Granocol, Normacol Plus). 8
AnalgesicsMany different analgesics are used in the management of pain. These may include:- Paracetamol- NSAIDs- Opioids- Adjuvants (control symptoms that may worsen pain) Think Clinical Services 9 9
FENTANYL PATCHES for Chronic PainSevere chronic pain– Oral morphine preferred Ease of dose adjustment Ease of availability– Reserve Fentanyl Use Cannot take oral morphine Vomiting or swallowing difficulty Severe renal impairment Think Clinical Services 10 10
FENTANYL PATCHES for Chronic PainCaution– Delayed onset of action– Prolonged duration of action– Opioid ADEs are difficult to control Monitor serious ADEs for 24 hrs after patch removal Serum concentrations ↓ slowlyEnsure safe disposal Think Clinical Services 11 11
Anticholinergic drugsHyoscine butylbromide is used to treat painful colic resulting from malignant bowel obstruction, and to reduce gastrointestinal secretions. It does not cross the blood–brain barrier so does not cause drowsiness or delirium. Its duration of action is less than 2 hours. It can be used subcutaneously.Belladonna alkaloids such as atropine have been used in palliating accumulated secretions and noisy breathing at the end of life. Think Clinical Services 12 12
AntiemeticsAntiemetics are often used prophylactically to counteract the emetic adverse effects of other drugs, especially opioids. However, care should be taken with this practice as all the commonly used antiemetics can themselves cause significant adverse effects.In the palliative setting, nausea and vomiting are common symptoms.Examples include: Metoclopramide (Maxolon, Pramin), Prochlorperazine (Stemetil), Domperidone (Motilium), Odansetron (Zofran) Think Clinical Services 13 13
Principles for managementKnow the person who is being treated and the impact that their illness is having on them.Know the disease that is being treated (reverse whatever can be reversed and treat symptoms simultaneously).Know the overall therapeutic aim of each intervention being introduced or ceased. Think Clinical Services 14 14
Principles for managementWork as a team, because it is unlikely that one person will have all of the solutions (and if you don’t have the answer to a particular problem, ensure that you involve the person who does); this includes working with subspecialists.Actively recognise periods of transition (rehabilitation, deterioration, terminal care). 15