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Welcome to the Aussie newsletter for GPnotebook. These monthly updates come in digestible portions for busy healthcare providers, to help keep you in the loop around updates on the GPnotebook website.
Think of these updates as a small feast – entrée, mains and dessert – served in a range of digestible portions: reading, watching and listening. The idea came from my own (less-than-healthy!) habit of catching up on news during hurried lunch breaks.
Entrée (read)
It’s summer, and most Australians are showering like it’s a national sport – on average eight times a week. But the question is, what do we tell our patients with eczema? Is cutting back on showers necessary, or does frequency have little impact on their skin? This update on bathing frequency is worth a look. The spoiler: a recent trial found no real difference in eczema symptoms whether people bathed daily or just once a week. You may find the information helpful to share with patients too, if they are unconvinced.
Mains (watch)
Thoughtful deprescribing isn’t about taking things away; it’s about making sure every medicine still earns its keep. As life, health and priorities change, so should medication lists. Proton pump inhibitors (PPIs) are amongst the most prescribed medications worldwide, and Australia is no exception.
With prolonged use of a PPI, risks increase for gastrointestinal infections (including Clostridioides difficile), community-acquired pneumonia, osteoporotic fractures, interstitial nephritis, and deficiencies in B12, iron and magnesium, particularly among older or immunocompromised individuals. Therefore, if there is no longer a clear clinical benefit, reducing or stopping the medication is a sensible next step.
This 8-minute video by Dr Lisa Devine steps us through a pragmatic approach to deprescribing PPIs. Lisa starts with clarifying which patients should remain on the medications. Asking “why is this patient taking a PPI?” is the obvious first step here, and I’m often surprised how many patients are not really sure. That’s when we need to ask directly about a history of endoscopy, if they have ever been hospitalised for a bleeding ulcer, if they are taking one because of chronic nonsteroidal anti-inflammatory drug (NSAID) use, or if they’ve ever had heartburn or dyspepsia.
It’s best not to proceed with deprescribing if there is a history of Barrett’s oesophagus, chronic NSAID use with bleeding risk, severe oesophagitis or a documented history of a bleeding gastrointestinal ulcer. But in all other situations, it’s worth at least a serious discussion around ceasing the medication.
Decreasing, stopping, monitoring and managing relapses are all covered in the video. Non-drug approaches are important adjuncts to maximise success, and it’s often easy to forget simple instructions (like advising patients to avoid eating 2 hours before bedtime). Another helpful reminder is that rebound upper-gastrointestinal-tract symptoms are common but are not a reason to abandon efforts altogether.
Whether to continue or deprescribe a PPI should always come back to the patient and the evidence about benefit versus harm. Australians have made impressive progress in reducing unnecessary use over the past 10 years. Let’s keep that momentum going.
Dessert (listen)
Parents come to see you with their toddler, who had a runny nose and fever for a few days, followed by clinical improvement but with the onset of bright red cheeks, which caused them to worry. Even a medical student could pick the parvovirus “spot diagnosis” here… but wait! We need to look after the whole family, not just the diagnosis!
This podcast is exactly what a frontline care provider needs in a situation like this. It spells out what we need to think about across all the groups who might be affected – from a pregnant mum to a sibling in-utero to a grandfather on chemotherapy – without the hassle of cross-checking multiple specialty guidelines.
We owe it to our patients to consider less common causes, many of which can still be diagnosed by a thorough history-taking and examination, with no need for investigations. I appreciated the reminder to consider laryngopharyngeal reflux (with this, symptoms of heartburn are not always present), and to never ignore unilateral foul-smelling nasal discharge in a child.
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