26 September 2017

Reconsider aggressive treatments in older patients

Aged Care Clinical Patients

After years of being told that patients weren’t being treated aggressively enough for hyperglycaemia and hypertension, doctors are now advised to consider deprescribing some of these medications in over-65s.

As part of a new suite of Choosing Wisely recommendations, President of the Internal Medicine Society of Australia and NZ, Dr Robert Pickles, stressed the importance of a medication review for patients over-65 to see whether deprescribing was appropriate.

Benzodiazepines, anti-psychotics, hypoglycaemic agents, antithrombotic agents, anti-hypertensives and anti-anginal agents were all medications to consider, he said.

This was because there was little benefit, but a higher chance of harm, in trying to achieve aggressive treatment targets such as a blood pressure of <130/80 or HbA1c <7% in frail older patients with multiple co-morbidities, the group said.

Instead, consider deprescribing when the indication of a specific medicine has changed, the risk of harm outweighs the benefit in the patient’s expected lifespan, or if the patient is non-adherent or experiencing toxicity from the drug.

To date, almost 160 recommendations have been issued since the inception of Choosing Wisely two years ago.

As part of the Society of Obstetric Medicine of Australia and NZ contribution, they advised against D-Dimer tests to exclude venous thromboembolism at all during pregnancy, methylenetetrahydrofolate reductase polymorphism testing as part of a routine evaluation for thrombophilia in pregnancy, and testing for inherited thrombophilia for placental mediated complications.

Repeat testing for proteinuria in established preeclampsia and testing for erythrocyte sedimentation rate were also cautioned against for pregnant women.

Australian children were also having too many X-rays, according to the paediatric division of the Royal Australasian College of Physicians, which urged doctors not to routinely order the tests for a diagnosis of bronchiolitis, asthma and nonspecific abdominal pain.

Only one in 100 children with typical bronchiolitis would get any clinical benefit from a chest X-ray, and abdominal X-rays were similarly ineffective for nonspecific abdominal pain.

Associate Professor Peter Connaughton, president of the Australasian Faculty of Occupational and Environmental Medicine, also urged doctors to be actively engaged in assisting patients return to work because of the evidence supporting its psychological and physical benefits.

“We recommend health professionals only certify a patient as being totally unfit for work when it is absolutely clinically necessary, and when appropriate, encourage your patients to continue working in some capacity as part of their overall healthcare management,” he said.

Declining health, slower recovery times and longer duration of disability were all risks associated with absence from work.

The group also cautioned against ordering X-rays and other low back imaging as part of a preplacement medical examination, or for acute non-specific back pain where serious spinal problems were not suspected.

Other advice included:

–          Do not routinely prescribe oral antibiotics to children with fever without an identified bacterial infection

–          Do not routinely prescribe salbutamol or systemic corticosteroids to treat bronchiolitis in children

–          Do not routinely treat gastroesophageal reflux disease (GORD) in infants with acid suppression therapy

–          Do not request daily full blood counts, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) as measures of response to antibiotic treatment if patients are clinically improving

–          Do not request Holter monitoring, carotid duplex scans, echocardiography, electroencephalograms (EEGs) or telemetry in patients with first presentation of uncomplicated syncope and no high-risk features

–          Do not request computerised tomography pulmonary angiography (CTPA) as first-choice investigation in non-pregnant adult patients with low risk of pulmonary thromboembolism (PTE) by Wells’ score (score <= 4); imaging can be avoided in low risk patients if D-dimer test is negative after adjusting for age

–          Do not repeat chest X-rays when screening asbestos-exposed workers unless clinically indicated

For a full list of recommendations, visit www.choosingwisely.org.au