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BPJ 61 June 2014

Best Practice Journal

Proton pump inhibitors: When is enough, enough?

Proton pump inhibitors (PPIs) are one of the most widely used medicines in New Zealand; in 2013 omeprazole was the third most commonly dispensed medicine in the community. PPIs are highly effective at reducing symptoms caused by gastric acid, and are generally well tolerated. However, they should not be prescribed indefinitely, without review. PPIs should be used at the lowest effective dose for the shortest possible time. “As needed” use, rather than a regular daily dose, may be appropriate for some patients. Patients should be warned that rebound acid secretion often occurs following withdrawal of treatment, even after periods as short as four weeks. Many patients will be able to manage symptoms during this withdrawal period with alternative medicines, such as antacids.

There is also a Peer Group Discussion on this article

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Managing gastro-oesophageal reflux disease (GORD) in adults: an update

Heartburn, the cardinal symptom of gastro-oesophageal reflux disease, is experienced by 15 – 20% of adults at least once a week. The patient’s history and their response to an empiric trial with a proton pump inhibitor (PPI) are used to diagnose GORD in primary care. Endoscopy often provides limited diagnostic information as the majority of patients with GORD will not have visible lesions. The role of endoscopy is therefore limited to investigating patients with possible complications of GORD, e.g. erosive oesophagitis or Barrett’s oesophagus. PPIs are the mainstay of treatment for GORD, but should be prescribed at the lowest effective dose or “as needed” for patients with mild to moderate forms of GORD. Fundoplication is currently the most effective treatment for patients with severe or complicated GORD.

There is also a Peer Group Discussion on this article

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Biliary colic and complications from gallstones

Gallstones are common among the general population, but because they rarely cause symptoms many people are unaware of their presence. Over a ten-year period, approximately one-third of people with gallstones will develop the painful symptoms of biliary colic. This can be a precursor to more serious conditions, such as acute cholecystitis and pancreatitis that require acute advanced endoscopic or surgical assessment. The presence of upper abdominal pain, despite normal physical examination and blood test results, is consistent with uncomplicated biliary colic. An ultrasound should be arranged for all patients with features suggestive of biliary colic to confirm a diagnosis. Patients with biliary colic are generally managed in the community with non-steroidal anti-inflammatory drugs (NSAIDs) and lifestyle advice while awaiting assessment for laproscopic cholecystectomy. View Article

Assessing diabetic peripheral neuropathy in primary care

Diabetic peripheral neuropathy is one of the most common long-term complications of diabetes. It develops in up to half of all people with diabetes, and is one of the main risk factors contributing to foot ulceration and eventual amputation. In developed nations the main cause of non-traumatic lower limb amputation is “diabetic foot”, which is a result of a combination of decreased sensation and reduced arterial supply. Assessing for peripheral neuropathy is a routine part of ongoing care for patients with diabetes. Treatment of diabetic neuropathy includes optimal control of hyperglycaemia, appropriate foot care (often involving input from a podiatrist), and symptomatic management of any neuropathic pain.

There is also a Peer Group Discussion on this article

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Upfront: “A disaster in the making”: it’s time to take action against misuse of oxycodone

Dr Jeremy McMinn is a consultant psychiatrist and addiction specialist at Capital & Coast DHB. He is also the Co-Chair of the National Association of Opioid Treatment Providers and the New Zealand Branch Chair of the Australasian Chapter of Addiction Medicine. We invited Dr McMinn to answer a series of questions about the role of oxycodone, both as a legitimate option for pain control, and a medicine with a serious potential for misuse. The time for debating who to blame has passed. Oxycodone, and opioid prescribing in general, is already out of hand and we need to collectively take action before it is too late. View Article

Rising antimicrobial resistance

Associate Professor Mark Thomas from the University of Auckland, in conjunction with Dr Alesha Smith and Professor Murray Tilyard from bpacnz recently published an article in the New Zealand Medical Journal, entitled: “Rising antimicrobial resistance: a strong reason to reduce excessive antimicrobial consumption in New Zealand”. View Article

Changes to the National Immunisation Schedule: rotavirus vaccine now added

Changes to the National Immunisation Schedule will soon take effect, with the introduction of rotavirus vaccine, free of charge, from 1 July, 2014. In addition, the Prevenar 13 pneumococcal vaccine, which protects against 13 serotypes of pneumococcal disease, replaces Synflorix, which protects against 10 serotypes. Dr Bryn Jones, Chief Advisor at the Ministry of Heath, expects that the schedule change will have a significant impact on the health of young children: “Thousands of children and their families are affected by rotavirus every year. For most, it’s a few days of unpleasantness, but it can lead to dehydration and hospitalisation. We expect that rotavirus vaccine will save hundreds of children every year from a trip to hospital.” View Article

Fluoxetine brand change: Arrow-Fluoxetine sole subsidised brand from 1 July

From 1 July 2014, Arrow-Fluoxetine will be the sole subsidised brand of fluoxetine. Fluox will not be subsidised after 1 July 2014, and there is no guarantee that it will continue to be available for private purchase by patients once current stocks have run out. Therefore, most patients will need to be assisted in changing brands (if they have not done so already) to continue to receive fully subsidised treatment with fluoxetine. View Article

News Updates

Reminder: Most broad-spectrum antibiotics do not interact with combined oral contraceptives | Oseltamivir (Tamiflu) and Zanamivir (Relenza): Are they actually effective? | Emergency contraception: potential problems in overweight women? View Article

Correspondence: Allopurinol dosing; Management of pain

Allopurinol dosing in renal impairment | Non-pharmacological management of pain View Article

Peer Group Discussion

We look back at the key messages and practice points from selected articles in Best Practice Journals View Article