Question: 1 2 3 4 5 6 7 8 9 10

Stopping medicines in older people

1. Which of the following medicines may usually be abruptly stopped? Your peers Answer
Warfarin 93%
Paroxetine 1%
Alendronate 95%
Omeprazole 9%
Lorazepam 1%

Question 1 comments

It is possible to abruptly stop rather than taper warfarin. Some clinicians tail off long-term warfarin treatment over several weeks but the need for this is unclear. Alendronate can also be stopped abruptly without the need for tapering. Antidepressants such as paroxetine should be tapered rather than stopped abruptly, to reduce the risk of developing a discontinuation syndrome and to allow time to assess the possible re-emergence of depressive symptoms. Discontinuation syndrome appears to occur more frequently with paroxetine and venlafaxine which may partly be due to the shorter half-life of these drugs.

Tapering the dose of an acid suppressant (both PPIs and H2RAs) is recommended because of the risk of rebound hypersecretion of gastric acid. This acid rebound may be confused with re-emergence of the original reason for prescribing an acid suppressant and the patient may be put back on the medicine unnecessarily.

Benzodiazepines, such as lorazepam, if taken on a long term basis should be withdrawn gradually over a number of months.

2. Which of the following medications should usually be tapered when stopping? Your peers Answer
Low-dose fluoxetine 14%
Metoprolol 96%
Atorvastatin 2%
Amitriptyline 97%
Levodopa 92%

Question 2 comments

Beta-blockers are the cardiovascular medicine most often associated with adverse withdrawal events. Abrupt withdrawal may cause rebound hypertension, tachycardia, arrhythmia or angina. These events may be physiological withdrawal reactions or an exacerbation of the underlying condition. Gradual dose reduction is required.

Tricyclic antidepressants should be withdrawn slowly, especially if they have been taken for six weeks or more. If stopped suddenly, withdrawal effects may include anxiety, headache, insomnia, gastrointestinal disturbance, irritability and myalgia. It may also be difficult to differentiate withdrawal symptoms from recurrence of depression.

Antiparkinsonian medicines (e.g Levodopa) should not be stopped abruptly as there is a small risk of neuroleptic malignant syndrome. Reduce the dose gradually over about four weeks.

Fluoxetine at low doses may not need to be tapered, as it has a long half-life. This means that fluoxetine concentrations decline gradually and withdrawal symptoms are unlikely or very mild. In contrast, short half-life SSRIs such as paroxetine and citalopram need to be tapered slowly as they can cause significant withdrawal symptoms if stopped suddenly.

In most cases statins can be stopped without the need for tapering. The decision to stop a statin is based on an assessment of individual benefits and risks. For example, stopping may be justified in a person at relatively low risk of a cardiovascular event, who is also poorly compliant or experiencing troublesome adverse effects. Statins should not be stopped in patients admitted with (or history) of cardiovascular events including ACS, MI or stroke. Studies have shown it is important to continue statin treatment to reduce the risk of a repeat event.

3. Which of the following statements about antidepressant discontinuation syndrome (ADS) are true? Your peers Answer
ADS is associated with short duration of treatment with an antidepressant 1%
ADS is associated with abrupt discontinuation or rapid dose reduction of an antidepressant 98%
One of the main symptoms associated with ADS is sedation 2%
ADS is only associated with tricyclic antidepressants 1%
To avoid ADS a typical tapering regimen would be to reduce the dose by 25% every four weeks 92%

Question 3 comments

Antidepressant discontinuation syndrome is more likely with a longer duration of treatment and a shorter half-life of the treatment drug and for this reason antidepressants should normally be withdrawn over at least a four week period.

Antidepressant discontinuation syndrome can occur with rapid discontinuation of any antidepressant (i.e. includes SSRIs, TCAs and venlafaxine).

Symptoms are variable but typical symptoms include – Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances and Hyperarousal (anxiety/agitation) (FINISH). Sedation is not one of the typical symptoms.

Symptoms are likely to appear within one week of rapid dose reduction or abrupt discontinuation of an antidepressant. Symptoms are often mild and short lived and resolve without treatment in about ten days.

For patients with more severe symptoms the pre-reduction dose may need to be restarted which usually results in resolution of symptoms within 24 hours. Subsequent tapering then needs to be at a slower rate.

4. Benzodiazepine withdrawal syndrome is associated with which of the following? Your peers Answer
Abrupt withdrawal of a short or long acting benzodiazepine 97%
Slow tapering of a short or long acting benzodiazepine 4%
Insomnia 97%
Tinnitus 57%
Weight gain 2%

Question 4 comments

Abrupt withdrawal of any benzodiazepine may result in confusion, toxic psychosis, seizures or a condition termed benzodiazepine withdrawal syndrome which is similar to delirium tremens. Typical symptoms of this include insomnia, loss of appetite, weight loss, sweating, perspiration, tinnitus and disturbances of perception.

Benzodiazepine withdrawal syndrome can occur within one day of stopping a short-acting benzodiazepine or up to three weeks after stopping a long-acting benzodiazepine.

Slow tapering is necessary for people who have taken benzodiazepines on a long term basis but withdrawal symptoms can occur in some people after only a few weeks of taking a benzodiazepine. This emphasises the importance of limiting the prescribing of benzodiazpeines to short courses (one to two weeks) at the lowest effective dose.

Withdrawal should be gradual over a number of months (e.g. six months). The longer a patient has been taking a benzodiazepine, the more likely they are to develop dependence and tolerance.

Medicines for weight loss

5. The use of orlistat for weight loss may be associated with which of the following adverse effects? Your peers Answer
Constipation <1%
Faecal 93%
Fatty/oily stools 98%
Tachycardia 2%
Vitamin deficiency 86%

Question 5 comments

Gastrointestinal adverse effects, relating to orlistat’s mechanism of action, are common and experienced by about one in four people. These include fatty/oily stools, faecal urgency, oily spotting and flatus with discharge. These adverse effects are typically short-lived as patients learn to avoid high fat diets to minimise these effects. Constipation is not usually one of the gastrointestinal effects associated with orlistat.

Patients taking orlistat may require supplementation with fat soluble vitamins (vitamins A, D, E, K and beta Carotene) because a long term decrease in fat absorption may result in a decrease in vitamin levels.

Cardiac adverse effects such as tachycardia are not normally associated with orlistat.

6. The use of sibutramine for weight loss may be associated with which of the following adverse effects? Your peers Answer
Constipation 77%
Diarrhoea 4%
Sedation 2%
Tachycardia 96%
Hypertension 86%

Question 6 comments

Adverse effects reported by patients taking sibutramine include insomnia, nausea, dry mouth, constipation and anxiety. Diarrhoea and sedation are not usually associated with Sibutramine use.

Other potentially more serious adverse effects include an increase in heart rate and blood pressure. For the first three months after starting sibutramine, blood pressure and pulse rate should be measured fortnightly. Treatment should be stopped if, at two consecutive visits, there is an increase in resting heart rate of 10 bpm or systolic/diastolic blood pressure of 10 mmHg.

Sibutramine is contraindicated in patients with inadequately controlled hypertension, coronary heart disease, CHF, peripheral artery disease, arrhythmia or stroke.

Paediatric oral health

7. Which statement(s) about managing teething pain are true? Your peers Answer
Teething may cause fever, diarrhoea and other systemic symptoms 8%
There is little evidence that topical teething gels effectively reduce pain associated with teething 92%
Teething gels containing choline salicylate are contraindicated in New Zealand 7%
Topical anaesthetics are recommended as first-line treatment of teething pain and discomfort 1%
Paracetamol or ibuprofen may be used for teething pain in infants aged three months or older 98%

Question 7 comments

Although parents often report fever, diarrhoea and other systemic symptoms in their infants who are teething, it is most likely that these symptoms have another cause. Typical symptoms of teething include excessive drooling, chewing/mouthing, appetite loss and generally unsettled behaviour. If a child who is teething becomes systemically unwell, they should be assessed for the possibility of an underlying medical condition.

Topical teething gels and anaesthetics are not recommended as there is little evidence that they are effective in reducing the pain and discomfort associated with teething. Teething gels containing choline salicylate are contraindicated in children aged 16 years or under in some countries, due to the theoretical risk of Reye’s syndrome. However in New Zealand, these products are available as Medsafe is satisfied that the safety of teething gels containing choline salicylate in children is acceptable when they are used at recommended doses.

First-line treatment for teething pain includes self-care measures such as gently rubbing the gum or using a chilled teething ring. Simple oral analgesics (paracetamol, ibuprofen) may be used as required in children aged three months or older.

Extra for experts - What is Reye’s syndrome?

Reye’s syndrome is a potentially fatal condition observed in cases where febrile children have been given aspirin (acetylsalicylic acid). The syndrome is characterised by nausea, vomiting, headache, excitability, delirium and combativeness, progressing to coma. Cases of Reye’s syndrome peaked in the 1980s and dramatically declined after warnings against using aspirin in children were issued. It is not fully understood whether aspirin is the sole cause of Reye’s syndrome, or whether the presence of a metabolic disorder is also a significant factor. There have been rare cases of Reye’s syndrome in adults, but the illness is generally less severe and causes no lasting neural or hepatic damage.

There are variable opinions of national drug regulatory authorities as to whether aspirin should be contraindicated in children aged under 16 years or under 12 years. In New Zealand, current medicine safety datasheets for aspirin preparations carry a warning for children aged under 12 years. However, given the availability of alternatives to treat fever in children it would be prudent to take the cautious approach of not using aspirin in children aged under 16 years.

Although no fatalities due to Reye’s syndrome have been attributed to the use of salicylates other than aspirin (e.g. teething gels containing choline salicylate), some countries have also cautioned against the use of these products in children aged under 16 years.

8. Which statement(s) about treating oral thrush are true? Your peers Answer
First-line treatment is with miconazole oral gel 95%
First-line treatment is with nystatin suspension 10%
If the infection has not resolved after seven days, treat with mupirocin ointment (Bactroban) <1%
The same product used to treat a breast-feeding infant with oral thrush may be used on the mother’s nipples 95%

Question 8 comments

It is recommended that miconazole oral gel is used first, for seven days to treat oral thrush in infants and children. If the infection has not fully resolved after seven days, but there has been some response to miconazole treatment, continue for a further seven days.

If miconazole oral gel has not had any effect after seven days or is inappropriate (e.g. child less than six months, insufficiently developed swallowing reflex), a second-line alternative is nystatin suspension, 1 mL, four times per day, for seven days.

As oral thrush is caused by the fungus Candida, antibacterial products (e.g. mupirocin) have no place in treatment. In addition, as mupirocin is effective against MRSA, its use should be reserved for this.

To prevent re-infection after a case of oral thrush, it is important that feeding equipment, dummies and toys that have been in contact with the baby’s mouth are sterilised. Mothers who are breast feeding may have contracted the infection on their nipples. The same antifungal product used for the baby may be used on the mother’s nipples.

9. Which of the following may an avulsed permanent tooth be stored in while the child is being transported to the dentist? Your peers Answer
Water 4%
Saline 88%
Milk 91%
Child’s mouth 21%
Gauze 3%

Question 9 comments

Ideally, an avulsed permanent tooth should be placed back in the socket, however this may not be practical in a young child if there is a risk of swallowing or aspirating the tooth. In this case, the tooth should be stored in a clean container, immersed in fresh, cold milk or saline. Tap water should not be used as it is not a sterile solution. As the tooth needs to remain hydrated, it needs to be in a solution rather than being wrapped in gauze.

Extra for experts - Re-implanting an avulsed permanent tooth in older children and adults

Locate the avulsed tooth. Ensure that it is handled by the crown and not the roots. Debris can be removed from the tooth by gentle rinsing with saline. If saline is not available, use fresh, cold milk or saliva from the patients mouth. Do not scrub or rub the tooth and avoid touching the roots.

Place the tooth back into the socket. Look at the adjacent teeth to judge the line/angle of the replaced tooth. It may be kept in place by gently biting down on a gauze pad or using a finger.

The patient should be transported to the dentist immediately.

Note that an avulsed primary tooth should NOT be re-implanted as this may cause damage to the developing permanent tooth bud.

10. Which of the following are associated with sucking a dummy (pacifier)? Your peers Answer
Increased risk of otitis media 89%
Decreased risk of sudden infant death syndrome (SIDS) 86%
Increased risk of dental caries 6%
Early cessation of breast feeding 90%
Early eruption of primary teeth 1%

Question 10 comments

Use of a dummy is associated with an increased risk of development of otitis media. This is thought to be due to increased bacteria and viruses reaching the middle ear because the Eustachian tube is opened as a result of the sucking motion. In addition, sucking increases the amount of saliva in the mouth, creating a favourable environment for microorganisms. Note that other risk factors such as bottle feeding and attending a day care facility are even more strongly associated with otitis media.

Infants who use a dummy are two to three more times likely to cease breast feeding early than infants who do not use a dummy. Dummies have also been associated with a shorter duration of breast feeds and fewer feeds per day. It is not known if the use of the dummy discourages breast feeding or contributes to a poor sucking technique or if use of a dummy is simply a marker for breast feeding problems.

However not all associations with the use of a dummy are negative. Infants who use dummies have a possible decreased risk of sudden infant death syndrome (SIDS). A meta-analysis of seven studies confirmed this association (1 SIDS death prevented for every 2733 infants who use a dummy when placed for sleep).1 It is thought that the mechanism of action may be related to the lowered arousal threshold during dummy use. The American Academy of Paediatrics recommends that dummies can be offered during sleep time, provided that it does not interfere with breast feeding.

The use of a dummy does not appear to increase the prevalence of caries unless it has been routinely dipped in a sugary substance and it does not have any association with the early eruption of primary teeth.

  1. Hauck F, Omojokun O, Siadaty M. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics 2005;116(5):e716-23.