#foam4gp

[gpotgor]

Rosacea option - Brimonidine gel

Rosacea is one of those diseases that seems to either be really easy to control or absolutely frustrating to treat adequately. In UpToDate it specifically mentions that trial and error is the most common approach to treatment options. As with all skin things, there's a good summary up on Dermnet (although I was surprised by the Rosex advert at the top of the screen!) that confirms we don't really know the aeitology. This goes some way to explaining why it's hard to treat in some cases. The basics apply to all patients with avoidance of precipitating factors coming front and centre (hot showers, spicy food, caffeine, alcohol all common triggers - monastic living could be useful), but I recently found out that there's a newish treatment option available for rosacea erythema which seems to be getting a good wrap on patient support group websites. Brimonidine tartrate gel was approved by the TGA in August last year lagging behind the FDA approval in 2013. The research appears to show a significant difference between the active ingredient and the carrier alone in reducing facial erythema. It's a highly selective alpha2-adrenergic receptor agonist and works through cutaneous vasoconstriction. Makes sense it can reduce erythema. Noted though are the potential adverse effects reported as: erythema, pruritus, flushing and skin burning sensation! Contraindicated in concurrent use of TCA, MAOI, tetracyclic antidepressants. Use is once daily and results are usually seen pretty quickly. Might be worth a try. References: http://dermnetnz.org/acne/rosacea.html https://www.tga.gov.au/artg/artg-id-212325 CMI and PI http://www.dermnetnz.org/treatments/brimonidine.html http://emedicine.medscape.com/article/1071429-overview

[gpotgor]

PBS + TGA changes to Mifepristone prescribing

From Feb 1 2015 there will be some significant changes in Australia that will enable more women to access medical termination of pregnancy. The primary change is that MS2Step registered prescribers, who are primarily GPs (Obstetricians/Gynaecologists and Dip Obs are certified to prescribe outside the MS2Step program), are now able to prescribe for gestations up to 63 days - up from 49 days. There have been changes to the packaging and more information about contraindications and precautions. In terms of precautions, the main change is that for women > 35 year of age and smoking >15 cigarettes a day, caution is advised as these women were generally excluded from clinical trials. And a new contraindication is the patient having no access to emergency medical care up to 14 days after commencing management. More info at https://www.ms2step.com.au/ for healthcare professionals. For others not able to register you can see the TGA approval information on their website.

[gpotgor]

Updates to the Therapeutic Guidelines

For those of us in Australia, the Therapeutic Guidelines (TG) is one of the "go to" sources for prescribing information. It's not the only one, but in my opinion it is the best and encompasses the use of evidence based treatment, is compiled by expert groups, and gives background and practical information including dosing and prescribing information. It costs, but if you work in a public hospital or AMS (see my previous post) you can access it via the Victorian Clinician's Health Channel for free. I also used it a lot when I was a medical student, so it's become quite embedded in my practice. I've even been known to read it for pleasure. This post is about some of the recent changes to the Antibiotic section of the TG, which have been significant in a number of areas. The introduction has a few changes and aims to support appropriate and optimised prescribing. They utilise the mnemonic MIND ME, thus:

While obvious and straight forward, this "creed" is always useful to consider. It also underpins the rest of the introductory section. For all of us, it's worth reading the antimicrobial resistance and stewardship sections - and follow the links through to NPS and ACSQHC websites for more info and practice guidelines. For GPs, the update includes some practical guidance for the management of acute gastroenteritis - in particular in aged care but also with a new treatment algorithm for early management and a comparison of microbiological testing for Clostridium Difficile. There have been a lot of changes in the pneumonia section with comprehensive notes about the rationale behind empiric antibiotic regimens in mild community acquired pneumonia - including the use of combination therapy when required (basically if no improvement on clinical review 48 hours after commencing monotherapy - or if you can't review them within 48 hours). In case you were wondering, the combination in question in amoxycillin 1g TDS for 5-7/7 and doxycycline 100mg BD for 5-7/7. Just an aside... how many doctors do you know prescribe roxithromycin for chest infections? Seems like a relatively common occurrence and not just used for hypersensitivity to penicillin. For a more detailed coverage on the changes, check out the TG press release [pdf]. Happy reading and appropriate prescribing! * As a footnote, I'd like to commend the TG for the correct use of the word regimen when describing a course of prescription, rather than the often misused term regime, which is something altogether different. Please feel free to correct your colleagues at will.

[gpotgor]

Access to the Victorian Clinicans Health Channel

The Victorian Clinicians Health Channel is a portal website that provides access to lots of electronic resources for health practitioners who work in the public health sector (in Victoria, Australia in case that wasn't clear). As a junior doctor this was a great resource for accessing clinical information, and in particular access to some mobile resources such as iMIMS (or mobile MIMS for the non-iPhonecentric), BMJ Best Practice, eTG, and the AMH (and more). The good news is that if you work in an Aboriginal Community Controlled Health Organisation in Victoria you can also access these resources for free. Head over to http://www.health.vic.gov.au/clinicians/registration.htm to register. If you're at an ACCHO / AMS then in the Your Hospital or Health Service Details section select 'Other' and 'Aboriginal Community Health Services'. Then follow the various instructions to register for the mobile service you're interested in. Bingo!