The Royal Australian College of General Practitioners: tests, treatments and procedures clinicians and consumers should question

PPIs are very effective and widely used medications for treating gastroesophageal reflux disease (GORD) and peptic ulcer disease. However, there is evidence of inappropriate prescribing, with a high proportion of patients kept on maximal doses long term. After initial symptom control, the lowest dose and frequency that provides ongoing symptom control should be reached by ‘stepping down’, and the medication ceased when no longer required. This reduces the risk of possible adverse effects to the individual, and the costs of long term treatment.

Adverse effects of long term use include increased risk of GI infection (incl. clostridium difficile), community acquired pneumonia, osteoporotic fractures, interstitial nephritis, and nutritional deficiencies (B12, Fe, Mg), particularly in the elderly or immunocompromised. Exceptions, for which prolonged treatment may be necessary, include Barrett's oesophagus, high grade oesophagitis, and GI bleeding.

The cost of anti-acid medication was $450 million in 2013-14, with prescription volume increasing 9% annually.

Supporting evidence

  • Hughes JD1, Tanpurekul W, Keen NC, Ee HC. Reducing the cost of proton pump inhibitors by adopting best practice. Qual Prim Care. 2009;17(1):15-21.
  • www.nice.org.uk/guidance/cg184/chapter/1-recommendations
  • A. S. Raghunath, C. O’Morain & R. C. McLoughlin. Review article: the long-term use of proton-pump inhibitors. Aliment Pharmacol Ther 2005; 22 (Suppl. 1): 55–63.
  • T Ali, DN Roberts, WM Tierney. Long-term safety concerns with proton pump inhibitors. The American journal of medicine, October 2009 Vol 122, Issue 10, Pages 896–903
  • Reimer C. Safety of long-term PPI therapy. Best practice & research Clinical gastroenterology. 2013;27(3):443-54.

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The benefit gained from treating elevated blood pressure or lipids is proportional to a patient’s baseline risk of a cardiovascular event. Patients with multiple risk factors who are at high risk of an event will gain the most benefit from treatment. Patients with elevated blood pressure or lipids but who are 'low risk' (< 10% 5-year risk according to the current National Vascular Disease Prevention Alliance (NVDPA) absolute CVD risk guidelines) do not require medication. The NVDPA guidelines also recommend treatment of blood pressure persistently greater than 160/100 mmHg regardless of baseline risk, and for other patients with conditions considered high risk, or with existing cardiovascular disease (see guidelines).

Ideally, patients should share in the decision to commence medication, with an understanding of the potential benefits and harms. Lipid-modifying drugs cost the PBS $1.1 billion in 2013-14, more than any other class of medication.

Supporting evidence

 
  • Cholesterol Treatment Trialists' (CTT) Collaborators, Mihaylova B, Emberson J, Blackwell L, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet. 2012 Aug 11;380(9841):581-90. doi: 10.1016/S0140-6736(12)60367-5. Epub 2012 May 17.
  • Blood Pressure Lowering Treatment Trialists' Collaboration, Sundström J, Arima H, Woodward M, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014 Aug 16;384(9943):591-8.
  • NVDPA Absolute cardiovascular risk guidelines.

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There is no evidence that self-monitoring of blood glucose (SMBG) affects patient satisfaction, general well-being or general health-related quality of life. A 2012 Australian review found SMBG may possibly reduce HbA1c levels by 0.25-0.3%, considered clinically insignificant. SMBG actually increased hypoglycaemia risk, although causation was uncertain. This recommendation aligns with the 2015 draft NICE guidelines for self-monitoring of blood glucose, the Canadian Agency for Drugs and Technologies in Health (CADTH) recommendations and the Scottish Intercollegiate Guidelines Network. Therefore, use HbA1c levels to guide therapy, and promote lifestyle interventions regardless of diabetes control. Exceptions (i.e. not ‘routine’) may include: symptomatic hypoglycaemia; heavy machinery operators on a sulfonylurea; elderly people with renal failure; pregnancy; and possibly short-term education about diet influencing blood sugar. Australian government spending on test strips was $143 million in 2012. Diabetics not on insulin who used SMBG, averaged 300 test strips annually.

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Major risk factors for vascular disease include older age, male sex, hypertension, smoking, dyslipidaemia and diabetes. Calculators using cardiovascular risk factors are widely available to determine a patient's individual risk for a vascular event. The additional information obtained by screening asymptomatic adults at low risk for a vascular event, via a resting ECG or stress test, is very unlikely to alter risk stratification or reduce overall events related to coronary artery disease. The potential harms of these tests have been found to equal or exceed the potential benefits in this population.

In the absence of clinical trial data demonstrating an overall benefit, coronary artery calcium score is also not recommended in this population (National Vascular Disease Prevention Alliance (NVDPA) guidelines.

Similarly, screening with carotid duplex ultrasound in low-risk patients results in many more false-positive than true-positive results. This in turn leads to a significant number of unnecessary angiographies or surgical procedures, with the attendant risks of stroke, myocardial infarction and death.

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Based on epidemiological data, the prevalence of benzodiazepine (BZD) abuse is generally low in the therapeutic setting. However, the incidence of BZD misuse and abuse is much higher in (people who abuse alcohol and other drugs, either currently or in their past history.

When BZDs are combined with other CNS depressants (e.g., alcohol, antidepressants, antipsychotics, opioids), patients are at risk of respiratory depression, heavy sedation, coma and death. Alcohol and BZDs can produce cross-tolerance, and regular use of both can make withdrawal more severe and/or protracted.

Patients who use two or more psychoactive drugs in combination (polydrug use) and those with a history of significant mental illness may be more vulnerable to major harms. When treating polydrug users, avoid initiating BZDs, and for patients already taking them, reduce and cease prescription of BZDs in a supervised manner.

Supporting evidence

  • Dell’osso B, Lader M. Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. European Psychiatry 28 (2013) 7–20
  • Sheehan D, Raj A. Benzodiazepines. In: Shatzberg A, Nemeroff C, editors. The American Psychiatric Publishing Textbook of Psychopharmacology Fourth edition. Arlington, VA.: American Psychiatric Publishing; 2009. p. 465–86
  • Mills K, Deady M, Proudfoot H, et al. Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings. Sydney: National Drug and Alcohol Research Centre, University of New South Wales.
  • Lingford-Hughes AR, Welch S, British Association for Psychopharmacology ERG, et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol. 2012;26(7):899-952

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All RACGP members were invited, and five GPs selected, to join the Choosing Wisely panel. They raised 28 issues, researched these and voted on a shortlist of 10. The voting for this shortlist was based on the amount of supporting evidence available, the degree of importance for patients, and the frequency of the test or treatment being used by Australian GPs. Opinion from the entire College membership was then sought via online survey, to choose five of the shortlisted 10. Additional free-text comment was encouraged, with good response rates. This national vote determined the final five topics.

Following an NPS Representatives meeting, two on that list were found to duplicate other Colleges' choices, and it was felt the RACGP could endorse these rather than replicate them. Therefore the next two highest voted options were selected instead.

Last reviewed 22 April 2015

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