Practical Prescribing Guide Flashcards
Good prescribing practice MCNZ
Choosing Wisely encourages patients to ask their health professionals these four questions:
Do I really need to have this test treatment or procedure?
What are the risks?
Are there simpler, safer options?
What happens if I do nothing?
Choosing Wisely campaign has 5 principles
all activities must be health professional led
consumer focused
work across the health professions
evidence based
completely transparent
Examples of NZ recommendations
Don’t delay the introduction of solid/complementary foods to infants – ASCIA Infant Feeding Advice recommends early introduction of solid foods to infants, from 4-6 months old.
Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D-dimer assay is positive.
Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
Don’t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
Do not perform surveillance urine cultures or treat bacteriuria in elderly patients in the absence of symptoms or signs of infection.
Do not perform population-based screening for Vitamin D deficiency.
Do not routinely test and treat hyperlipidemia in those with a limited life expectancy.
Do More Screening Tests Lead to Better Health? Choosing Wisely
Ex Antibiotics
side effects, such as a rash, dizziness and stomach problems.
In rare cases, they can cause severe allergic reactions.
“If antibiotics can’t find bacteria to kill they eat your gut”
Overuse of antibiotics also encourages the growth of bacteria that can’t be controlled easily with drugs. That makes you more vulnerable to antibiotic-resistant infections and undermines the usefulness of antibiotics for everyone.
Consider NNT (number needed to treat) & NNH (number needed to harm)
“You’re most likely to get better on your own within ….,
your immune system will take care of this”
“Our bodies are designed to heal themselves”
When to consider antibiotics (+prescribe rest)
Safety netting
Antibiotics should usually only be considered when symptoms last longer than a week, start to improve but then worsen again, or are very severe.
Worrisome symptoms that can warrant immediate antibiotic treatment include a pain and tenderness over your sinuses, or signs of a skin infection, such as a hot, red rash that spreads quickl
things to bring to a no antibiotics discussion
Management tips for the common cold
There are no very effective treatments for the common cold but antibiotics certainly do not help and definitely cause harm.1 In short:
- Lower expectations - advise that any cough may last for up to 4 weeks.
- Taking regular paracetamol as needed may be helpful.
- Avoid over the counter cough medicines - (probably not effective).
- Vapour Rub on children’s chests may help with cough for those aged 2 to 11.2
- Decongestants such as oral pseudoephedrine (need a controlled drugs form in NZ) and nasal xylometazoline 0.1% are probably effective (neither are subsidized).
- Honey works for some coughs in children; 1 tsp for one to five-year-olds.
- Ipratropium nasal spray is effective for rhinitis
STRATEGIES TO DISCUSS VIRAL VS BACTERIAL
When a viral infection is suspected, explain why an antibiotic is not justified, provide good advice about symptomatic management and give an idea of the time course for the particular self-limiting infection
Manage patient expectations – reassure pts that they made the right decision to seek assessment and just because they do not require an antibiotic, it does not mean that their symptoms are not legitimate.
Opening question “What do you want to talk about today ?
“ Ask ICEFF Involve pts in decisions about their health care and as part of this provide education about the issue of antimicrobial resistance, and not only what this means for them, but the community as a whole
In most cases, only prescribe antibiotics for bacterial infections if:
- Symptoms are significant or severe
- There is a high risk of complications
- The infection is not resolving or is unlikely to resolve
- Balance the risks and benefits of antibiotic use for individuals – is there a risk of not using an antibiotic for that individual, at that time
If prescribing, choosing the right antibiotic, at the right dose, for the right length of time (cellulitis flucloxacillin 5/7)
Write an entry in the notes explaining your decision to prescribe an antibiotic
Consider the use of a delayed prescription, i.e. only to be used/collected if symptoms persist or worsen
Antibiotics Guide, choices for common infections - 2017 (bpac.org.nz)
SAFE PRESCRIBING OF NSAIDS /COX2
Prescribe all NSAIDs with caution, in all pt groups, even over short periods of time
Prescribe the lowest effective NSAID dose, for the shortest possible time, and review the need for continued use at each consultation
Older patients (>60?), patients with increased cardiovascular risk, pts with type 2 diabetes, and patients with reduced renal function or a history of renal problems are at increased risk of NSAID-related complications and should be advised about adverse effects and regularly monitored when taking NSAIDs (add to alerts)
Contraindication
- MI in last 12 months,
- CHF, hypersensitivity precipitated by aspirin/nsaids,
- history of recurrent GI ulceration bleeds ,
- hx NSAID precipitated bleeds
Advise patients not to self medicate OTC or take other peoples meds
Naproxen (up to 1000 mg per day) or Ibuprofen (up to 1200 mg per day, not as effective for inflammatory conditions) are the recommended first-line choices for adults based on our current knowledge of NSAIDs and cardiovascular risk;
Ibuprofen is the most appropriate NSAID for children
Diclofenac higher CV risk
Celecoxib more period specific
? Omeprazole reduces gut effects by 50%?
Avoid prescribing long-acting formulations of NSAIDs, where possible, as these are associated with an increased risk of GI adverse effect
Antihistamines for allergic rhinosinusitis: ‘Achoo’sing the right treatment
Oral antihistamines reduce rhinosinusitis symptoms by ~10-30% versus placebo over 2-12 weeks.
Individual antihistamines appear to have comparable efficacy.
More patients attain moderate or better improvement with intranasal corticosteroids (~78%) versus antihistamines (~58%).
Systematic review (13 RCTs, 5066 patients) of antihistamines plus intranasal corticosteroids versus intranasal corticosteroids alone over 2-6 weeks. Antihistamine did not add clinically meaningful benefit. Other systematic reviews found similar.
There appears to be no meaningful differences between antihistamines and leukotriene receptor antagonists or in adding antihistamines to intranasal corticosteroids.
CONSIDER RISKS OF PRESCRIBING IN PREGNANCY
