The Royal Australian College of General Practitioners
Recommendations from the Royal Australian College of General Practitioners (RACGP) on treating hypertension or hyperlipidaemia, prescribing benzodiazepines, self-monitoring of blood glucose, proton pump inhibitor therapy and screening for vascular disease. The Royal Australian College of General Practitioners (RACGP) is Australia’s largest professional general practice organisation and represents urban and rural general practitioners. We represent more than 30,000 members working in or towards a career in general practice. There are more than 125 million general practice consultations taking place annually in Australia.
Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
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.
Recommendation released April 2015
- 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
Recommendations 1 - 5 (April 2015)
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.
Recommendations 6-10 (March 2016)
The RACGP Working Group established for Wave 1 of Choosing Wisely identified 32 candidate topics for Wave 2, then shortlisted fifteen, spread across four categories – screening, imaging, pathology and treatment. The shortlisting criteria were: quality of supporting evidence; importance for patients; and number of Australian GPs using the test or treatment. A dedicated workshop was held at the RACGP Annual Scientific Meeting, ‘GP15’, and the entire RACGP membership was asked to vote for their ‘top five’ via online survey. Additional free-text comment was encouraged, with good response rates. The top five topics from this national vote were written up by the Working Group and reviewed by the RACGP Expert Committee – Quality Care.
- 1 Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
- 2 Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
- 3 Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- 4 Don't screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
- 5 Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
- 6 Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead.
- 7 Don’t order chest x-rays in patients with uncomplicated acute bronchitis.
- 8 Don’t routinely do a pelvic examination with a Pap smear.
- 9 Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
- 10 Don’t test thyroid function as population screening for asymptomatic patients.