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AUSTRALIA’S LEADING INDEPENDENT MEDICAL PUBLICATION I www.australiandoctor.com.au

27 MAY 2016

GOODWILL HUNTING

FIGHTING FIT

HOW TO TREAT

Don’t take advantage of the altruistic nature of GP supervisors Editorial, page 32

Are you a good role model for your patients?

Insomnia

All change on infant feeding advice MICHAEL WOODHEAD AFTER years of conflicting advice about avoiding allergenic food in infancy, paediatricians now say they should be introduced as early as four months. New consensus guidelines agreed by Australian allergists, paediatricians and lactation experts recommend that solid foods be introduced from 4-6 months, and these should include peanut butter, cooked egg, dairy and wheat products. The advice applies to all babies, including those at high risk of allergy, and is based on latest research showing that early exposure to allergens may reduce the risk of eczema and food allergies, according to the Australasian Society for Clinical Allergy and Immunology. The new infant feeding guidelines also advise women against using ‘hypoallergenic’ hydrolysed formulas to prevent allergy because there is no consistent evidence that they have a protective effect. The revised advice is the product of a roundtable meeting of the Centre for Food and Allergy Research in Melbourne on 13 May and is supported by the NHMRC. “We are pleased we have reached a unanimous consensus among the experts, advising Australian families on

Smart Practice, page 15

Earn CPD points online

‘A gasp of air’ GPs give cautious welcome to Labor’s Medicare anti-freeze ELECTION 2016 PAUL SMITH LABOR’S pledge to end the Medicare freeze has been described as giving a “gasp of air to a drowning man”, amid claims it does little to fix the funding crisis gripping the specialty. Labor will lift the freeze on all MBS rebates in January, if elected, in an attempt to ensure GPs continue to bulk-bill patients. Rebates will then be increased in line with indexation indefinitely every July. The move, which Labor says will cost $2.4 billion over the next four

years, has been welcomed by both the RACGP and the AMA. However, the indexation formula that will be used still means rebates will fail to keep pace with the consumer price index, and it is likely to add less than 90 cents to a level B rebate. Labor said it would not reverse the devaluation of rebates already inflicted by the Medicare freeze introduced in 2014, saying it would be too expensive. Labor leader Bill Shorten announced the policy at the Reliance Medical Practice on the Central Coast, NSW, where the doctors at the practice bulk-bill 97% of their patients.

cont’d next page

Clinical director Dr Rodney Beckwith told Australian Doctor his two practices had only weathered the freeze by offering new doctors joining the business a reduced cut of the Medicare revenue they generate. “It’s now a 65–35 split; otherwise, we can’t continue as a business,” he said. “It’s a hard conversation to have and it’s generally the former practice owners [we recruit] who understand the reasons why. “When I first started five years ago, we were giving doctors 80%.” He described Labor’s pledge to kill off the freeze as a “lifesaver”, saying it would allow his two clinics to continue to bulk-bill. But Dr Beckwith said Medicare

rebates were still so low that ending the freeze was like “saving a drowning man by allowing him a gasp of air”. What happens if the freeze remains in place is still largely unanswered. Australian Doctor’s survey of 510 GPs — giving the first detailed insight into the views of front-line doctors — found the majority (53%) believe bulk-billing rates will collapse. They also fear that under the freeze, the health of vulnerable patients will suffer (62%), along with a significant increase in avoidable hospitalisations (57%) and presentations to EDs (66%). cont’d next page

THE BIG FREEZE: YOUR RESPONSES

Our exclusive GP survey reveals the full impact of the $1bn Medicare cuts. News Review, page 13

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News

ONLINE THIS WEEK australiandoctor.com.au

Most commented Turnbull’s pathology ‘peace deal’ another attack on general practice - bit.ly/1Tt8T1E Practices hit for $120m under Turnbull’s ‘backroom’ pathology deal - bit.ly/1OQecYQ Labor pledges to end the rebate freeze - bit.ly/1OCF2yi

Medical Must-See ‘Natural’ caesarean bit.ly/20dgS3B

Changes to infant feeding advice from page 1

infant feeding,” said Professor Katie Allen, a paediatric allergist at the Murdoch Children’s Research Institute, Victoria. “This will achieve consistent guidelines across both national and state health bodies, which will make guidelines as clear and easy as possible for all parents to follow.” According to the guidelines, exclusion diets should not be recommended during pregnancy or breastfeeding, as there is no evidence that this prevents allergies. Consuming oily fish may help prevent eczema because of the omega-3 fatty acid content. Probiotic supplements may also help prevent eczema. However, there was not enough evidence to make recommendations on their use in pregnancy and breastfeeding.

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In another change to previous advice, the guidelines recommend breastfeeding for at least six months but now note that there is no evidence to show it is effective in preventing allergies. They suggest that cows milk formula may be used if breastfeeding is not possible, and there is no advantage of using soy or goats milk in reducing allergy risk. Regular cows milk or other milks, such as soy and goats milk, are not recommended as the main source of milk before 12 months of age. The guidelines also note that babies have very sensitive facial skin, and therefore, the redness that occurs in contact with many foods could be a sign of irritation rather than food allergy.

ELECTION 2016

General practice loses in Turnbull’s pathology deal PAUL SMITH GENERAL practices will lose $120 million a year under Malcolm Turnbull’s ‘backroom deal’ to cap rents for co-located pathology collection centres, analysts warn. The Prime Minister’s agreement with elements within the pathology industry is aimed at ensuring pathology giants Primary Health Care and Sonic Health Care continue to bulk-bill for pathology tests when the government pulls the plug on the bulk-billing incentives, worth $650 million over four years. But general practice seems to be the sacrifice. The government has told pathology providers it would save them millions by revamping and enforcing laws that ban practices from charging rents more than 20% above their so-called market value. There are currently 5400 centres co-located with general practices, although there is no clear data on the rents being paid. Pathology Australia, a lobby group for the industry, has often referred to an unnamed general practice in Melbourne that was allegedly

being paid $13,000 per square metre a week by an unnamed pathology company. Practice managers argue the rents paid are not inflated but reflect the financial value of the extra revenue generated for pathology companies. Pathology Australia, however, claims the payments are so large that they risk being used as inducements for referrals, illegal under the Health Insurance Act. Analysts from Macquarie Securities said that with around 2000 collection centres each, Sonic and Primary could save between $100 million and $120 million a year under the Turnbull deal. In a briefing document to investors, they argued the rent for a 20m2 space would drop from $70,000 to $12,000 a year. Even after the axe falls on pathology bulk-billing incentives, both companies would be $50-70 million better off, they said. The RACGP condemned Turnbull’s agreement as a “backroom deal”. “What the government has done is broker a deal to

With around 2000 collection centres each, Sonic and Primary could save between $100 million and $120 million a year under their deal with Prime Minister Malcolm Turnbull. benefit the large pathology companies at the expense of general practices mostly operated as small businesses,” president Dr Frank Jones said. In its February report, Blood Money, the Grattan Institute said the money flowing into general practice had been “incorporated into income flow expectations of

From the campaign trail Doctor won’t see you now SO you are a national party leader making a big health policy pledge that you say will secure GP medical care for millions. A big story? Not if it’s the Daily Telegraph covering Bill Shorten and his plan to end the Medicare freeze. The anti-ALP tabloid opted for the headline, ‘The doctor won’t see you now, thanks to Bill’, with the paper accusing Mr Shorten of forcing patients at the Reliance Medical Practice in NSW to wait while he used the venue to “spruik” his big idea. The paper claimed a second GP practice later took to Facebook to launch an attack on the Labor leader, claiming he had forced the “cancellation of doctors appointments and then not turning up”.

in general practice since the millions squandered on the GP super clinics fiasco.

Medicare ‘pause’ De facto health minister TERRY Barnes is back. Readers will remember him as Tony Abbott’s former health policy adviser who came up with the doomed $5 co-pay policy, which led to his former boss’ premature redundancy. He claims in the Australian Financial Review that the MBS, which pays $37.05 for a 20-minute consultation, is “basically adequate for most general practices”. But then, Mr Barnes also believes the political influence of AMA president Professor Brian Owler is so immense that he is the de facto Health Minister. If this really is the case, then he’s not doing a very good job, given Medicare rebates have flatlined, fee-for-service for chronic disease care is being rolled back and no federal health minister has even attempted investment

www.australiandoctor.com.au

WHO invented the Medicare freeze as the country’s most important health policy? Tony Abbott? Peter Dutton? It was first employed in 2013 by a Labor government. Tanya Plibersek, health minister at the time, called it a “pause”, which would last eight months. So not everyone is impressed that Labor is coming to the rescue of general practice. “Plibersek in 2013 was the reason I had to stop bulk-billing in the first place,” one rural doctor wrote on the Australian Doctor website. “Now [the ALP] expects us to forgive and forget?” Paul Smith

GPs, partially offsetting the freeze on GP rebates”. “The fact remains that the prices paid by pathology corporations are commercial decisions, and it is disingenuous for the pathology industry lobby group to complain about the commercial outcomes that their members negotiated,” the report stated.

Anti-freeze cautiously welcomed from page 1

Both the AMA and the RACGP are ramping up their campaigns against the freeze before voters head to the polls on 2 July. The RACGP is spending $1 million on TV, radio and digital media ads with the catchline: “It’s just not right. In Australia, your wealth shouldn’t affect your health. Say no to the freeze on Medicare rebates.” However, many doctors say that whether the freeze stays or goes, the chronic underfunding of general practice is not being addressed by any party. Australian Doctor has requested a response from Federal Health Minister Sussan Ley’s office.


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Testing strip curbs a chance to rethink management CARMEL SPARKE NEW restrictions on supplies of blood glucose test strips for people with type 2 diabetes will be an opportunity for GPs to consider whether testing has positive outcomes for their patients, a diabetes expert says. Dr Gary Deed, chair of the RACGP’s diabetes-specific interest network, says PBS changes planned for 1 July should promote better quality of care, as routine blood testing without a structured approach is onerous, costly and not recommended in best-practice guidelines. Under the new rules, patients with type 2 diabetes not using insulin will receive just six months’ supply of subsidised blood glucose test strips under the National Diabetes Services Scheme (NDSS). After that, patients will have to see a GP or other health professional for further subsidised supplies.

‘It’s quite easy for GPs and diabetes educators to say this testing is important, but for the person living with diabetes, the impact is significant.’ — Dr Gary Deed “It’s probably a good reminder to think about the impact of using medical therapies such as these, and really thinking about individualising it, assessing the outcomes of what you are trying to do and not just saying ‘Off you go, test your strips for the rest of the time you have diabetes’,” Dr Deed said. “The change may promote a

better quality of care, because now professionals need to clearly articulate when the need is there and provide the rationale, for that prescription,” he told Australian Doctor. “It’s quite easy for GPs and diabetes educators to say this testing is important, but for the person living with diabetes, the impact is significant.”

The RACGP will be publishing new diabetes guidelines in June, which will include a section on self-monitoring in type 2 diabetes patients. Dr Deed said diabetes patients also needed to be aware that their NDSS products would no longer be available through Diabetes Australia, but instead be supplied through pharmacies.

GPs in the dark over metformin shortage THE cornerstone of type 2 diabetes patient treatment, extended-release metformin, is in scarce supply, and GPs have been left in the dark as to what is causing the shortage and how it will be resolved. A survey of 30 pharmacies around the country conducted by Pharmacy News has found that only four had stock of either the 500mg or 1000mg formulations of the extended-release (XR) medication. Diabetes Australia has also recently reportedly received dozens of calls from patients complaining about a lack of supply,

for management and we really need some clear guidance to sorting this out.” With no alternatives to extended-release metformin, patients already burdened with polypharmacy were having to take four tablets daily instead of two, he said. A spokeswoman for the TGA said it was yet to be formally advised of a shortage of Diabex and Diaformin by manufacturers. The manufacturers of metformin would not comment on the shortages when contacted by Pharmacy News.

said to have first surfaced in January. Dr Gary Deed, chair of the RACGP’s diabetes specific interest network, said diabetes patients would suffer because of the shortage, yet there had been no word from either the pharmaceutical companies or the health department on the issue. “It would be nice to have some clarity on it. If there’s a problem, then GPs need to be informed proactively, not reactively once we find a patient coming back from a pharmacy,“ he told Australian Doctor. “It’s one of the core initial and longer-term therapies that are used

In Brief Staff writers Be quick with post-stroke aspirin TIME is of the essence for giving aspirin to prevent early recurrent events after a stroke or TIA, an Australian expert says. Patients should be encouraged to take low-dose aspirin immediately after a stroke or TIA is suspected, according to Perth neurologist Professor Graeme Hankey. His comments are based on University of Oxford research showing that aspirin’s preventive benefits are as high as 80% in the immediate days following a stroke or TIA. Lancet 2016; online

Intensive BP control for over-75s IN elderly patients, keeping systolic blood pressure under 120mmHg lowers the risk of major cardiovascular events compared with targets of 140mmHg, a US study shows. Results from a randomised controlled trial showed that patients aged 75 or older who had their blood pressure intensively treated reduced their risk of MI and stroke by over 30% compared with patients on standard treatment. In addition, there was no substantial increase in major clinical adverse events associated with the intensive treatment. However, patients with diabetes, a history of stroke or heart failure, or postural hypotension were excluded from the study. JAMA 2016; online

Ulipristal approved for fibroids A DRUG currently used as an emergency contraceptive, ulipristal acetate (EllaOne), has received TGA approval for treating uterine fibroids. Marketed as Esmya, the progesterone-blocking drug is indicated for intermittent treatment of moderate to severe symptoms of uterine fibroids in adult women of reproductive age. In trials, three-month courses of ulipristal acetate have been shown to reduce pelvic pain and painful periods in women with symptomatic fibroids.

Carmel Sparke

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Reductions in total lesion count as early as week 1 with Epiduo® Gel vs adapalene, benzoyl peroxide and vehicle (all at least p<0.05).1,4

Clinically significant reductions in total lesion count sustained to 1 year year.1,5

Before prescribing, please review the PBS and Product Information available in the primary advertisement of this publication. REFERENCES: 1. EPIDUO Gel Product Information (7 August 2014). 2. Ayer J and Burrows N. Postgrad Med J 2006; 82: 500–506. 3. Thiboutot D et al. J Am Acad Dermatol 2009; 60: S1–S50. 4. Thiboutot D. J Am Acad Dermatol 2007; 57: 791–799. 5. Pariser D et al. J Drugs Dermatol 2007; 6: 899–905. ®Registered trademark of Galderma Australia Pty Ltd. ABN 12 003 976 930. 13B Narabang Way, Belrose, NSW 2085. EPI/019/0316a. McCann Health EPI0028. Date of preparation May 2016. NOT A REAL PATIENT, MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY. INDIVIDUAL RESULTS MAY VARY.

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27 May 2016 | Australian Doctor |

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Chiro banned from treating children Victorian Health Minister Jill Hennessy said she had been ‘physically shaken’ while watching the video and called for action against rogue practitioners. Photo: Youtube

AAP AND PAUL SMITH THE Melbourne chiropractor who hit the headlines after a video of him manipulating a newborn’s spine went viral has been stopped from treating children. Ian Rossborough’s AHPRA registration reveals details of an undertaking that stops him from performing “any chiropractic treatment” on patients up to the age of 18. The restrictions on his practice last until 2 June, while the Chiropractic Board of Australia investigates. An online video of Mr Rossborough manipulating a four-day-old baby was at the centre of demands from doctors that chiropractors stop using spinal manipulation on children, amid claims it was potentially dangerous. Melbourne spinal surgeon Dr John Cunningham — a prominent member of a group opposed to vaccination objectors — said the video of the baby made his “eyes water”. The video also prompted calls for sanctions against chiropractors who manipulated spines of babies and children to “treat” illnesses includ-

ing autism, ADHD and ear infections. Victorian Health Minister Jill Hennessy said she had been “physically shaken” while watching the video and called for action against rogue practitioners. “I can understand [why] doctors are outraged by the extremely distressing image of a four-day-old

baby having its spine cracked,” she said. Asked about the video last month, Mr Rossborough told Fairfax Media he did not diagnose the baby with colic or reflux as reported, and only ever screened patients for illnesses in case he should refer them to a medical practitioner. The action against him by AHPRA comes just weeks

after the RACGP told its members not to refer patients to chiropractors and called for Medicare funding for chiropractic to be pulled. College president Dr Frank Jones has now written to health ministers in all eight states and territories, as well as nurse leaders, urging a “unified response” to the chiropractic treatment of infants.

Doubts over chiro therapy for thoracic spine pain: study CHIROPRACTIC treatment of chronic non-specific thoracic spine pain is no better than sham therapy, a study shows. The research by Murdoch University chiropractors looked at the effectiveness of spinal manipulative therapy (SMT) and the Graston technique, which uses an instrument to break down scar tissue, compared with placebo. The 143 adult participants were randomly selected to receive either SMT, Graston technique or nonfunctional ultrasound. Each received 10 treatments over four weeks. The study found no difference in pain or disability scores between the three groups. But improvements were seen over time in all groups. Jo Hartley Chiropractic and Manual Therapies 2016; online.

Parents back vaccination despite lingering concerns VIRTUALLY all parents support childhood immunisation, yet around half have lingering concerns about vaccine safety, including that they may cause autism, a Melbourne survey shows. While 98% of parents support vaccination for their children, around 28% are worried about too many vaccines being given at once and 11% still fear that vaccines cause autism, according to research carried out by the Royal Children’s

Hospital in Melbourne. In a survey of more than 600 parents of children at two Victorian centres, up to 19% believed that childhood vaccines could cause allergies and 18% thought vaccines could weaken the immune system. Around one-quarter of parents thought they lacked sufficient knowledge to make an informed decision about vaccination. As a result of these concerns, about 2% of parents refused to vaccinate

Dr Margie Danchin.

their children and as many as 8% were worried enough to skip or delay some vaccinations for their children, the researchers said. Study co-author paediatrician Dr Margie Danchin said the findings suggested GPs could be more proactive in allaying parental fears about vaccination. Doctors are considered by families to be the most useful and trustworthy source of information on vaccines, she said, well ahead of ‘official’

government advice, online information, and family and friends. “Every child at some point comes up for their vaccinations, and there should be more of a focus on informed consent, so that parents know a little bit more about the vaccines their baby is having,” Dr Danchin said. The findings were presented last week at the congress of the Royal Australasian College of Physicians in Adelaide. Carmel Sparke

New dentists earn $15k more than new doctors NEWLY qualified dentists beat new doctors when it comes to graduate earnings. While both make the topfive list of earners after leaving university, dentists command the highest graduate starting salary, attracting an average of $77,663 per year and pushing doctors into second place. On average, new doctors command an average salary of $62,624, followed by engineers and surveyors, according to the Good Careers Guide.

(saxagliptin and metformin HCI extended-release) tablets

WARNING: Life-threatening lactic acidosis can occur due to accumulation of metformin. The main risk factor is renal impairment, other risk factors include old age associated with reduced renal function and high doses of metformin above 2 g per day.

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However, medical graduates are far more likely to secure a job than dental graduates, with a 97% employment rate after completing university, compared with 77% for new dentists. Meanwhile, pharmacists languish at the bottom of the postgraduate earners list, with an average starting salary of just $41,000. Graduates in architecture, the creative arts, tourism and hospitality all earn more than new pharmacists.

The Good Careers Guide 2016 is the first annual guide examining the employment prospects of science, IT, engineering and maths graduates and is published by the Good Education Group, an Australian-based private company. The aim of the guide is to fill the gap left by the Federal Government’s Job Guide, which was published for the last time in 2015. Jo Hartley

BEFORE PRESCRIBING PLEASE REVIEW PBS AND PRODUCT INFORMATION AVAILABLE IN THE PRIMARY ADVERTISEMENT IN THIS PUBLICATION OR ON REQUEST FROM ASTRAZENECA. KOMBIGLYZE® XR is a registered trademark of the AstraZeneca group of companies. Registered user AstraZeneca Pty Ltd. ABN 54 009 682 311.5 Alma Road, North Ryde, NSW 2113. AstraZeneca Medical Information: 1800 805 342. 426109.022. 13212. January 2016.


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NPS claims success in GP campaign MICHAEL WOODHEAD MORE than 7000 GPs have been targeted by the NPS’s equivalent of drug reps in an attempt to curb their overuse of pathology tests. NPS MedicineWise is claiming success for the campaign, which started in late 2014, after it boosted appropriate ordering for pathology tests from 19% to 32%. GPs received either face-to-face visits from NPS clinical service specialists or took part in small group meetings to discuss patient case scenarios, with the aim of improving the diagnostic approach to fatigue in line with Therapeutic Guidelines

recommendations. Presenting the findings at the National Medicines Symposium in Canberra, Dr Scott Dickinson of NPS MedicineWise said the positive impact of the GP visits boded well for forthcoming interventions aimed at imaging for low back pain and ankle and knee imaging. “It was a really good result, and overall, the feedback from GPs was very good,” Dr Dickinson told Australian Doctor. However, some GPs have expressed concerns about the impact of government-sponsored cost-saving interventions on clinical autonomy.

“We need to practise medicine as we see fit,” said Sydney GP Dr Ahad Khan. “If I don’t have answers, I need to search for answers by ordering tests,” he said. “In a court of law, you may have a patient whose illness you have missed because you have saved a few bucks by not ordering tests. What do you say to the jury and prosecutor who ask why you didn’t order the test?” “There’s a presumption that all patients fit into boxes, but we have to be open-minded and on the alert for atypical presentations.”

There could be legal repurcussions for not ordering tests to ‘save a few bucks’, says Dr Ahad Khan.

Dual bronchodilators backed Practices risk losing e-PIP over ICS for high-risk COPD over software confusion NEJM Using dual bronchodilators rather than adding an inhaled steroid may prevent COPD exacerbations while minimising pneumonia risk, a major study suggests. Treatment with an inhaled long-acting beta-agonist (LABA) and a long-acting muscarinic antagonist was more effective at preventing exacerbations than a LABA and inhaled corticosteroid, according to a randomised controlled trial in 3362 patients with moderate to severe COPD. In the 12-month study, indacaterol-glycopyrronium (Ultibro Breezhaler) proved more effective than salmeterolfluticasone (Seretide) in preventing exacerbations in patients with COPD who were at high risk of flare ups.

As well as reducing the overall rate of exacerbations by 11%, the dual bronchodilator regimen was associated with a lower rate of pneumonia than the combination containing a corticosteroid (3.2% vs 4.8%). Professor Christine Jenkins, head of respiratory discipline at the University of Sydney, said the findings backed growing evidence that inhaled steroids were only of benefit

for a subgroup of COPD patients with high eosinophil counts. “[This is] challenging the current treatment paradigm that these patients [at risk of exacerbations] should all receive inhaled corticosteroids,” she told Australian Doctor. “This trial provides evidence that combination dual bronchodilators are more effective than inhaled corticosteroid and LABA in reducing exacerbations in patients with moderate to severe COPD,” she said. Professor Jenkins declared she was a member of an advisory board for Novartis, makers of Ultibro Breezhaler.

Michael Woodhead New England Journal of Medicine 2016; online.

AROUND 100 practices are at risk of losing e-PIP payments worth thousands of dollars due to confusion over upgrades to practice software. Under rules introduced this month, practices have to upload a set number of shared health summaries to the MyHealth Record system in order to receive e-health Practice Incentives Program payments. There are more than 4870 practices signed up to the incentive, which is worth up to $50,000 a year. However, there are fears a small number of practices could miss out following a recent Microsoft Security upgrade that had rendered software unable to upload, or download documents from the MyHealth Record. A spokesperson for the Federal Department of Health said all software companies had resolved the technical issues, however, the AMA said that it was still concerned. AMA council of general practice chair Dr Brian Morton said practices might struggle

to get up to speed with software changes or register enough patients on the MyHealth Record system to be able to meet their e-PIP obligations. He claimed the health department had forged ahead with the reforms, going against advice from the sector. “There are glitches in software and the department of health says ‘it’s not our problem’ and people should take it up with their provider. It’s appalling,” Dr Morton added. Dr Nathan Pinskier, chair of the RACGP expert committee for eHealth and Practice Systems, estimated that fewer than 100 practices were likely to miss out on the PIP because they had not upgraded to the latest software or ensured they had installed ‘NASH certificates’. Medical Software Industry Association of Australia said it was not aware of any vendors whose software was still unable to upload clinical records to the MyHealth Record. Tessa Hoffman

Once daily1

This boy is more likely to be bullied

Fast results.† ‡ Lasting control.1,3–5 Proven for acne.

Than this boy 2

Reductioons in total lesion coount as early as weeek 1 with Epiduo® Gel vs adappaleene, benzoyl peroxide and vehicle (all at least p<0.005).1,1,44

Cliiniccally significant reductions in total lesionn count susttainned to 1 year.1,15

Before prescribing, please review the PBS and Product Information available in the primary advertisement of this publication. EPIDUO Gel Product Information (7 August 2014). 2. Ayer J and Burrows N. Postgrad Med J 2006; 82: 500–506. 3. Thiboutot D et al. J Am Acad Dermatol 2009; 60: S1–S50. 4. Thiboutot D. J Am Acad Dermatol 2007; 57: 791–799. 5. Pariser D et al. J Drugs Dermatol 2007; 6: 899–905. ®Registered trademark of Galderma Australia Pty Ltd. ABN 12 003 976 930. 13B Narabang Way, Belrose, NSW 2085. EPI/019/0316. McCann Health EPI0028. Date of preparation May 2016. NOT A REAL PATIENT, MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY. INDIVIDUAL RESULTS MAY VARY.

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New mums turning to Dr Facebook MICHAEL WOODHEAD PREGNANT women and new mums are turning to Facebook mothers’ groups for medical information, but the advice they get may be inaccurate or even dangerous, a study shows. Peer-to-peer sharing of health information is a growing trend on social media and many women are using Facebook mothers’ groups as a source of support and advice, according to Sarah Smith, a pharmacist at Calvary Hospital, ACT. In a study of 680 healthrelated posts on local Facebook mum’s groups, Ms Smith and colleagues found

One in 50 of the [Facebook] responses included advice that would be harmful if followed.

that the healthcare advice provided was predominantly anecdotal and one in five responses was inaccurate. Advice was sought mostly

for treatment for coughs and colds in infants (31%), teething (8%) and nappy rash (7%). Medication discussions related most often to anal-

gesics (36%), cough and cold treatments (20%) and antibiotics (8%). However, women who sought healthcare information online were seldom

advised to check with their GP or another health professional and there were few referrals to reputable online sources of health information. And worryingly, one in 50 of the responses included advice that would be harmful if followed. “This project highlighted that there is a definite need for healthcare professionals to provide clear direction on where new parents and pregnant women can access reputable, referenced and appropriate advice, particularly online,” the researchers concluded in their presentation to the National Medicines Symposium held

by NPS MedicineWise in Canberra last week. Ms Smith said parent groups have always been a great source of support for new parents, but the trend to use online platforms such as Facebook groups raised concerns about misinformation being shared in regard to medications and immunisations for babies and infants. “There are some fantastic, online, ‘consumer-friendly’ resources regarding these issues. “The websites of some of the big children’s and maternity hospitals are a great place to start,” she told Australian Doctor.

Panadol Osteo delisting may encourage opioid use THE higher cost of Panadol Osteo after PBS delisting may encourage a shift to stronger opioid analgesics, a study suggests. Patients with osteoarthritis who take extended-release paracetamol (665mg) are more likely to stay on the medication and less likely to progress to opioid analgesics (4.2% vs 7.3%) compared with users of regular paracetamol, an analysis of PBS data has shown. Researchers from the University of NSW said their findings, from a review of the paracetamol use of 46,255 patients between 2009 and 2011, showed that patients with osteoarthritis who used regular paracetamol were more likely to shift up the ‘analgesic pyramid’ to codeine and stronger opioids. “Patients may be less likely to move up the analgesic pyramid to use narcotic analgesics if they are prescribed extendedrelease paracetamol,” they concluded. Better analgesia and lower tablet burden with extendedrelease paracetamol might explain why patients were more likely to continue using

Telehospital cofounder Dr Jon Field says the service will never replace faceto-face consults.

Gold Coast specialists set up first ‘telehospital’ The Pharmacy Guild says removing Panadol Osteo from the PBS means patients are now paying 2-3 times more for the medication. the formulation compared with those using immediate release paracetamol products, they said. Panadol Osteo was removed from the PBS on 1 January and patients now have to buy the product over the counter. According to the Pharmacy Guild, the government costsaving measure meant many patients now have to pay two to three times more for the medication compared with when it was available on

prescription. Concession card holders had previously been able to get two packs for the price of $6.10 on prescription, but delisting and subsequent price increases means patients may now have to pay $12-20 for the same quantity, the Guild said. The study was funded by GSK, manufacturers of Panadol products. Michael Woodhead Australian Family Physician 2016; 45:321-25.

IN what is claimed to be an Australian first, Gold Coast specialists have set up a ‘telehospital’, which offers video consultations to patients anywhere in the country. The virtual hospital called Docto offers GP access to more than 50 specialists who cover the whole range of clinical areas usually found in a tertiary or teaching hospital, including dermatology, paediatrics, orthopaedics, dentistry and neurology. Medicare rebates for telehealth consults are claimable for GP-referred patients with an average gap fee of between $50 and $99, depending on the specialty, according to co-founder Dr Jon Field, director of intensive care at Gold Coast University Hospital. The service, which was set up in January, is already carrying out about six telehealth

consults a day on a mixture of patients, some referred by GPs and others who access the service through commercial arrangements, such as through a travel insurance firm. “Any doctor can refer, so a GP, whether urban or rural, can refer to us. They can ring up for advice on the management of a patient from a specialist and arrange referral and appointments for a video consult. Medicare rebates are paid for eligible patients. “While [Docto] will never replace a faceto-face consultation, we can get pretty close,” Dr Field said. The telehospital based at Gold Coast Private Hospital also offers 24-hour online emergency advice for private patients who pay a subscription. Carmel Sparke

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CONFERENCE & EXHIBITION 26–28 August 2016 | Brisbane Convention & Exhibition Centre

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6

| Australian Doctor | 27 May 2016

NEW at the Brisbane GPCE in 2016: Q Q NEW keynote sessions showcasing the industry’s top innovators & influencers Q Q Mental Health Skills Training (GPMHSC accredited) Q Q Exciting NEW Active Learning Modules – 40 Category 1 QI&CPD points Q Q MORE practical/surgical skills-based sessions

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AMGPR0086_AD_REV

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1

2016-04-28T16:08:06+10:00

SHE’S PROLIA PROTECTED

®

*

*Prolia®

reduces the risk of osteoporotic fracture compared with placebo1–3

onthly m 6-

confiden ce

1–

3

With demonstrated reductions in fracture risk compared with placebo,

1–3

you can feel confident that each dose of Prolia offers 6 months of protection. ®

PBS Information: Authority required (STREAMLINED) as treatment for osteoporosis. Refer to PBS Schedule for full information.

Before prescribing please review the full product information available from www.amgen.com.au/Prolia.PI For information on Prolia® or to report an adverse event involving Prolia® please contact Prolia® Medical Information on 1800 646 998. PROLIA MINIMUM PRODUCT INFORMATION. INDICATIONS: Treatment of osteoporosis in postmenopausal women to reduce risk of vertebral, non-vertebral and hip fractures. Treatment to increase bone mass in men with osteoporosis at increased risk of fracture. CONTRAINDICATIONS: Hypocalcaemia. Hypersensitivity to denosumab, CHO-derived proteins or any component. Pregnancy and in women trying to get pregnant. PRECAUTIONS: Correct hypocalcaemia prior to initiating therapy. Monitor calcium in patients predisposed to hypocalcaemia. Adequate intake of calcium and vitamin D is important. Evaluate patients for risk factors for osteonecrosis of the jaw (ONJ); use with caution in these patients. Very rare reports of atypical femoral fractures. ADVERSE EFFECTS: Hypocalcaemia, skin infections (predominantly cellulitis) and pancreatitis. DOSAGE AND ADMINISTRATION: Single subcutaneous injection of 60 mg, once every 6 months. Ensure adequate intake of calcium and vitamin D. No dose adjustment required in the elderly or in renal impairment. PRESENTATION: Pre-filled syringe with automatic needle guard. References: 1. Prolia® (denosumab) Approved Product Information, available at www.amgen.com.au/Prolia.PI. 2. Cummings SR, et al. N Engl J Med 2009;361:756 – 65. 3. Papapoulos S, et al. Osteoporos Int 2015;26:2529–58. Prolia® is a registered trademark of Amgen. Amgen Australia, Level 7, 123 Epping Road, North Ryde, NSW 2113, ABN 31 051 057 428. www.amgen.com.au. AUS4525 – Approved April 2016. S&H 04/16 AMGPR0086_AD_FP

AMGPR0086_AD_FP_400x280_[f2].indd 1

4/28/16 3:56 PM


AD_008___27MAY_16

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2016-05-20T16:30:18+10:00

News

Two in the race for that other election TESSA HOFFMAN TWO specialists will fight it out to become the new AMA president later this month. Federal AMA vice-president Dr Stephen Parnis and WA AMA president Dr Michael Gannon are standing, with the election to be decided in a poll on 29 May. Dr Parnis, a consultant emergency physician at St Vincent’s Hospital in Melbourne, has said if elected

he would lobby to shore up the medical workforce pipeline and for improvements to e-health. “Too often, those whose agenda is to shirk responsibility for health misrepresent the facts about our health system, and seek to vilify our profession,” Dr Parnis said. “Task substitution, unnecessary medical schools, and the misrepresentation of medical com-

plications as mistakes are obvious examples.” Meanwhile, Dr Gannon, head of the department of obstetrics and gynaecology at St John of God Hospital in Perth, said he would lobby government to outlaw ‘junk’ private health insurance policies, fight for better funding for public hospitals and champion general practice. “The AMA needs strong leadership with an appetite

to engage constructively with government, whichever political party is in power. “There are currently reviews into the MBS, private health insurance and primary healthcare underway. “It is vital that the profession has a strong voice in Canberra, and is willing to embark on constructive interaction with government in responding to the recommendations that these reports

will inevitably include.” The role of vice-president will go to one of two GPs: Dr Tony Bartone and Dr Brian Morton. Melbourne GP Dr Bartone is a former AMA Victoria president. Dr Morton is the current chair of the AMA council of general practice. The winners will be announced at the AMA national conference in Canberra.

In Brief Staff writers Pay-for-performance fails chronic care SEVEN years of GP payfor-performance has failed to significantly reduce mortality rates for chronic diseases in the UK, a study shows. Researchers looked at a composite outcome of deaths from conditions attracting payments, including ischaemic heart disease, hypertension, stroke, diabetes, asthma and COPD. The UK’s Quality and Outcomes Framework was associated with a reduction of 3.68 deaths per 100,000 population — a nonsignificant outcome. The “apparent failure” to reduce mortality might be because financial incentives are not useful to reduce population health. It could also lie with the design of the UK system, the authors said. Lancet 2016; online.

Children’s liquid Panadol recalled

ENLIVA is a once-a-day active supplement supplemen that may help maintain normal cholesterol cholestero levels with in healthy individuals when combined wit diet and lifestyle. Always read the label. Use only as directed. If symptoms persist consult your healthcare professional. ENLIVA contains Lactobacillus Plantarum (AB-LIFE) 1.2 billion CFU. May assist in the maintenance of normal/healthy cholesterol levels in healthy individuals. May help to reduce intestinal absorption of cholesterol from dietary sources. BGP Products Pty Ltd. trading as Mylan EPD. ABN 29 601 608 771. 299 Lane Cove Road, Macquarie Park NSW 2113. Ph: 1800 225 311. ENLIVA is a registered trademark. AU-ENL-2015-2. Date Prepared: April 2015. ABB3136/AD

8

| Australian Doctor | 27 May 2016

www.australiandoctor.com.au

THREE batches of children’s Panadol 5-12 years colour-free suspension medicines have been recalled by the TGA because of a low risk of an allergic reaction. An ingredient used may have been contaminated with small particles. The expiry date for each of the products, which come in 200mL bottles, is February 2018. The batch numbers are 136418 (strawberry flavour), 136444 (strawberry flavour) and 136443 (orange flavour). CORRECTION: The article ‘Big Food Battler’ (page 10, Australian Doctor, May 20) said the Australian Food and Grocery Council had claimed the cost of implementing the government’s star rating system was $700 million. This was incorrect; the figure the council used was $200 million.


292325_KOMBIXR431944_2016_BRAND_ADMR_FP_HR

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2016-04-18T12:07:35+10:00

HbA1c CONTROL

1–3^

Sustained HbA1c lowering over 2 years in type 2 diabetes patients not adequately controlled on metformin alone1–3*†

^

Saxagliptin 5mg and metformin IR administered as separate components. †Comparable glycaemic control has been demonstrated between metformin IR and metformin XR.4 Bioequivalence of Kombiglyze® XR with coadministered saxagliptin and metformin XR tablets has been demonstrated.1

*

XR CONVENIENCE

1#

#

Once-daily DPP4i+METFORMIN XR combination1

NOW PBS LISTED FOR

TRIPLE THERAPY

WITH SU5

Streamlined Authority Code Dual oral combination therapy: 5761. Streamlined Authority Code Treatment phase continuing: 5762. Streamlined Authority Code Triple oral combination therapy with a sulfonylurea: 5705. Refer to PBS Schedule for details of full PBS listing.

PBS Information: Authority Required (STREAMLINED). Type 2 diabetes. Refer to PBS Schedule for full Authority Required Information. WARNING: Life-threatening lactic acidosis can occur due to accumulation of metformin. The main risk factor is renal impairment, other risk factors include old age associated with reduced renal function and high doses of metformin above 2 g per day.

treatment with Kombiglyze XR ); renal impairment – assessment of renal function is recommended prior to initiation and periodically thereafter ( discontinue treatment if evidence of renal impairment is present ); change in clinical status in previously well controlled patient; impaired hepatic function; administration of iodinated contrast agent; hypoxic states; surgery; vitamin B12 levels; alcohol intake; *hypoglycaemia when used in combination with SU or insulin; *arthralgia ( continuation of therapy should be individually assessed in severe cases ); pregnancy ( category C ); lactation; use in elderly; not for use in children ( see full PI ). INTERACTIONS: Saxagliptin: No clinically significant interactions observed with metformin, glibenclamide, pioglitazone, digoxin, simvastatin, diltiazem, ketoconazole, rifampicin, omeprazole, aluminium hydroxide + magnesium hydroxide + simethicone, famotidine, or an estrogen /progestin oral contraceptive ( see full PI ). Metformin: Careful patient monitoring and dose adjustment of metformin and /or the interfering drug is recommended in patients who are taking cationic medications ( eg. amiloride, digoxin, morphine, procainamide, quinidine, quinine, ranitidine, cimetidine, triamterene, trimethoprim, or vancomycin ) that are excreted via the proximal renal tubular secretory system ( see full PI ). ADVERSE REACTIONS: Hypoglycaemia, URTI, urinary tract infection, headache, *hospitalisation for heart failure, sinusitis, gastroenteritis, vomiting, nasopharyngitis, abdominal pain, rash, blood creatine phosphokinase increased, hypertrigyceridaemia, anaemia, depression, anxiety, *hypertension; mild gastrointestinal symptoms, bronchitis, dyspepsia, back pain, peripheral oedema when used with TZD, taste disturbance; others see full PI. Post marketing experience: Acute pancreatitis, *arthralgia and hypersensitivity reactions with saxagliptin. DOSAGE AND ADMINISTRATION: One tablet ( 5mg / 500mg or 5mg /1000mg) or two tablets 2.5mg /1000mg once daily with the evening meal with gradual dose titration to reduce gastrointestinal side effects associated with metformin. For initial combination therapy start with one tablet 5mg / 500mg once daily. Patients with inadequate glycaemic control on this starting dose should further have their metformin dose increased to one tablet 5mg /1000mg or two tablets 2.5mg /1000mg once daily. The maximum dose is 5mg / 2000mg taken as two 2.5mg /1000mg tablets once daily. Tablet must be swallowed whole, and never crushed, cut, or chewed. PRESENTATION: KOMBIGLYZE XR 5mg / 500mg ( light brown ), 5mg /1000mg ( pink ) are available in blister packs of 7 and 28 tablets, KOMBIGLYZE XR 2.5mg /1000mg ( light yellow ) are available in blister packs of 14 and 56 tablets. DATE OF FIRST INCLUSION IN THE ARTG: 10 October 2013. DATE OF MOST RECENT AMENDMENT: 26 October 2015.

BEFORE PRESCRIBING PLEASE REVIEW FULL PRODUCT INFORMATION AVAILABLE ON REQUEST FROM ASTRAZENECA *Please note changes in Product Information. ON 1800 805 342 OR www.astrazeneca.com.au/PI HbA = haemoglobin A ; DPP4i = dipeptidyl peptidase- 4 inhibitor; SU = sulfonylurea; XR = extended release KOMBIGLYZE® XR ( saxagliptin /metformin hydrochloride extended release ). INDICATIONS: As an adjunct to diet and exercise to improve glycaemic control in adults with type 2 diabetes mellitus when treatment with both saxagliptin and metformin is appropriate. CONTRAINDICATIONS: A history of a serious hypersensitivity reaction to any DPP- 4 inhibitor. Hypersensitivity to the active substances or to any of the excipients of Kombiglyze XR; diabetic ketoacidosis, diabetic pre- coma; moderate or severe renal impairment ( creatinine clearance < 60 ml /min ); acute conditions with the potential to alter renal function; acute or chronic disease which may cause tissue hypoxia; during or immediately following surgery where insulin is essential, elective major surgery; hepatic impairment; acute alcohol intoxication, alcoholism; lactation. PRECAUTIONS: Not for Type 1 Diabetes or diabetic ketoacidosis. Has not been studied in combination with GLP-1 agonists. Lactic acidosis; serious hypersensitivity reactions; acute pancreatitis ( discontinue

1c

1c

References: 1. KOMBIGLYZE ® XR Approved Product Information. 2. DeFronzo RA et al. Diabetes Care 2009; 32:1649 –1655. 3. DeFronzo RA et al. Diabetes Care 2009; 58:A147, Abstract 547- P. 4. Fujioka K et al. Clinical Therapeutics 2003; 25 ( 2 ):515 – 529. 5. Pharmaceutical Benefits Scheme at www.pbs.gov.au. KOMBIGLYZE ® XR is a registered trademark of the AstraZeneca group of companies. Registered user AstraZeneca Pty Ltd. ABN 54 009 682 311. 5 Alma Road, North Ryde, NSW 2113. AstraZeneca Medical Information: 1800 805 342. 431944.022. WL292325. April 2016.


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News

No more 24-hour RNs in aged care

Australian Doctor: Last year, a NSW Parliamentary inquiry said 24-hour, highquality care was essential for this very frail and complex patient group. Are you worried that quality will fall without guarantees that RNs are staffing facilities? Jillian Skinner: No I’m not, because no other state or territory has an equivalent regulatory requirement for RNs. And there’s no evidence that there is a drop in

10

| Australian Doctor | 27 May 2016

standards or outcomes for those residents. One of the things we had to consider was the potential impact on smaller facilities where they’d have to close because they could not afford to undertake this regime. This is so particularly for facilities in country areas where there’s not a high acuity, but they’d have to put an RN on duty when they are not necessarily needed. But without these

Photo: Newspix

The NSW Government has been criticised for abandoning rules that require registered nurses to staff high-need residential aged care centres around the clock. Here, Health Minister Jillian Skinner responds to claims that the move will put some of the most complex patients in the health system at risk.

rural facilities, in some cases you’d have residents separated from their families and social networks by hundreds of kilometres. AD: How do you ensure aged care operators don’t simply cut staff to save money and thereby compromise patient care? JS: The regulation of aged care is the Commonwealth’s responsibility. Under the Quality of Care Princi-

ples and Aged Care Funding Instrument, the level of nursing experience is tailored to meet the needs of the person, and certain complex care needs must be managed by a registered nurse. AD: GPs working in aged care say they will be less inclined to prescribe “as needed” pain or sedative medications because they can’t be sure there’s an RN to administer them.

www.australiandoctor.com.au

JS: If you can demonstrate to me where in any other state this has been a problem, fine, but we’ve not found one. NSW Health has been conducting a consultation process to update the Poisons and Therapeutic Goods Regulation, which regulates medication management in aged care facilities. It is proposed that while not requiring an RN on hand 24/7, nurses will need to ensure the facility complies with the safe and appropriate use of medicines. AD: Without RNs, surely you would have more ambulance call-outs and patients taken into EDs? JS: There is evidence to show that having a registered nurse on duty 24/7 does not actually decrease the rate of hospitalisation for residents. An unexpected accident can happen anywhere, and an enrolled nurse would respond in the same way as

a registered nurse and seek medical assessment. Programs such as Geriatric Rapid Acute Care Evaluation in Hornsby have worked. The emergency department there has formed a relationship with 70 or 80 nursing homes now where they provide backup and advice. In Sutherland, the Geriatric Flying Squad has prevented 370 hospital presentations each year. AD: For patients with high rates of dementia, are RNs not necessary to pass on important clinical information to GPs or emergency services? JS: Enrolled nurses are able and qualified to provide an adequate clinical handover where a registered nurse is not present. NSW Health has strategies in place to share hospital discharge summaries with both GPs and MyHealth Record. Ms Skinner spoke with Mic Cavazzini.


SPO0013_AusDoc_Root

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1

2016-05-16T16:23:13+10:00

W TED NO LIS S PB

SPIOLTO Respimat : An advance in COPD care built on the strong roots of SPIRIVA (tiotropium) ®

®

®

‡1-4

110mL improvement in FEV1 AUC(0-24) response at 6 weeks vs SPIRIVA Respimat (p<0.0001)1,2 ‡ Over 100 clinical trials and over 13 years of prescribing experience in Australia3,4

NEW ONCE DAILY 1

VISIT LUNGLEARNING.COM.AU FOR MORE INFORMATION PBS information: Authority required (STREAMLINED) Code 5763. Chronic obstructive pulmonary disease (COPD). Refer to PBS schedule for full authority information.

Please review Product Information before prescribing. Full Product Information is available at www.boehringer-ingelheim.com.au/PI. Further Information is available from Boehringer Ingelheim Pty Ltd. SPIOLTO® RESPIMAT® 2.5 micrograms/2.5 micrograms [tiotropium (as bromide monohydrate)/olodaterol (as hydrochloride)] solution for inhalation. INDICATIONS: Once-daily maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). CONTRAINDICATIONS: Hypersensitivity to tiotropium, olodaterol, atropine or its derivatives, or to any of the excipients. PRECAUTIONS: Should not be used: more frequently than once daily; in treatment of asthma (LABAs may increase the risk of asthma-related hospitalisations and death); acute episodes of bronchospasm, or initiated in acutely deteriorating COPD. Immediate hypersensitivity reactions, paradoxical bronchospasm, narrow-angle glaucoma, prostatic hyperplasia, bladder-neck obstruction, severe hepatic impairment, moderate to severe renal impairment (CrCl ≤ 50 mL/min), cardiovascular disorders, convulsive disorders, thyrotoxicosis, QT interval prolongation, unusual responsiveness to sympathomimetic amines; increases in pulse rate, blood pressure and/or symptoms of clinically significant cardiovascular effect, myocardial infarction within past year, unstable or lifethreatening cardiac arrhythmia, hospitalisation for heart failure within past year, paroxysmal tachycardia (>100 beats per minute), hypokalaemia, hyperglycaemia, pregnancy, lactation, children. Avoid solution or mist entering eyes. INTERACTIONS: Co-administration with other anticholinergics, adrenergic agents, xanthine derivatives, steroids, non-potassium sparing diuretics, beta-blockers, MAO inhibitors, tricyclic antidepressants, QTc interval prolonging drugs, LAMAs, LABAs. ADVERSE EFFECTS: Very common: nasopharyngitis. Common: pneumonia, bronchitis, influenza, urinary tract infection, sinusitis, cough, dyspnoea, back pain, dry mouth. Others, see full PI. DOSAGE: For oral inhalation. 5 μg tiotropium and 5 μg olodaterol given as two puffs once daily, at the same time each day. Do not exceed recommended dose. Cartridges to be used only with SPIOLTO RESPIMAT inhaler. August 2015. References: 1. SPIOLTO Respimat approved Product Information (10 June 2015). 2. Beeh KM et al. Pulm Pharmacol Ther 2015; 32: 53 –59. 3. National Institutes of Health. Tiotropium in COPD patients. Available from www.clinicaltrials.gov/ct2/results?term=%22tiotropium%22+AND+%22COPD%22&Search=Search (last accessed 4 December 2015). 4. SPIRIVA HandiHaler approved Product Information (22 May 2015). ® Registered trademark. Boehringer Ingelheim Pty Ltd. ABN 52 000 452 308. 78 Waterloo Road, North Ryde, NSW 2113. McCann Health SPO0013. AUS/SPRES-151171a. JANUARY 2016.


22676

Maxigesic

AD

Full page

F

HR

-

1

2015-06-15T11:51:02+10:00

WHY EVERY DOCTOR

SHOULD MAKE THE SWITCH TO MAXIGESIC

®

Pain scores at rest: (mm VAS score)

Maxigesic Ibuprofen# Paracetamol#

Clinically proven to reduce pain levels by at least 32% more than a full daily OTC dose of either Paracetamol or Ibuprofen alone.1

Hours post-surgery Ibuprofen 1200mg/day or Paracetamol 4000mg/day in 4 divided doses.

#

}PROVEN EFFECTIVENESS IN DENTAL STUDIES

Ref 1

} DELIVERS MAXIMUM DOSAGE MAXIGESIC® is the only combination analgesic that delivers the maximum recommended daily OTC dose of Paracetamol 4000mg and Ibuprofen 1200mg, if required.* }SIMPLE, FLEXIBLE DOSAGE REGIMEN 1–2 tablets up to 4 times per day, if required, offers flexibility and control in managing daily pain. * 2 tablets of MAXIGESIC® taken every 6 hours over a 24 hour period

Please review the full Product Information before recommending at www.maxigesic.com.au

HARTLEY ATKINSON, Pharmacologist and Inventor of MAXIGESIC®

DOUBLE ACTION PAIN RELIEF WITHOUT CODEINE References: 1. Merry, A. F., Gibbs, R. D., Edwards, J., Ting, G. S., Frampton, C., Davies, E. and Anderson, B. J. (2010). “Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial” British Journal of Anaesthesia 104(1): 80-88. Result achieved in a trial of post-operative pain relief after removal of 1–4 wisdom teeth using Maxigesic® compared with Paracetamol 4000mg or Ibuprofen 1200mg alone per day in four divided doses. Maxigesic® film coated tablets (Paracetamol 500mg and Ibuprofen 150mg; 10s, 16s and 30s) are a Pharmacist Only (S3) Medicine for the temporary relief of pain and reduction of fever. The usual dosage for Adults and Children over 12 years is 1-2 tablets taken every 6 hours with a full glass of water, as required, up to a maximum of 8 tablets in 24 hours. Patients should not take more than 8 tablets in a 24 hour period. Incorrect use can be harmful. Do not use in children under 12 years or if patients have kidney disease. Do not use if patients have asthma or a stomach ulcer. Do not combine with any other Paracetamol or Ibuprofen containing medicines. Patent No. 2005260243.

AFT Pharmaceuticals Pty Ltd | Sydney | ABN 29105636413 | WEBSITE www.aftpharm.com FREE PHONE 1800 2387 4276 | FREE FAX 1800 041 026 | EMAIL customer.service@aftpharm.com


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2016-05-19T16:49:20+10:00

News Review

The big freeze: GPs respond Last week, Australian Doctor surveyed GPs on their response to the Federal Government’s pledge to extend the Medicare freeze. Here is what you said.

I PAUL SMITH

IF you are thinking about an election strategy to gently sail your party ship to victory, it may not be the best idea to suddenly start firing broadsides at the much-loved system meant to provide patients universal access to medical care. But that is what Prime Minister Malcolm Turnbull did with his Budget promise to extended the Medicare rebate freeze into the next decade. There has been a heated political row during the election campaign on its likely effects — whether bulk-billing will collapse, whether patients will walk away from GP care, whether Medicare itself is doomed. Here, we offer the views of doctors on the frontline. Half believe bulk-billing will collapse, half believe practices in poor communities will become unviable. Australian Doctor also asked GPs to describe their reaction when they heard the freeze would be extended. We print here just a small selection of the 430 comments you made. cont’d next page

10%

34%

Privately bill all/ vast majority of patients

Bulk-bill all patients

Demographic Female: Male:

32% 68%

GP: GP registrar:

91% 9% (n=510)

What are your current billing arrangements?

36%

Mixed billing

Do you support the Federal Government’s decision to extend the rebate freeze to 2020? Yes: No: Don’t know:

20%

Bulk-bill children and concession cardholders only www.australiandoctor.com.au

2% 92% 6%

In response to the rebate freeze, within the next 12 months, I will:

18% Leave my billing unchanged

37% Increase/introduce fees for all patients

29% Increase/introduce fees for all patients except children or concession cardholders

0% Reduce my fees

15% Yet to decide 27 May 2016 | Australian Doctor |

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News Review “Frustrating and seems like deranged priorities — taking money from health and education while spending it on useless, expensive military equipment, and housing people in inhuman off-shore detention centres.”

“No surprise, when bulk-billing rates are so high.”

“Outrageous and incredibly naive. It’ll just shift the problem to the hospital system at a vastly higher cost, which primary care/ preventative care could have contained.”

What will be the main effects of the extended Medicare freeze on general practice (you can choose more than one)? Nothing

“The government is taking a lend of the good nature of GPs who try to do the best for their patients. They are cost shifting an expense onto our shoulders, and want the complaints to be against us … It is another way of devaluing our community service.”

5%

GP bulk-billing rates will collapse

“I do not bulk-billl and this freeze reinforces my desire to be uncoupled from the shackles of Medicare.”

51%

Increased co-payments will allow GPs to substantially improve care

20%

GP practices in poor communities will close

56%

Health of vulnerable patients with significant needs will be badly hit

57%

Significant increase in ED presentations Other

“Astounded that the government would choose to damage the most cost-effective part of the health system.”

62%

Significant increase in avoidable hospitalisations

66 %

“I am very angry, disappointed and disillusioned. As a lifelong Liberal voter, this is the final straw.”

49%

Significant fall in the quality of care GPs can offer

“Gutless attempt to introduce co-payment.”

“Good thing. Patients should have to pay. This stops doctors taking advantage of the Medicare system. Medical services should never be cheaper than a haircut.”

66% 12%

“It had to occur — bulk-billed medicine is a scam.”

My average out-of pocket fee: now vs next 12 months (% of GPs)

“Inexperienced political decision without involving people at a grassroots level. To make any economy sustainable, you need to make the primary and preventive healthcare strong, rather than pumping money to tertiary care.”

“Angry that government feels they can walk all over GPs again and again and not expect a backlash. Angry at the intention to dismantle Medicare.” 33

22

15

5 5

6 1

< $5

Zero

NA

$35

$15-25

2

Average out-of-pocket fee for concessional/child patients:

3

5

14 10

6

5

NA

7

“I would like all GPs to form a united front — to increase fees as a general rule or to strike. It seems that drastic measures are the only ones that the government will take notice of.”

20

$35

5

21

$25-35

7

12

$15-25

5

$10-15

3

$5-10

< $5

Zero

2

4

10

9

$10-15

10

9

$5-10

13

$25-35

“Attempted destruction of the social fabric that keeps Australia a fair, just and safe place to live.”

“Absolute shock ... Who else in the current workforce would tolerate a wage freeze, especially when doctors have to add on all the extras costs — bandages, dressings ointments — at no cost to a patient.”

10

30 %

“I have already had to close my long-running practice and join a group to keep my head above water.”

“Horrified and concerned at the effect this decision may have on the long-term viability of Aboriginal Health Services.”

“I want to retire as I can no longer practise what I believe in: good quality universal healthcare for all.”

Average out-of-pocket fee for non-concessional patients:

Now

Now

The next 12 months

The next 12 months

In the federal election, which party will you vote for? Coalition: Labor Party: Greens: Nationals: Other party: I will not vote: No answer:

16% 20% 13% 8% 12% 8% 29%

To find your new role today visit

Jobs for people who care 14

| Australian Doctor | 27 May 2016

www.australiandoctor.com.au


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2016-05-19T10:36:31+10:00

Smart Practice Tech Talk Carmel Sparke

Hippocrates wasn’t mum on smartphones

Physician, exercise yourself PRACTICE PEARLS

Why not give it a go? You have nothing to lose but your expanding waistline. DR JOHN JORY

I

REMEMBER a joke from the Sydney University medical school magazine around 1968: “I went to my 40-year reunion the other night.” “How did you find it?” (Disconsolate): “They were all so old and fat and bald that they didn’t recognise me.” In February, I attended my 45th reunion, and couldn’t help but reflect constantly over the evening on the veracity of the above joke. Five years ago, at our 40th, almost everybody was more or less recognisable. This time round, however, it was as if most of my year mates were made of wax and, in the ensuing five years, somebody had cranked up the heat and they’d started to melt. Also in my student years, I would occasionally visit Uncle Bill at Miranda. Because I was a medical student, he took it for granted that I would be as interested in his health as he was, which explains why my visits were only occasional. “He told me to stop smoking and lose some weight,” he snarled, bristling with indignation, during yet another detailed, lengthy and convoluted tale of his latest visit to the doctor. “And there he was, the big fat slob, sitting there, smoking a cigarette and telling me what I should be doing.” At the time, I felt inclined to point out that he was seeking

health advice from his doctor, and not the other way round. A few decades of counselling, however, have taught me that there are no absolute rights or wrongs, only contexts. If I had been counselling my uncle, I would indeed have pointed out that he was there to seek the doctor’s advice not to follow his lifestyle. If I had been counselling the doctor, however, I would have asked him how he could feel comfortable being the very antithesis of

These latter months in which I have been contributing articles to Australian Doctor are not the first time I have appeared in its pages. Back in 2007, I actually made the front page. After the killing of Dr Khulod Maarouf-Hassan in her surgery by a deranged patient, the intrepid sleuths at Australian Doctor tracked me down because I have a black belt in martial arts and interviewed me on the desirability of doctors learning self-defence. As a result of this, I spent a con-

What can you, as a busy GP, do to be an example to your patients and an asset to yourself? the model he was proposing to the patient. Can’t we see that being role models for our patients would not only give us far more credibility with them, but would also be best for our own health and wellbeing? The physical deterioration of so many of my colleagues as they passed the 65-year mark was a clear indication that meaningful exercise was a foreign concept to far too many. Why do we, as doctors, let ourselves and our patients down by not taking care of our own health and wellbeing?

siderable amount of my spare time organising self-defence courses for doctors. Before Dr Maarouf’s death I was aware of three doctors practising martial arts in Victoria. Afterwards, I was aware of three doctors practising martial arts in Victoria. When I advise my patients on exercise programs, I do so from an experiential base, which gives me practical knowledge and credibility. I couple this with dietary advice for which I am a living, breathing advertisement. Unsurprisingly, a disproportionwww.australiandoctor.com.au

ately large number of my patients heed my warnings, follow my advice and change their lifestyles. What can you, as a busy GP, do to be an example to your patients and an asset to yourself? • Prioritise exercise. The moment you start to believe your own excuses for not exercising, you are lost. • Make an external commitment to an exercise schedule. If exercising by yourself at home worked, the garages of the world wouldn’t be filled with exercise bikes, rowing machines and other such useless middle-class clutter. Most people need a group, a class or a trainer. • Walking is the healthiest means of transport to carry you from where you are to where you are going to do some exercise. Walking is not sufficient exercise. If you kid yourself or your patients that it is, you are doing both of you a grave (excuse the pun) disservice. The same goes for golf. • Exercise programs such as tai chi, badminton, swimming, ballroom dancing and Zumba are valid. Forget your know-all doctor nonsense and realise that, at the beginning of any exercise program you are just an unskilled, uncoordinated klutz, just like everybody else. Why not give it a go? You have nothing to lose but your expanding waistline. ● Dr Jory is a GP, psychotherapist, sociologist and social commentator in Melbourne, Vic.

SMARTPHONES may have been a couple of millennia in the future, but Hippocrates might well have imagined their role in a consult. Writing about 2500 years ago, the Greek physician said: “Any man who is an intelligent being must … be able to understand and judge what physicians say and what they administer to his body, being versed in each of these matters to a degree reasonable for a layman.” He could have been describing the parents of a sick child, arriving at their consultation with you, armed with links to online information. While an internet-informed parent can at times be challenging, they also present opportunities, says New Zealand social worker and academic Dr Andrew Thompson, who quoted the father of medicine in a recent journal article titled Hippocrates and a Smartphone: Exploring the Evolving Doctor and Parent Relationship. According to Dr Thompson, information technology has revolutionised healthcare and this is having a profound impact on the parent–doctor relationship. A growing body of literature suggests parents are being transformed from passive recipients to active participants in the diagnosis and treatment of their child’s complex health conditions. It also means there are now not just two opinions in the room — the parent and the doctor — but also sometimes a third, Dr Google. While this can sometimes speed up diagnostic processes, improve patient outcomes, compliance and information exchange, it also has a downside. Not only do patients present information from dubious sources, but they also want to discuss it — at length — during the consultation. Happily, most studies suggest that parents turn to the internet not because they don’t trust their doctor, but because they want additional information. As parents become better informed about their child’s health, they start to form a collaborative relationship with their doctors. Overall, Dr Thompson views the internet as a useful development, notwithstanding a special band of worried parents you’ve probably already encountered in your practice. “If smartphones were available to Hippocrates, would he have encouraged his patients to use one? I suggest that he would, with some reservations about the impact of cyberchondria,“ he concludes. Ms Sparke is a freelance medical journalist. Reference on request.

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Grand Rounds

A rare complication THE AUTHOR This article is reproduced with permission from the Lancet. For the full article, please see: bit. ly/1TjrJrW

ENT

An elderly patientâ&#x20AC;&#x2122;s rhinosinusitis heads in a potentially fatal direction.

A

PREVIOUSLY healthy 75-year-old woman presented with a 10-day history of progressive headache, fatigue and fever, and gradual onset periorbital oedema and reddish chemosis of the left eye.

Examination

â&#x20AC;&#x153;

HAVE AN INTERESTING CLINICAL CASE?

Send it to grandrounds @cirrusmedia.com.au Photos are encouraged.

On examination, she was alert and oriented without obvious neurological abnormalities. She had normal visual acuity and light reflex bilaterally. Eye movement was restricted on upward gaze of the left eye due to the oedema but was otherwise normal. The patient denied rhinorrhoea but on nasal endoscopic examination in our otolaryngological clinic, we saw purulent discharge from the orifice of the left sphenoidal sinus. She had a raised white blood cell count, C-reactive protein and D-dimer. Contrast-enhanced CT of the paranasal sinuses and brain showed opacification of the left sphenoidal sinus, and filling defects of the left superior ophthalmic vein and cavernous sinus, which appeared as high-intensity signals on diffusionweighted MRI (see figure). No subdural abscesses or brain abscesses were

present. We diagnosed thrombosis of the cavernous sinus and left superior ophthalmic vein. We requested review from a neurologist, who pointed out mild nuchal rigidity. Examination of the cerebrospinal fluid showed raised polynuclear leucocytes and Streptococcus constellatus, and bacterial cultures from the blood and sphenoidal sinus also grew S. constellatus.

Treatment We drained the sphenoidal sinus via endoscopic endonasal surgery and started antibiotic treatment for six weeks and anticoagulation with unfractionated heparin for 11 days, followed by warfarin for seven weeks. The patient recovered well. At last follow-up 18 months after initial presentation, she was symptom-free.

Discussion Cavernous sinus thrombosis is an intracranial complication of rhinosinusitis. Other possible sources are facial skin infection or dental infection. The most common causative microorganism is Staphylococcus aureus, followed by Streptococcus milleri group comprising S. constellatus, S. intermedius and S. anginosus.

Figure 1: (A) Contrast-enhanced CT showing filling defects in the cavernous sinus (arrows). (B) Diffusion-weighted MRI showing high signal intensity in the cavernous sinus (arrows).

Members of this group have a propensity to form abscesses and cause invasive pyogenic infection. Typical symptoms and signs of cavernous sinus thrombosis include fever, ptosis, proptosis, chemosis, cranial nerve palsy, headache, periorbital swelling and papilloedema. The eye signs in our patient resulted from venous congestion caused by thrombosis of the cavernous sinus and connecting veins. Her headache was related to sphenoiditis and the

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Kids quiz Dr Paul Lang

The vomiting infant A SIX-week-old breastfed baby boy presents with a 1-2 week history of increasing vomiting. Vomiting is a common presentation

in the first few months of life, with a number of potential causes. Dr Lang is a GP at Adelaide Paediatrics, SA.

THE QUIZ

cavernous sinus thrombosis. Numerous conditions can cause similar symptoms and signs, and isolated sphenoiditis does not always have the typical nasal symptoms such as rhinorrhoea. High signal intensity on diffusion-weighted MRI and filling defects on post-contrast CT at the same site is characteristic of venous thrombosis, and bacterial culture from all possible sources should be sought, ideally before starting antibiotics. Aggressive multifaceted management is crucial.

Paranasal infection should be surgically drained and treated with broad-spectrum antibiotics. Heparin or warfarin are often given for anticoagulation, although evidence for efficacy is lacking and the role of this treatment is unclear. Rhinosinusitis is relatively common and physicians need to be aware of the potential consequences. A high index of suspicion and appropriate imaging studies are important for making an early and proper diagnosis. ●

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consequently, if it is likely there will be a benefit from medical imaging. In particular, the CDRs focus on: suspected lower limb DVT; suspected pulmonary embolism; acute lower back pain; and adult and paediatric ankle, cervical spine and head trauma. This very practical app is likely to improve GP confidence in not

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Q. Differential diagnoses may include: a. UTI b. Gastro-oesophageal reflux c. Pyloric stenosis d. Cows milk protein intolerance e. Gastroenteritis f. All of the above A. The answer is f. If recent weight measurements are available, these can be a useful adjunct to clinical assessment. In an otherwise systemically well baby with nonbilious vomiting and a normal examination, recent good weight gain is a reassuring finding. Q. Presuming this baby has uncomplicated gastro-oesophageal reflux, management may include: a. Feeding advice to prevent overfeeding b. Early introduction of solids from three months of age c. Trial of a proton pump inhibitor d. ‘Winding’ during feeds and positioning baby in an upright position after feeds e. Use of a feed thickener f. A 2-3 week trial of

avoiding cows milk products in the maternal diet (if reflux is moderately severe and associated with irritability) A. The answer is a, d, e and f. Q. Particularly concerning features on further history would include: a. Poor weight gain b. Vomiting up to 3-4 hours after the last feed c. Blood or bile-stained vomiting d. Bowels not open for five days e. Recurrent projectile vomiting f. Poor feeding/lethargy A. The answer is a, c, e and f. Weight loss suggests excessive fluid losses and dehydration. A vomiting baby presenting with any concerning features (as outlined above) or associated significant fever requires further investigation. Bile-stained vomiting warrants exclusion of gut obstruction. PPIs have not been proven to be of benefit for irritable babies with simple regurgitation.

Haematemesis, however, suggests oesophagitis and commencing omeprazole 5mg daily would be appropriate. Recurrent projectile vomiting in the above scenario at six weeks of age would raise the suspicion of pyloric stenosis. Q. Regarding clinical suspicion of pyloric stenosis, which of the following are true? a. No family history makes this unlikely b. Abdominal X-ray is the most appropriate first line imaging c. The finding of a hypokalaemichypochloraemic metabolic alkalosis would be supportive biochemical evidence d. Pyloric ultrasound in experienced hands is often diagnostic e. Conservative nonsurgical management will often lead to spontaneous resolution of this condition f. Weight loss or poor recent weight gain is often a presenting feature A. The answer is d and f.

Please review full Product Information before prescribing. Product Information is available from Galderma Medical Information ph: 1800 800 765. EPIDUO® Gel (adapalene 0.1% & Benzoyl peroxide 2.5%). Indication: Cutaneous treatment of acne vulgaris on the face, chest and back when comedones, papules and pustules are present, and the condition has not responded to first line treatment. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Precautions: For external use only. It should not be applied to damaged, broken or eczematous skin; should not come into contact with eyes, mouth, nostrils or mucous membranes. Epiduo contains propylene glycol (E1520) that may cause skin irritation. Avoid excessive exposure to sunlight. Epiduo may cause bleaching and discolouration. Refer to full PI. Use in pregnancy (Cat D): Should not be used during pregnancy or if pregnancy is planned during treatment. Use in lactation: Use caution and only on areas away from the chest. Interactions: None known; avoid concurrent use of retinoids, benzoyl peroxide and medicines with similar mode of action. Adverse effects: common (≥1%): dry skin, irritative contact dermatitis, scaling, desquamation, erythema and burning. For other effects (<1%), see full PI. Dosage and administration: Apply a thin film of gel to affected areas once a day on a clean, dry skin. Avoid eyes and lips. Presentation: 30g, 2g (sample) tubes; 30g bottle with pump. Store below 25ºC. S4. Based on approved PI dated: 7-Aug-2014. The full PI is available on request from Galderma Australia, 13B Narabang Way, Belrose, NSW 2085. Reference: 1. EPIDUO Gel Product Information (7 August 2014). ® Registered trademark of Galderma Australia Pty Ltd. ABN 12 003 976 930. 13B Narabang Way, Belrose, NSW 2085. EPI/019/0316a. McCann Health EPI0028. Date of preparation May 2016. Once daily1

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How to Treat www.australiandoctor.com.au

PULL-OUT SECTION

C COMPLETE HOW TO TREAT QUIZZES ONLINE www.australiandoctor.com.au/cpd to earn CPD or PDP points. w

INSIDE A useful developmental model Prevalence History-taking Nonpharmacological treatments Pharmacotherapy When to refer Case study

THE AUTHORS

INSOMNIA

DR ANUP DESAI senior staff specialist, department of respiratory and sleep medicine, Prince of Wales Hospital; medical director, Sydney Sleep Centre; consultant physician, Prince of Wales Private Hospital; clinical senior lecturer, faculty of medicine, University of Sydney; and conjoint senior lecturer, faculty of medicine, University of NSW, Sydney, NSW.

Introduction INSOMNIA is a distressing difficulty with sleep onset, sleep maintenance and/or early morning wakening, where the individual’s sleep is insufficient for their needs. These symptoms arise despite adequate time in bed to achieve sleep. Chronic insomnia is defined

as sleep difficulties being present for at least one month and occurring three or more times a week. Insomnia was previously defined as either primary (no other conditions deemed to be responsible for the poor sleep) or secondary (another disorder causally respon-

sible for the poor sleep). In practice, determining cause and effect is very difficult. Bidirectional or interactive effects between insomnia and certain coexisting conditions, such as depression, are now widely accepted. The DSM-5 has now removed the primary

and secondary causal attribution labels. ‘Insomnia disorder’ is now recognised as a condition requiring independent clinical attention, regardless of other medical problems that may be present. cont’d next page

Copyright © 2016 Australian Doctor All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the publisher. For permission requests, email: howtotreat@cirrusmedia.com.au

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ROSEMARY CLANCY senior clinical psychologist, the Sydney Clinic, and clinical psychologist, Sydney Sleep Centre, Sydney, NSW.

BEFORE PRESCRIBING PLEASE REVIEW PBS AND PRODUCT INFORMATION AVAILABLE IN THE PRIMARY ADVERTISEMENT IN THIS PUBLICATION OR ON REQUEST FROM ASTRAZENECA. KOMBIGLYZE® XR is a registered trademark of the AstraZeneca group of companies. Registered user AstraZeneca Pty Ltd. ABN 54 009 682 311.5 Alma Road, North Ryde, NSW 2113. AstraZeneca Medical Information: 1800 805 342. 426109.022. 13212. January 2016.

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How to Treat – Insomnia A useful developmental model for their sleep disturbance. When insomnia becomes chronic, the insomnia persists despite the trigger resolving (see perpetuating factors).

THE ‘three Ps’ model is useful to help understand the development and persistence of insomnia. The three Ps stand for predisposing, precipitating and perpetuating factors.

Perpetuating factors

Predisposing factors

These are factors that maintain or even exacerbate the problem, for example, heightened anxiety/arousal levels or the development of depression. Other perpetuating factors include behaviours or coping strategies, such as napping during the day or spending excessive amounts of time in bed. With ongoing perpetuating factors, insomnia becomes learned over months and years, even though the initial stressor that may have been involved in its development has disappeared.

A predisposing factor does not cause a problem, but may increase the likelihood of it occurring. Such factors could include a family history of poor sleep, being a ‘worrier’ or never being a ‘good sleeper’.

Precipitating factors These are triggers and may include acute stress/grief, lifestyle changes, the development of an illness or the birth of a baby. Many patients with insomnia can identify a trigger

Prevalence INSOMNIA is the most commonly reported sleep disorder. Prevalence rates range from 4-48%, depending on the criteria used. In a review paper examining the epidemiology of insomnia, about 33% of the population reported experiencing at least one insomnia symptom, such as sleep-onset difficulties. Similar rates (32%) were found in a 2004 NSW survey.

The prevalence is reduced when reporting daytime dysfunction is included, dropping to between 9% and 15%, while the range broadens from 8% to 18% with the addition of sleep dissatisfaction. Age and sex influence prevalence rates. Women are more likely to report all criteria — insomnia symptoms, frequency, daytime dysfunction and sleep

dissatisfaction — compared with men. Insomnia increases in the peri- and postmenopausal phases, and prevalence rates are higher in older adults compared with younger adults.

Insomnia and psychiatric disorders There is a strong comorbidity between chronic insomnia and

both major depressive disorder and generalised anxiety disorder.2,5 The highest attributable risk factor for first-episode depressive disorder is pre-existing insomnia.6 In one study, those with insomnia had 40% psychiatric comorbidity compared with those without, and were almost 40 times more likely to develop new major depression compared with non-

insomniac subjects.4 The SA DRIVE study of young adult drivers found that short sleep duration had a linear relationship with level of psychological distress.7 Those with less than five hours’ sleep duration who were non-distressed at baseline were more likely to report experiencing psychological distress at follow-up.

fatigue, sleepiness, quality of life, for example. Typically, patients with primary insomnia experience more fatigue than sleepiness per se. If the patient is falling asleep frequently during the day, rather than just being tired of fatigued, look for sleep-breathing disorders, especially obstructive sleep apnoea. • Whether the patient is undertaking behaviours known to interfere with sleep, such as using caffeine, alcohol, nicotine or recreational drugs; daytime napping; late-evening exercise; working late on the computer; and being available for work 24 hours a day. • An evaluation for comorbid conditions, especially other sleep disorders, such as obstructive sleep apnoea, restless legs syndrome, shift work sleep disorder and sleep phase syndromes. • An evaluation for other comor-

bid conditions, such as medical and psychiatric conditions and substance abuse. These conditions need to be optimally treated. • An evaluation for medications that may cause insomnia. Note: GPs are generally familiar with the clinical features of obstructive sleep apnoea. Patients with restless legs syndrome frequently experience at least one sleep-related symptom (one or more of an inability to fall asleep, inability to stay asleep, and disturbed sleep). Shift-work sleep disorder and advanced or delayed sleep-phase syndromes represent disorders of circadian rhythm, whereby the patient’s physiological sleep time, as set by their circadian body clock, is at odds with their desired/required sleep time. If these sleep disorders are present, they may require treatment first or in parallel.

sleep thoughts.

believe that change is not possible or wanted.

History-taking UNDERSTANDING the cycle of the patient’s current sleep patterns, family history and factors associated with the onset and maintenance of insomnia gives the clinician a better idea of the problem and enhances rapport. The following points may guide history-taking: • The predominant problem for the patient and how they feel their lifestyle may have been compromised by poor sleep. • The patient’s normal bed routine, which might identify unhelpful behaviours or concerns, for example, lying in bed awake for long periods, watching television in bed or anxiety about sleeping. • The patient’s normal sleep routine, which will help to determine whether the patient suffers from sleep-onset or sleep-maintenance problems or both. Very variable sleep routines may be identified.

Comorbid conditions and medications Identify and treat other conditions that cause insomnia: • Active psychosocial stressors • Inadequate sleep hygiene due to lifestyle factors that impair sleep • Active psychiatric disorder, such as anxiety or depression • Medical conditions: breathing-related sleep disorder, restless legs syndrome, chronic pain, nocturnal cough, hot flushes • Drug or substance use or abuse: consumption or discontinuation of medications, drugs of abuse, alcohol or caffeine (International Classification of Sleep Disorders, 2005) Medications that can cause insomnia • CNS stimulants: sympathomimetics, ephedrine, phenytoin • Antidepressants: bupropion, SSRIs, venlafaxine • Decongestants: pseudoephedrine • Bronchodilators: theophylline • Antihypertensives: beta-blockers, diuretics, clonidine, methyldopa • Corticosteroids

A sleep diary over a two-week period is often useful to more objectively characterise the

patient’s bed and sleep routine. • The impact of the sleeping problem on daytime function —

Non-pharmacological treatments CBT CURRENTLY, the major non-pharmacological treatment for insomnia is CBT, which has the most broad, long-term and compelling evidence base. Mindfulness-based therapies and acceptance and commitment therapy are accumulating evidence for efficacy in insomnia treatment.8 CBT targets maladaptive behaviours and cognitions that maintain insomnia, and introduces healthy sleep behaviours in conjunction with raising the individual’s awareness of unhelpful and unrealistic

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Insomnia behavioural treatments Two of the most effective behavioural methods of treating insomnia are stimulus control therapy and sleep or bed restriction (see box, ‘Insomnia behavioural treatments’). These treatments can be instigated from the GP’s surgery, along with a rationale of the benefits of changing present habits to improve sleep. It is worth noting that some individuals may have defined themselves by their insomnia and may www.australiandoctor.com.au

Stimulus control therapy The rationale is to reassociate the bed and the bed environment with successful sleep. Broomfield and colleagues have called this the quarterhour rule.

Sleep restriction Most individuals try to make up for poor sleep by spending more time in bed, supposedly to increase cont’d page 22


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NOW WITH 7 STRENGTHS PBS LISTED: 5, 10, 15, 20, 25, 30 & 40 µg/h. PBS Information: Restricted benefit. Chronic severe disabling pain not responding to non-opioid analgesics. Authority required for increased maximum quantities and/or repeats. Refer to PBS Schedule for full Authority Required Information.

Please review Product Information and State and Federal regulations before prescribing. The Product Information for NORSPAN® patch can be accessed at www.mundipharma.com.au/Products.html FOLLOWING A COMPREHENSIVE BIOPSYCHOSOCIAL ASSESSMENT, A TRIAL OF AN OPIOID ANALGESIC SUCH AS NORSPAN® PATCH MAY BE INDICATED AS PART OF A MULTIMODAL PAIN MANAGEMENT APPROACH AFTER CONSERVATIVE NON-PHARMACOLOGICAL AND PHARMACOLOGICAL TREATMENTS HAVE BEEN TRIED AND ARE INADEQUATE.2 NORSPAN® TRANSDERMAL DRUG DELIVERY SYSTEM MINIMUM PRODUCT INFORMATION. NAME OF THE MEDICINE Buprenorphine. INDICATIONS Management of moderate to severe pain. CONTRAINDICATIONS Hypersensitivity to buprenorphine or patch components, myasthenia gravis, delirium tremens, pregnancy, severely impaired respiratory function, concurrent non-selective MAO inhibitors (or within 14 days of their administration), treatment of opioid dependence or withdrawal. PRECAUTIONS In chronic, non-malignant pain, medication modifies pain only to some extent. A comprehensive assessment is essential; non-pharmacological options should be explored before starting pharmacological therapy. Advise patients about expected outcome of therapy. Initiate opioid therapy as a trial. Careful, regular assessment and monitoring is required to establish clinical need for ongoing treatment with opioid analgesics. Reassess or discontinue if there is no improvement of pain and/or function. Cease if there is any evidence of misuse or abuse, or if it is having a detrimental effect. Not suitable as an as-needed analgesic due to delayed onset of action. Use with caution in convulsive disorders, head injury, shock, reduced level of consciousness of uncertain origin, intracranial lesions or increased intracranial pressure, severe hepatic impairment, history of seizure disorder, hypotension, hypovolaemia, biliary tract disease, pancreatitis, inflammatory bowel disorders, prostatic hypertrophy, adrenocortical insufficiency, chronic renal and hepatic disease, in debilitated patients, following abdominal surgery, known or suspected drug or alcohol abuse problems, serious mental illness, patients with electrolyte abnormalities and cardiac conditions increasing the risk of QT prolongation, congenital or medication-induced QT prolongation, driving or operating machinery, pregnancy (Category C). Do not use in breastfeeding women. Not recommended for children under 18 years. Do not use in immediate post-operative period, within 24 hours of cordotomy or other pain-relieving surgery. Reduce dosage in hypothyroidism and monitor severely febrile patients for enhanced drug absorption. Advise patients on measures to prevent constipation, consider prophylactic laxative use. Cease treatment if paralytic ileus is present or suspected. Physical dependence (addiction) and abuse may develop, diversion for non-medical use into illicit channels of distribution may occur. Abuse, misuse in ways other than indicated or intentional compromise of the transdermal delivery systems containing opioids poses a risk of overdose and death, and the risk is increased in patients with a personal or family history of substance (drug and alcohol) abuse or addiction. Tolerance and physical dependence can develop during chronic opioid therapy. Withdrawal syndrome may occur following abrupt discontinuation. Use lowest dose (5 mcg) as starting dose in opioid-naïve patients. Avoid exposing application site and surrounding area to direct external heat sources. Increased alanine aminotransferase levels have been noted. INTERACTIONS Contraindicated in patients concurrently receiving non-selective MAO inhibitors or within 14 days of stopping treatment. Caution is advised with selective MAO inhibitors. Increase in QTc interval may occur with higher doses (40 mcg per hour). Consider this in patients with congenital QT prolongation or those taking anti-arrhythmic medications in either class IA (quinidine, procainamide) or class III (amiodarone, sotalol), or any other medicines which prolong QT interval. Increased risk of urinary retention and/or reduced gastric motility (i.e. severe constipation) may occur when used concurrently with anticholinergic drugs. CNS depressants (sedatives, hypnotics, general anaesthetics, opioids, phenothiazines, centrally acting anti-emetics, benzodiazepines, alcohol) can cause respiratory depression, hypotension and profound sedation or coma.

Some general anaesthetics (halothane) and other drugs can decrease hepatic elimination of buprenorphine. CYP3A4 inhibitors (protease inhibitors, azole antimycotics, calcium channel antagonists, macrolide antibiotics) might increase buprenorphine levels. Enzyme inducers (phenobarbitone, carbamazepine, phenytoin, rifampicin) could lead to increased clearance and reduced efficacy. Buprenorphine has also been shown to be a CYP2D6 inhibitor in vitro. INR levels may potentially increase with concurrent warfarin. ADVERSE EFFECTS Adverse reactions are similar to those observed with other opioid analgesics and tend to reduce over time except for constipation. Very common ( ≥ 10%) adverse reactions include application site reaction (includes erythema, oedema, pruritus or rash at application site), constipation, dizziness, dry mouth, headache, nausea, pruritus, somnolence and vomiting. Common ( ≥ 1% to < 10%) adverse reactions include abdominal pain, anorexia, anxiety, asthenic conditions (including muscle weakness, lethargy, fatigue and malaise), chest pain, confusion, depression, diarrhoea, dysgeusia (taste disturbance), dyspepsia, dyspnoea, exanthema, insomnia, nervousness, pain, paraesthesia, peripheral oedema, rash, sweating, tiredness, tremor, vasodilatation. DOSAGE AND ADMINISTRATION Adults: For transdermal use only over 7 days. The initial dose is 5 µg/hr, especially in opioid-naïve patients and during conversion from other opioids (up to 90 mg oral morphine-equivalents/day and combination analgesics). Titrate until adequate analgesia and improvement in function is achieved, continuing short-acting supplemental analgesics as required. Do not increase dose at less than 3-day intervals. To increase dose, remove current patch and apply a higher strength patch or a combination of patches at a different site (the current site should not be used for 3-4 weeks). No more than two patches should be applied at the same time. Apply to intact, non-irritated, relatively hairless skin of upper outer arm, upper back, or upper or side of the chest, avoiding large scars. Use only water to clean skin, and dry before applying patch. Apply patch immediately after removal from pouch. Press firmly in place for 30 seconds. Bathing, showering or swimming should not affect the patch, however if edges start peeling off, tape down with skin tape. If patch falls off, apply a new one. Avoid exposing the application site to external heat sources as an increase in absorption may occur. On removal, fold used patch bringing adhesive sides together, and dispose of safely, out of reach of children. Serum concentrations will decrease gradually, and subsequent opioids should not be administered within 24 hours. Monitor patients to assess the optimum dose and treatment duration. If adequate pain relief cannot be achieved at maximum patch doses, convert to around-the-clock strong opioid. No dosage adjustment is required in renal impairment, in mild to moderate hepatic impairment or in the elderly, but use with caution if at all in severe hepatic impairment as accumulation of buprenorphine may occur. Not recommended in patients under 18 years of age. Please review Product Information before prescribing. Product Information is available from Mundipharma Pty Limited, 88 Phillip Street, Sydney, NSW 2000. Phone 1800 188 009. DATE OF FIRST INCLUSION IN THE AUSTRALIAN REGISTER OF THERAPEUTIC GOODS (THE ARTG) 9 May 2005. DATE OF MOST RECENT AMENDMENT 23 November 2015. References: 1. NORSPAN® transdermal drug delivery system Product Information, Nov 2015. 2. Analgesic Expert Group. Therapeutic Guidelines: Analgesic. Version 6. Melbourne: Therapeutic Guidelines Limited, 2012. ® NORSPAN is a registered trade mark. Mundipharma Pty Limited ABN 87 081 322 509 88 Phillip Street, Sydney, NSW 2000. Tel: 1800 188 009. Saatchi & Saatchi Wellness MNO0095_AD_FPC AU-3149 April 16.


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How to Treat – Insomnia from page 20 sleep opportunity. The result is less consolidated sleep, more time in bed awake and more time spent worrying about not sleeping. Under these circumstances, individuals spend more time awake than asleep in bed. Restricting time in bed to the reported sleep time increases the homeostatic drive for sleep. Good sleepers will have a sleep efficiency of more than 85%, which means that sleep time and time in bed are closely matched.

Beyond CBT to metacognitive therapies Mindfulness-based therapies and acceptance approaches — which are known as metacognitive frameworks for insomnia intervention — focus on building an awareness of mental and physical states, observing the shifting nature of mental processes, and defocusing from insomnia symptoms with an adaptive, values-based perspective that looks at building greater life quality, notwithstanding perceived insomnia symptoms. Metacognitive (awareness of one’s cognitive process) techniques differentiate insomnia-specific thought content and activity — for example, expectations about sleep, increase in mental activity in bed environment, fears regarding daytime consequences of sleep loss — from one’s relationship to sleep beliefs, such as emotional salience of thought content, and attachment to, and meaning of, thoughts in relation to one’s values. For example, inflexible attachment to the thought, “Medications are the only way I can get sleep,” disrupts genuine consideration of alternative ideas, and amplifies the emotional salience of the thought and associated negative effects. Unless there is cognitive flexibility allowing consideration of alternative thoughts (“Maybe I can use other alternatives to medication”), secondary arousal can become a mechanism for insomnia maintenance. Mindfulness- and acceptancebased therapy models promote indirect, experiential change strategies (observing and describ-

Insomnia behavioural treatments Stimulus control therapy • Go to bed only when you are drowsy. • Limit activities in bed to sleep and sex. • Get up at the same time every morning. • If unable to sleep within around 15 minutes, get up. • Go to another room and do something non-stimulating — no surfing the net, watching television, catching up with work or household tasks. You need to feel less tense and more ready for sleep before going back to bed. Keep light levels low. • Repeat the process as many times as necessary to facilitate faster sleep initiation. Sleep restriction or bed restriction • Slowly decrease time in bed by 30 minutes every 3-4 days, from either bedtime or getting-up time, until the time in bed matches the sleep time. Less than 5.5 hours in bed is usually not recommended. Then gradually increase time as sleep improves. Involve your patient in the process • Help your patient to estimate their sleep efficiency by using the following formula. Work out usual sleep time divided by time in bed: (Total sleep time/ total time in bed) x 100 = sleep efficiency; For example, (6/8) x 100 = 75%

ing thoughts and thinking shifts), and widen the focus of change to incorporate one’s broader values. The Buddhist tradition of accepting impermanence is key in recognising that attachment to desired outcomes causes suffering and distress, and promotes reactivity, rigidity and mood/emotional/physiological dysregulation. Instead of changing the triggering stressor, mindfulness works to change the relationship with stress, building non-judgemental awareness of the present moment, selfcompassion and non-attachment

to particular outcomes. This promotes adaptivity, flexibility and pragmatism. The mindful reappraisal encourages a process-focus, from actions to reduce stress to simply observing the features of being stressed. With no further struggle to be rid of the stress, the attention is no longer selectively focused on a perceived threat, promoting an attenuated stress reaction.

Education about good sleep habits or sleep hygiene Education about sleep is a very

important component of understanding how present behaviours can be changed to improve sleep. There are many myths about sleep and challenging these beliefs allows individuals to be more aware of their current responses. Learning about behaviours known to interfere with sleep — such as caffeine, alcohol, nicotine, recreational drug use, daytime napping, timing of exercise and what not to do in bed — helps to maintain good sleep behaviours. The bed and bedroom needs to be somewhere that is comfortable, quiet, dark and allows the individual to look forward to sleep time. Setting aside some wind-down time prior to sleep is an important component of relearning sleep. Not being available for work 24 hours a day is another important issue to address.

Exercise, light and relaxation therapy: A good combination Anxiety is very common in individuals with insomnia, with 50% reporting they are kept awake at night by mental overactivity. Anxiety, worry and the ensuing heightened arousal response are detrimental to sleep. Exercise reduces muscle tension and physiological arousal, promoting better sleep. It also improves mood, and allows the individual to get out and do something. It is a positive active behaviour compared with lying awake waiting for more sleep. However, exercis-

ing in the evening artificially raises core body temperature and must be completed at least 3-4 hours prior to expected bedtime to allow the body to cool down, which is necessary for sleep onset. A constant waking time is a crucial component of setting sleep boundaries. Getting up at the same time means there is a definite end to the sleep time, regardless of the quality of the night-time sleep. Getting-up time is more important than a regular bedtime, which does not necessarily guarantee sleep onset. Early-morning light also resets the brain’s sleep clock. Relaxation reduces high levels of both physical and mental arousal. However, relaxation alone is not as effective as a standalone treatment compared with a combination of the other treatments. Relaxation techniques need to be seen in the context of reducing tension and the arousal response as opposed to being a means of getting to sleep, which puts pressure and effort onto sleep. Relaxation techniques include progressive muscle relaxation, focused breathing strategies, imagery training, meditation and hypnosis. Relaxation needs to become part of the individual’s usual lifestyle — a means of having time out, where the patient first learns to recognise increased stress responses and, second, becomes more confident in reducing those stress responses that result from day-to-day living.

Pharmacotherapy of this, some drugs currently have US Food and Drug Administration approval for the long-term management of insomnia in adults in North America.

PHARMACOTHERAPY is currently indicated in Australia for the short-term (2-4 weeks) management of insomnia in adults. There are many hypnotic agents available in Australia, each with different pharmacokinetic profiles and differing adverse effects. There is greater evidence for the efficacy of prescription agents rather than over-the-counter or natural products that are promoted to improve sleep. Research into sleep mechanisms has identified multiple target areas for hypnotic agents. As a result, several new drugs have been developed to treat insomnia — some of which are only available overseas at present, while others are being tested in late-phase clinical drug trials around the world. Recent research has also examined the real-world issue of long-term hypnotic use in studies of 6-12 months’ duration. As a result

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Benzodiazepines Benzodiazepines target the GABA type A receptor and non-selectively stimulate GABAA subunits, leading to a hypnotic effect, as well as anxiolytic, myorelaxant and anticonvulsant effects. In short-term, randomised, double-blind, placebocontrolled trials, they have been shown to reduce sleep latency, increase total sleep duration and improve sleep continuity. Different benzodiazepines will affect these sleep parameters to different extents, depending on their individual pharmacokinetics. Studies also show that benzodiazepines decrease cont’d page 24 www.australiandoctor.com.au


10879SER_AD_400X280 2015-10-13T11:58:19+11:00

For Type 2 diabetes patients inadequately controlled with Metformin1,2

1. Nesina Product Information. 2. Nesina Met Product Information.

Please review Product Information before prescribing. To access a copy of the Product Information please go to www.servier.com.au/PI or telephone 1800 153 590. Minimum Product Information – Nesina 25MG, 12.5MG, 6.25MG (alogliptin benzoate) / Nesina Met 12.5MG/500MG, 12.5MG/850MG, 12.5MG/1000MG (alogliptin benzoate/metformin hydrochloride) Pharmacology: Nesina: Alogliptin is a competitive inhibitor of dipeptidyl peptidase 4 (DPP-4), an enzyme that rapidly degrades incretin hormones. Nesina Met: 2 oral antihyperglycaemic drugs used in the management of T2D. Alogliptin, is a DPP-4 inhibitor, and metformin hydrochloride, is a member of the biguanide class. Indications: Nesina: To improve glycaemic control in patients ≥18 years old with T2D when diet and exercise do not provide adequate glycaemic control, as add on to metformin, a sulphonylurea, a TZD, insulin (with or without metformin), or in combination with metformin and a TZD when dual therapy does not provide adequate glycaemic control. Nesina Met: To improve glycaemic control in patients ≥18 years old with T2D when diet and exercise do not provide adequate glycaemic control and treatment with both alogliptin and metformin is appropriate: when treatment with metformin alone does not provide adequate control; or in combination with a TZD or with insulin, when dual therapy does not provide adequate control. Can be used to replace separate tablets of alogliptin and metformin in patients already being treated with this combination. Contraindications: Nesina: Hypersensitivity to any components of Nesina. Nesina Met: Renal disease or dysfunction (serum creatinine levels ≥135 µmol/L for men, ≥110 µmol/L for women or creatinine clearance < 60 mL/min); acute or chronic metabolic acidosis, including diabetic ketoacidosis, diabetic coma or pre-coma; hypersensitivity to any components of Nesina Met; temporarily discontinue in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials. Precautions: Nesina & Nesina Met: Should not be used in type 1 diabetes; hypoglycaemia in combination with metformin and TZD, insulin or insulin secretagogues; hepatic effects; acute pancreatitis (discontinue Nesina/Nesina Met); serious hypersensitivity reactions incl Stevens-Johnson syndrome and angioedema (discontinue Nesina/Nesina Met); effect on fertility has not been studied; lactation not studied in humans. Nesina: Should not be used for the treatment of diabetic ketoacidosis; renal impairment (assess renal function prior to initiation and periodically thereafter); severe hepatic impairment; cardiac failure NYHA class IV; pregnancy (Cat B3). Nesina Met: lactic acidosis; monitor renal function; medications that may affect renal function or metformin disposition; iodinated contrast agents – see contraindications; hypoxic states; impaired hepatic function; alcohol; surgery; vitamin B12 levels; safety/efficacy not established when used as dual therapy with sulphonylureas; change in clinical status of patients previously controlled; pregnancy (Cat C). Interactions: Nesina & Nesina Met: No clinically significant interactions were observed with CYP-substrates or inhibitors, or with renally excreted drugs. Nesina Met: nifedipine, glimepiride, cationic drugs, drugs that induce hyperglycaemia. Adverse Reactions: Nesina & Nesina Met: upper respiratory tract infection, nasopharyngitis, headache, abdominal pain, gastroesophageal reflux disease, pruritis, rash. Nesina Met: metallic taste, diarrhoea, loss of appetite, nausea, vomiting. Dosage and Administration: Nesina: 25mg taken orally once daily with or without food. Swallow tablets whole with water. When combined, maintain dose of metformin or TZD. Consider lower dose of insulin to reduce risk of hypoglycaemia. The safety and efficacy of Nesina when used as triple therapy with metformin and a sulphonylurea have not been fully established. No dose adjustment in mild renal impairment or mild to moderate hepatic impairment. Nesina 12.5mg for patients with moderate renal impairment. Nesina 6.25mg for patients with severe renal impairment. No dose adjustment based on age. Nesina Met: Taken orally twice daily with food with gradual dose escalation to reduce metformin GI side effects. Swallow tablets whole with water. Individualise starting dose based on the patient’s current regimen. Maximum daily dose of 25mg alogliptin and 2000mg metformin. Consider lower dose of insulin to reduce the risk of hypoglycaemia. No dose adjustment in mild renal impairment. Should not be used in moderate to severe renal impairment or hepatic impairment. No dose adjustment based on age. Not indicated for initial combination therapy. Overdosage: consult Approved PI Date of most recent amendment to Nesina/ Nesina Met Approved Product Information: 9 April 2015 Sponsor: Takeda Pharmaceuticals Aust Pty Ltd. 2–4 Lyonpark Rd, Maquarie Park NSW 2113 Distributed by Servier Laboratories (Australia) Pty. Ltd. 8 Cato Street Hawthorn VIC 3122. Material prepared September 2015.

PBS Information: Nesina – Authority required for dual therapy. STREAMLINED: 4349. Nesina Met – Authority required STREAMLINED: 4423/4427. Refer to PBS schedule for full information.

TAC10879 10/15

Life-threatening lactic acidosis can occur due to accumulation of metformin. Risk factors include renal impairment, old age and the use of high doses of metformin above 2000 mg per day.


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How to Treat – Insomnia from page 22 slow-wave sleep and REM sleep, with an increase in stage 2 sleep — a light stage of sleep. Some of the commonly used benzodiazepines and their halflives are shown in table 1. Temazepam and oxazepam are commonly used in Australia for insomnia because of their relatively short half-lives. This minimises residual daytime drowsiness and psychomotor impairment, which can be a problem with the longer-acting agents and in the elderly. Common adverse effects of benzodiazepines include over-sedation, light-headedness, memory loss and slurred speech. Over-sedation and respiratory depression are possible with concurrent use of other CNS depressants, such as alcohol and antidepressants. Tolerance, dependence and rebound insomnia may occur in patients taking benzodiazepines. No tolerance has been demonstrated with temazepam in studies of 4-8 weeks’ duration. However, tolerance is a potential problem with longer-term administration of this class of drugs, reinforcing the recommendation for short-term use only. Dependence is rare in patients taking normal therapeutic doses of benzodiazepine for short periods. However, it is thought about one-third of patients on long-term treatment have difficulty reducing or stopping their medication because of this adverse effect. Rebound insomnia is characterised by a worsening of sleep relative to baseline after stopping a hypnotic. It has mainly been demonstrated with the shorteracting benzodiazepines, such as triazolam, and may be more marked when the drug has been taken regularly for long periods. When discontinuing a long-term benzodiazepine, therapy should be withdrawn slowly over several weeks or months, with small dose reductions each week. There is a lack of long-term studies evaluating benzodiazepine safety and efficacy. For this reason, and given the adverse events detailed above, benzodiazepines should be used for the shortest time possible, with a definite duration of use agreed with the patient at the outset.

Non-benzodiazepine benzodiazepine receptor agonists There are three marketed drugs in this class: zolpidem, zopiclone and zaleplon. In North America, zopiclone is sold as eszopiclone (the active (s)-isomer). A long-acting form of zolpidem has also been introduced in Australia (Stilnox CR). Zaleplon is not currently available in Australia. Non-benzodiazepine benzodiazepine receptor agonists more selectively stimulate the GABAA receptor compared with benzodiazepines, which non-selectively stimulate this receptor. As a result, these drugs have a marked hypnotic effect but fewer anxiolytic, myorelaxant and anticonvulsant effects, contributing to a more favourable side-effect profile. Zopiclone and zolpidem have

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ence or abuse potential. The melatonergic antidepressant agomelatine, a potent MT1/ MT2 agonist, has also been shown to be effective in the treatment of depression-associated insomnia.

Sedating antidepressants and atypical antipsychotics

Table 1. Benzodiazepines and their half-lives Benzodiazepine

Half-life in hours (active metabolite)

Diazepam

20-100 (36-200)

Clonazepam

18-50

Nitrazepam

15-38

Flunitrazepam

18-26 (36-200)

Clobazam

12-60

Lorazepam

10-20

Temazepam

8-22

Alprazolam

6-12

Oxazepam

4-15

Triazolam

2

comparable efficacy to benzodiazepines in reducing sleep latency, decreasing nocturnal awakenings and increasing total sleep time. Oral zopiclone has a rapid onset (15-30 minutes), and its elimination half-life is around five hours, increasing with age. Zolpidem has a similar onset of action (30 minutes), although its elimination half-life is shorter (2.4 hours). For patients who wake up in the middle of the night and cannot go back to sleep after taking zolpidem, Stilnox CR may be more suitable because of its longer duration of action. Common adverse effects of non-benzodiazepine receptor agonists include bitter taste, dry mouth, nausea and sleepiness (zopiclone); nausea, dizziness, headache and drowsiness (zolpidem CR); and headache (zaleplon). Compared with benzodiazepines, non-benzodiazepine receptor agonists cause less residual morning sedation and psychomotor impairment, and do not affect normal sleep patterns. There are also fewer reports of dependency and misuse. Rebound is less frequent and milder than that seen after the discontinuation of benzodiazepines. No tolerance to nonbenzodiazepine receptor agonists has been demonstrated in doubleblind trials of up to five weeks’ duration. Eszopiclone was shown to maintain effectiveness in a six-month, double-blind, placebo-controlled study of 788 subjects. Improvements in sleep and daytime function were also maintained during a six-month open-label extension. During the 12 months of the study, few adverse effects and no

behaviour has not been definitively established in the literature. The associations to date are through case reports and small case series.

Melatonin receptor agonists

tolerance was reported. After this trial, eszopiclone was approved by the US FDA for the long-term treatment of sleep-onset and sleepmaintenance insomnia. Zolpidem has also been shown to maintain effectiveness for 6-12 months, although these studies were not double-blinded. In past years, there has been much media interest and some concern regarding possible neuropsychiatric adverse reactions with zolpidem. Australian Adverse Drug Reactions Advisory Committee bulletins, released in 2002 and February 2007 (Zolpidem and bizarre sleep-related effects), detail several possible adverse effects that have been reported with zolpidem since it has been marketed in Australia. These include hallucinations, confusion, amnesia and episodes of sleepwalking, sleep eating and other parasomnia behaviour. After the February 2007 bulletin, the Australian product information was revised for Stilnox and Stilnox CR. In particular, warnings were added regarding the possibility of sleep-related side effects with zolpidem (sleepwalking, ‘sleep driving’, preparing and eating food). It has been emphasised that the use of alcohol and other CNS depressants with zolpidem appears to increase the risk of such behaviours, as does the use of zolpidem at doses exceeding the maximum recommended dose. Taking zolpidem too early before sleep time appears to be a further risk factor for hallucinations and confusion. Despite the recent warnings, it is important to note that a causal relationship between zolpidem and parasomnia www.australiandoctor.com.au

The suprachiasmatic nucleus in the hypothalamus of the brain is responsible for the regulation of our circadian or diurnal rhythms. The sleep–wake cycle in humans, one such circadian rhythm, causes increased sleepiness overnight (from around 2-6am) and in the mid-afternoon hours. Melatonin helps to regulate this circadian rhythm through its action on melatonin receptors (MT1 and MT2 receptors) in the suprachiasmatic nucleus. Agonism or stimulation of the MT1 receptor has a sleep-promoting effect, and stimulation of the MT2 receptor helps to synchronise the circadian clock and adjust the timing of sleep. This pathway of sleep regulation has been explored for therapeutic potential in insomnia using drugs that stimulate the MT1 and MT2 receptors. Circadin is a prolonged-release formulation of melatonin available in Australia. It attempts to mimic the physiological release of melatonin, with peak concentrations occurring 1.6-2.6 hours after a dose. It is indicated in Australia for the short-term treatment of primary insomnia in patients who are 55 or over. Circadin should be taken 1-2 hours before bed because it has a gradual onset of action. Side effects include headache, nasopharyngitis, back pain and arthralgia. Circadin does not appear to cause impaired daytime alertness, dependence, withdrawal effects or rebound insomnia. Ramelteon is a highly selective and potent MT1 and MT2 agonist. It is available in North America and has been tested in clinical trials in Australia. In North America, it has been approved for the long-term treatment of sleep-onset insomnia. Unlike benzodiazepines and non-benzodiazepine receptor agonists, this drug is not classified as a scheduled or controlled drug by the US Drug Enforcement Administration, as trial data so far have not demonstrated depend-

Antidepressants with sedative effects are occasionally prescribed for insomnia. The doses used tend to be lower than those used for depression. Caution should be used when prescribing these drugs to treat primary insomnia because there are few studies that examine their efficacy and safety in nondepressed patients with insomnia, and they can cause significant side effects, particularly in the elderly. Amitriptyline and doxepin are most commonly used in Australia, causing sedative effects primarily via their anticholinergic properties. Side effects of these tricyclic antidepressants include anticholinergic effects — such as dry mouth, blurred vision, constipation, urinary retention and delirium — and alpha-adrenergic effects, including orthostatic hypotension and dizziness. In addition, many antidepressants can exacerbate periodic limb movements during sleep. Mirtazapine — a selective alpha-2, serotonin and histamine receptor blocker — is another antidepressant associated with sedation and increased total sleep time. Weight gain, restless legs symptoms and residual morning sleepiness (due to its long half-life) are potential limiting side effects. Most SSRIs will also exacerbate insomnia in the first few weeks of use through increased sleep fragmentation. This side effect tends to diminish with continued use. Newer sedating antipsychotics, such as quetiapine and olanzapine, are increasingly used in the treatment of insomnia, especially comorbid insomnia, but have not been studied extensively for this purpose.

Antihistamines There is little published data on the efficacy of first-generation histamine antagonists in insomnia, and adverse effects can be high. Promethazine, diphenhydramine and other H1 antagonists are the usual sleep-promoting agents in over-the-counter preparations. These agents extend sleep duration, but are associated with rapid tolerance to the hypnotic effect, residual daytime sedation due to long half-lives and anticholinergic side effects.

Over-the-counter therapies Valerian is commonly used as a sleep aid and is available over the counter. However, evidence for its efficacy in insomnia is inconclusive. Melatonin can be obtained over the counter as part of health supplements or as a compounded product by some pharmacists. The dose of melatonin can vary among these products, and there is no TGA regulation of the compounding process. In contrast to Circadin, it is not feasible to produce a compounded prolonged-release melatonin product. Good-quality efficacy


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nights a week,” simulating usual use for many patients. The study showed that patient and investigator rating of sleep was better in the zolpidem arm, but not all sleep parameters were consistently improved with zolpidem when the two arms were compared. For example, overall patient-reported sleep latency and total sleep time, after five weeks, were not different between the groups. However, importantly, there were no rebound effects from the drug on the nights the active drug was not taken, and no tolerance to zolpidem was demonstrated over the eight weeks. This study suggests some efficacy and safety with this approach over an eight-week period. More research is needed to determine whether the approach is useful and safe for a longer term.

studies are not available for overthe-counter melatonin, although available evidence would suggest a mild hypnotic effect.

Which hypnotic to use? There are many factors that need to be taken into account when prescribing a particular hypnotic for a patient. Consider the following: • The drug’s side effects • The potential for the drug or its adverse effects to interact with other medications, including CNS active agents • Concurrent alcohol use • The patient’s comorbid conditions, for example, benzodiazepines should be avoided in patients with significant respiratory disease • The patient’s prior experience with hypnotics • The patient’s own preferences and expectations • The cost of the drug • The intended duration of use In addition, hypnotics should be appropriate for the type of insomnia symptoms the patient is experiencing. For sleep onset or initiation problems only, drugs with rapid onset and short or ultra-short half-lives should be considered, for example, triazolam, zaleplon, ramelteon and zolpidem. For sleep onset and maintenance problems, drugs with rapid onset and longer half-lives should be considered, for example, zolpidem CR and zopiclone. For sleep maintenance problems only, a delayed onset and long half-life are preferable, for exam-

ple, temazepam, estazolam and Circadin.

Hypnotics: duration of use All prescribed hypnotics in Australia are currently indicated for short-term use (less than a month). Therefore, these drugs should be prescribed for the shortest time possible, with a definite duration of use agreed at the outset. However, as noted previously, eszopiclone is now indicated for long-term use in North America for sleep-onset and sleepmaintenance insomnia. In addition, the FDA has approved ramelteon for the long-term treatment of sleep-onset insomnia and zolpidem extended-release for the treatment of insomnia without limitation in length of use.

Despite this, the author feels that more long-term efficacy and safety data are required before these medications are routinely prescribed for long-term use. In addition, it is important to remember that CBT has been shown to be superior in the long term for the management of insomnia in research studies to date.

Intermittent use of hypnotic therapy: Does it work or cause harm? A double-blind, placebo-controlled trial has investigated the intermittent use of zolpidem over eight weeks. Subjects were instructed to, “Take the medication when you think you need it, at bedtime, between three and five

Investigational drugs Research into sleep mechanisms has identified multiple target areas for hypnotic agents. As a result, several drugs are being investigated as treatments for primary insomnia. These include drugs that act on the serotonergic system, others that act on the orexin neurotransmitter pathway (important in the pathogenesis of narcolepsy), and those that selectively work on the GABA and histaminergic pathways. With intense research and interest in this area of sleep medicine, many new drugs are likely to be available on the market in future years, with the hope that some of these drugs will prove safer and superior to existing agents.

When to refer GPs are well placed to identify insomnia, characterise it and start treatment. Non-pharmacological treatment for insomnia should be initiated by GPs, depending on interest and expertise. This therapy might include education regarding good sleep habits, addressing active psychosocial stressors and the initiation of cognitive behavioural approaches. Patients with suspected obstructive sleep apnoea, restless legs syndrome or difficult-to-control psychiatric problems should be referred to specialists for further investigation and management of their comorbid conditions. Pharmacotherapy, if required, should only be used in the short term, in conjunction with the initiation of non-pharmacological strategies to treat insomnia. Referral to experienced sleep psychologists or sleep physicians is important if the insomnia does not improve.

References

1. Frances A, (editor). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th edn. American Psychiatric Association, Washington DC, 2000. 2. Breslau N, et al. Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Biological Psychiatry 1996; 39:411-18. 3. Chorney et al. The interplay of sleep disturbance, anxiety and depression in children. Journal of Pediatric Psychology 2008; 33:339-48. 4. Ford DE, Kamerow DB. Epidemiological study of sleep disturbance and psychiatric disorders. An opportunity for prevention? Journal of the American Medical Association 1989; 262:1479-84. 5. Buysse DJ, et al. Diagnostic concordance for DSM-IV sleep disorders: A report from the APA/ NIMH DSM-IV. American Journal of Psychiatry 1994; 151:1351-60. 6. Cole M and Dendukuri N. Risk factors for depression among elderly community subjects: A systematic review and metaanalysis. American Journal of Psychiatry 2003; 160:1147-56. 7. Glozier N, et al. Short sleep duration in prevalent and persistent psychological distress in young adults: The DRIVE study. Sleep 2010; 33:09. 8. Ong J, et al. Improving sleep with mindfulness and acceptance: A metacognitive model of insomnia. Behaviour Research and Therapy 2012; 50:651-60. 9. Ansfield M, et al. Ironic effects of sleep urgency. Behaviour Research and Therapy 1996; 34:523-31. 10. Espie C. Insomnia: Conceptual issues in the development, persistence and treatment of sleep disorder in adults. Annual Review of Psychology 2002; 53:215-43. 11. Harvey AG. A cognitive model of insomnia. Behaviour Research Therapy 2002; 40:869-93.

Case study: Non-drug management of insomnia GINA, aged 42, has a generalised anxiety disorder. Her 20-year history of intermittent insomnia episodes has worsened into a nearconstant difficulty maintaining sleep for the past two years. She generally experiences sleep maintenance difficulties, with waking

periods from 2am to 4am after about four hours of sleep for 11-12 days out of 14. She reports that her insufficient sleep worsens her worrying, leading to behaviours specifically employed to bring about sleep, which then lessens her sleep likelihood. She strongly

believes eight hours of sleep nightly is crucial to preventing physiological and psychological damage. Gina believes this sleep must be made to happen using a range of over-the-counter aids and prescription medications if sleep hygiene measures do not work. She conwww.australiandoctor.com.au

stantly monitors her fatigue levels during the day and believes she has only a finite amount of energy daily, which must be conserved, leading her to frequently curtail or cancel her social and work activities during the day. cont’d next page 27 May 2016 | Australian Doctor |

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How to Treat – Insomnia from previous page CBT treatment choices for Gina include education about good sleep habits, sleep hygiene and stimulus control measures, specifically focusing on behaviour change around standard rising time, getting early-morning sunlight, eschewing naps during the day and restricting time in bed if unable to sleep. These behaviours will ensure greater sleep efficiency, greater build-up in homeostatic drive to sleep and a strengthened association with bed as a conditioned signal for sleep rather than waking. There will also be a focus on reducing her CNS reactivity with daily practice of progressive muscle relaxation and controlled breathing strategies. To reduce her worry about sleeplessness, a daily ‘worry session’ could be introduced, conditioning her to attend to her worries to a specific time and place daily to reduce vulnerability to worry-driven sleep disruption at night. Then behavioural experiments could be used to gather evidence to challenge her fears. For example, a trial set over several days that contrasts a half-day conserving energy with only mundane tasks done at a slow pace with a half-day generating energy with more activity — then rating her fatigue, mood

and coping after each experimental session. Evidence for catastrophic thoughts — such as “I won’t function at all tomorrow; I will get fired” — and probability overestimations — “It is 95% likely I will get fired if I function badly” — can be addressed, along with a discussion on selective attention to negative sleep-related evidence, and ignoring neutral or positive evidence. A metacognitive perspective, on the other hand, will promote mindful awareness and indirect, experiential change strategies of observing and describing the experience of

insomnia. A primary focus for Gina and the therapist will be her struggle to control sleep and her use of aids (safety-seeking behaviours, medications) to make sleep happen, which ultimately generates more focus on sleeplessness, more intense distress and further ineffectual efforts to control sleep. This accords with findings of longer sleep-onset latency found in normal sleepers with a high mental load, when attempting to fall asleep quickly.9 The metacognitive framework of mindful acceptance can help Gina to broaden her focus from a narrow preoccupation with insom-

nia and its negative consequences. Such an approach will promote an understanding of shifts in her mental activity, her strong attachment to certain beliefs, insights about selective biases, a broader assessment of her values and building a quality of life around more compelling factors than the vagaries of her sleep. Through this broader focus, the therapist encourages a nonjudgemental and present-focused acceptance of her sleep experience, with acceptance of a range of cognitive and emotional phenomena in the moment and non-attachment to sleep outcomes. This promotes balance, flexibility and improved coping when confronting inadequate sleep and fatigue. The acceptance and commitment therapy component targets identification of Gina’s values under various life domains (family, close relationships, friendships, career, etc), which can then help her perceive the cost of an included or omitted behaviour in reference to a relevant value. This includes absenteeism from work due to morning tiredness when a core value is ‘investing in career’. In this manner, Gina’s behaviour change is more likely to follow from commitment to her personal values, rather than safety-seeking behaviours driven by her hour-by-hour mood, feelings or threat appraisals.

Conclusion NON-PHARMACOLOGICAL behavioural measures are the most efficacious treatments of insomnia, both in the short and long term. One of the ironies about insomnia management is that most GPs have considerable knowledge of CBT and insomnia strategies, but are not always sure how to instigate these treatments. GPs also appear hampered by their perceptions that patients expect a script for hypnotics, which is often not the case. Improvement in communication from both sides of the consultation would be beneficial in relation to the management of insomnia.

INSTRUCTIONS

How to Treat Quiz

Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes by post or fax. The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.

GO ONLINE TO COMPLETE THE QUIZ

Insomnia — 27 May 2016

www.australiandoctor.com.au/education/how-to-treat

1. Which THREE form part of the three Ps model for insomnia? a) Predisposing b) Prolonging c) Perpetuating d) Precipitating

4. Which THREE conditions may cause insomnia? a) Hypertension b) Restless legs syndrome c) Anxiety d) Chronic pain

2. Which TWO statements regarding the prevalence of insomnia are correct? a) Insomnia is the most commonly reported sleep disorder. b) In a review paper, about 55% of the population have reported experiencing at least one insomnia symptom. c) Age and sex do not influence prevalence rates. d) There is a strong comorbidity between chronic insomnia and major depressive disorder.

5. Which TWO medications may cause insomnia? a) Paracetamol b) Theophylline c) ACEIs d) SSRIs

3. Which TWO give the clinician a better understanding of the patient’s insomnia? a) Understanding the cycle of the patient’s current sleep patterns b) How keen the patient is to have their insomnia treated c) Factors associated with the onset and maintenance of insomnia d) How the patient’s family responds to their complaints of insomnia

6. Which THREE statements regarding the non-pharmacological treatment of insomnia are correct? a) CBT challenges maladaptive behaviours and cognitions that maintain insomnia and raises the individual’s awareness of unhelpful and unrealistic sleep thoughts. b) Mindfulness-based and acceptance approaches focus, among other things, on building an awareness of mental and physical states. c) There is currently an equivalent evidence base for both CBT and mindfulness-based therapies for treating insomnia. d) Two of the most effective behavioural methods of treating insomnia are stimulus

control therapy and sleep restriction or bed restriction.

light-headedness, memory loss and slurred speech.

7. Which TWO statements regarding the nonpharmacological management of insomnia are correct? a) Exercising immediately before going to bed is a useful technique because exercise tires one out, thus promoting falling asleep more rapidly. b) Checking work emails in bed last thing at night will alleviate anxiety and promote sleep. c) Anxiety is very common in individuals with insomnia, with 50% reporting they are being kept awake at night by mental overactivity. d) A constant waking time is a crucial component of setting sleep boundaries.

9. Which TWO statements regarding nonbenzodiazepine benzodiazepine receptor agonists are correct? a) There are three marketed drugs in this class, and all three are available in Australia. b) Compared with benzodiazepines, these drugs have a marked hypnotic effect but fewer anxiolytic, myorelaxant and anticonvulsant effects, contributing to a more favourable side-effect profile. c) Benzodiazepines and non-benzodiazepine receptor agonists cause the same amount of residual morning sedation and psychomotor impairment. d) Common adverse effects of nonbenzodiazepine receptor agonists include bitter taste, dry mouth, nausea, sleepiness, dizziness and headache.

8. Which THREE statements regarding the pharmacotherapy of insomnia are correct? a) Pharmacotherapy is currently indicated in Australia for the short-term (2-4 weeks) management of insomnia in adults. b) Benzodiazepines have hypnotic, anxiolytic, myorelaxant and anticonvulsant effects. c) Over-the-counter and natural products for sleep have been shown to be as effective as prescription agents. d) Common adverse effects of benzodiazepines include over-sedation,

10. Which THREE statements regarding the choice of hypnotics are correct? a) For sleep-onset or initiation problems, drugs with rapid onset and longer half-lives should be considered. b) Consider the drug’s side effects. c) Consider the patient’s comorbid conditions. d) Consider the cost of the drug.

CPD QUIZ UPDATE The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2014-16 triennium. You can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.

NEXT WEEK

26

HOW TO TREAT Editor: Dr Claire Berman Email: claire.berman@cirrusmedia.com.au

Next week’s How to Treat explores the range of preventative health measures which can be employed to halt the transmission of HIV. The author is Dr Catriona Ooi, clinical services lead, Western Sydney Sexual Health Centre, Western Sydney Local Health District, Sydney, NSW; and senior lecturer, Sydney Medical School — Westmead, University of Sydney, NSW.

| Australian Doctor | 27 May 2016

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REGISTER NOW! This practical, interactive seminar will provide you with updates on common complexities throughout pregnancy and infant care. Topics range from prenatal screening and perinatal anxiety and depression, to feeding issues, vaccination and worrisome rashes in infants.

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Complete the active learning module (ALM) and earn 40 Category 1 QI&CPD points.

To see the full agenda visit www.education.australiandoctor.com.au


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Therapy Update

How to manage requests for MTHFR testing? GENETICS

There is an increasing demand for MTHFR gene testing. How should GPs respond? KATE DUNLOP

M

THFR testing has become synonymous with the rapid increase in patient-driven healthcare. It is one of the most popular variants tested for nutritional genomic purposes because of its role in folate metabolism and hyperhomocysteinaemia.2 MTHFR testing can be requested as a single gene test ordered by a GP or medical specialist, or through direct-to-patient testing. However, the American College of Medical Genetics lists MTHFR genetic testing as uninformative, as a result of recent evidence against an association with thromboembolism.3 Anecdotally, GPs and genetics clinics report an increase in demand for testing and anxious clients seeking clinical advice for genetic testing results. The Centre

for Genetics Education NSW Health recorded an average of 1668 unique views per month since June 2015 to its MTHFR fact sheet. There is, however, a lack of evidence for MTHFR genetic testing. So what do we know about testing and how should we best manage it?

BOX 1. FREQUENCY OF MTHFR VARIANTS AS A PERCENTAGE OF THE POPULATION C677T (rs1801131)

A1298C (rs1801133)

-/-

-/+

+/+

-/-

+/-

+/+

Caucasian

30-55

40-50

4-25

45-50

40-45

10-12

Asian

30-60

35-50

3-20

50-65

30-45

2-4

Source: Molecular Diagnostic Laboratories.

What is MTHFR?

The MTHFR gene encodes an enzyme in the methylation cycle. MTHFR (5,10-methylenetetrahydrofolate reductase) converts 5,10-methylenetetrahydrofolate (5,10-methylene THF) to L-methylfolate (MTHF), and is an important cofactor in the biosynthesis of S-adenosyl methionine (SAMe), the primary methyl donor involved in regulating gene expression. Serum MTHF is the

It is one of the most popular variants tested for nutritional genomic purposes due to its role in folate metabolism and hyperhomocysteinaemia.

main circulating form of folate, making up approximately 80% of the total

folates.4,5 As well as creating SAMe, the folate cycle is also peripherally involved

www.australiandoctor.com.au

in the creation of essential phospholipids, such as phosphatidylcholine, and neurotransmitters, such as serotonin.6 MTHFR variants are common in the population. The two most commonly reported variants are C677T and A1298C, and around 40% of Caucasian and Asian patients will carry one copy of the C677T variant (box 1).

Clinical relevance As with most common variants, there is little evidence of clinical impact. The majority of research on MTHFR focuses on the C677T variant and its effect on folate metabolism. Those who carry one C677T variant (heterozygotes) have approximately 60% enzyme activity and those who carry two copies of the C677T variant (homozygous) have

approximately 30% enzyme activity.8 This can reduce the production of MTHF as a methyl donor in the methylation pathway and DNA methylation throughout the body.9 The impact of A1298C is still largely unknown, but it does not seem to significantly affect enzyme activity. MTHFR C677T genotype has also been associated with, but is not necessarily causative of, an increased risk of neural tube defects in offspring, neurodegenerative diseases, bone fracture, depression and infertility.10-14 Being homozygous for the T allele of the C677T variant has been shown to lead to increased levels of homocysteine.15,16 Elevated homocysteine, regardless of MTHFR status, has been previously thought to be a risk factor contâ&#x20AC;&#x2122;d next page 27 May 2016 | Australian Doctor |

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Therapy Update from previous page for thrombophilia and cardiovascular disease.17 However, while there is a demonstrated effect of MTHFR variants on homocysteine, there is no evidence that lowering homocysteine levels lowers the risk of thrombophilia, cardiovascular events or mortality.18 The British Society for Haematology does not include testing of MTHFR for evaluation of venous thromboembolism or heritable thrombophilia as the test result is not useful in guiding the management and subsequent prevention of these conditions.19

(box 2). A browse through MTHFR social media sites will quickly reveal fears surrounding MTHFR and various symptoms, the use of folic acid and which supplements a patient should take. Despite some community concerns surrounding folic acid supplementation, there is no evidence that folic acid supplementation has a negative clinical impact. The Framingham Offspring Study and US National Health and Nutrition Examination Survey have both demonstrated

that folic acid improves folate status and reduces the prevalence of hyperhomocysteinaemia.23,24 The existing recommendations stay the same. Regardless of MTHFR status, all women planning a pregnancy should take 0.4mg of folic acid a day, starting one month before conception and continuing at least until the 12th week of gestation.1 Additionally, while an MTHFR result may not be clinically informative on its own, it can be an opportunity to discuss

BOX 2. RECOMMENDATIONS FOR MANAGING A PATIENT WHO REQUESTS MTHFR TESTING • MTHFR testing is not recommended as it does not guide clinical practice. • MTHFR testing is not considered an appropriate referral to a genetics clinic. • Reassure the patient about the importance of knowing the folate levels rather than the variant itself. • Advise all patients to avoid or reduce lifestyle factors that can reduce folate metabolism eg, smoking, coffee and alcohol consumption.27 • Encourage all patients to consume a well-balanced diet with foods high in B6, B12 and folate.27 • Recommend folic acid supplementation at the usual recommended daily intake of 0.4mg/day for all patients planning a pregnancy.27 • If a patient is homozygous for MTHFR, further testing of B12, RBC folate and homocysteine may be warranted if low dietary folate or low B12 is suspected.

MTHFR and folate levels As folate cannot be synthesised by humans, it has to be consumed from dietary sources (green leafy vegetables, legumes), folic acid supplementation and fortification of foods.9 Under conditions of high folate, the enzymatic activity of the TT variant becomes similar to those of the wild

There is no evidence that folic acid supplementation has a negative clinical impact.

type CC.20 It is only when folate concentrations are low that the functional impact of the TT variant may become more significant.21 In Australia, because of mandatory fortification, folate deficiency is now rare. Since fortification, 64% of Australian women have been shown to be meeting the red blood cell (RBC) folate level of 906nmol/L required to prevent neural tube defects and only 0.5% have low RBC folate levels.22 Only patients with malabsorption conditions, macrocytic anaemia, coeliac disease or similar, or those who do not consume wheat products are at risk of folate deficiency. Regardless of MTHFR status, these patients may need to assess their diet for adequate folate or consider a folic acid supplement.

Managing MTHFR

Prevent the first break from happening.1

Recommend a bone mineral density scan when your patients turn 70 and PBS Information: Actonel EC. Restricted Benefit. Actonel EC Combi, Actonel EC Combi D. Authority Required (STREAMLINED). Refer to PBS schedule for full restricted and authority information.

BEFORE PRESCRIBING, PLEASE REVIEW FULL PRODUCT INFORMATION. FULL PRODUCT INFORMATION IS AVAILABLE FROM ACTAVIS PTY LTD OR BY CALLING 1800 678 302 ACTONEL EC, ACTONEL EC COMBI & ACTONEL EC COMBI D Presentations: Actonel EC 35mg tablets contain 35mg of risedronate sodium. Actonel EC Combi: 1 Actonel EC 35mg tablet and 6 calcium carbonate 1250mg (equivalent to 500mg elemental calcium) tablets, Actonel EC Combi D: 1 Actonel 35mg tablet and 6 daily sachets containing 2500mg calcium carbonate and 22μg cholecalciferol, equivalent to 1000mg elemental calcium and 22μg (880IU) vitamin D3 respectively. Indications: Actonel EC 35mg tablet, Actonel EC Combi, Actonel EC Combi D: Treatment of osteoporosis, treatment of glucocorticoid-induced osteoporosis, preservation of bone mineral density in patients on long term corticosteroid therapy. Contraindications: Risedronate: Hypersensitivity to the drug or ingredients, hypocalcaemia, inability to stand or sit upright for at least 30 minutes. Calcium carbonate: Hypersensitivity to the drug or ingredients; hypercalcaemia; hypercalciuria; nephrolithiasis. Cholecalciferol: Hypercalcaemia; hypercalciuria; nephrolithiasis; hypervitaminosis D. Precautions: Risedronate: Hypocalcaemia; bone and mineral metabolism dysfunction; calcium and vitamin D if dietary intake is inadequate; severe renal impairment; oesophageal reaction, inflammatory bowel disease; osteonecrosis of the jaw; dental examination with

Possibly more important than the clinical impact is the need to address the distress it can cause patients

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| Australian Doctor | 27 May 2016

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y p f o a R o in T is ta R M P A ®


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Optimising dietary folate intake can have the additional benefit of increasing intake of other vitamins, minerals and fibre.

the importance of eating a healthy diet, particularly for the elderly or pregnant population. Those who are homozygous for the C677T variant may want to pay particular attention to their folate intake, through supplementation and dietary sources as they may have a higher requirement for folate.25 Optimising dietary folate intake can have the additional benefit of increasing intake of other vitamins, minerals and fibre, and decreasing intake of satu-

rated fatty acids.26 Highlighting that it is not the mutation itself that matters, but the levels of folate and homocysteine, and the ways in which these can be well measured and maintained, may go some way to providing reassurance. The Centre for Genetics Education’s GP information and patient fact sheet can be accessed from its website (see Online resources).

Conclusion

While MTHFR is not a test that is generally recommended, it is increasing in popularity, particularly through direct-to-patient avenues. As our understanding of genetics and nutritional genomics evolves, and the uptake of direct-to-patient testing increases, GPs will be increasingly impacted by genetic testing. While not necessarily clinically relevant, MTHFR offers an opportunity to promote healthy eating with regards to folate and folic acid supplementation. Ms Dunlop is director of the Centre for Genetics Education.

Online resources NSW Health. About MTHFR: Information for GPs bit.ly/1pDtDb5 NSW Health. MTHFR gene testing for patients bit.ly/26sM3Na References available on request.

TAKE-HOME POINTS

And you could prevent the second.2,3

• MTHFR variants are common.

Fracture protection within 6 months †Across

2,3†

vertebral and non-vertebral fractures.

• MTHFR genetic testing is not recommended as it does not guide management and can cause unnecessary distress in patients. • MTHFR variants do not have implications for family planning and are not an indication for referral to a clinical genetics service.

you could prevent the first break from ever happening.4,5 preventive dentistry; avoid invasive dental procedures; atypical stress fractures; pregnancy (Category B3); certain medications (e.g. calcium supplements, antacids). Calcium carbonate and/or Cholecalciferol: Impairment of renal functions; monitoring of serum calcium levels and renal function; other drugs containing vitamin D; sarcoidosis; immobilised patients due to the increased risk of hypercalcaemia; disease associated with unregulated overproduction of calcitriol; malabsorption. Adverse Effects: Risedronate: Common: abdominal and musculoskeletal pain. Uncommon: glossitis, iritis, and duodenitis, abnormal liver function tests. Postmarketing: vary rare: hypersensitivity and skin reactions, including angioedema, generalised rash and bulbous skin reaction, uveitis and osteonecrosis of the jaw. See full PI. Calcium carbonate and/or Cholecalciferol: Uncommon: hypercalcaemia, hypercalciuria. Rare: flatulence, constipation, nausea, abdominal pain, diarrhoea, pruritus, rash and urticaria. Dosage and Administration: Actonel EC 35mg tablets: take with a glass of plain water with or without food, once a week, taken on the same day each week. Actonel EC should be taken in an upright position. Patient should avoid lying down for 30 minutes. Tablets must be swallowed whole. Actonel EC Combi: Two component therapy consisting of 7 tablets in a blister, 1 Actonel EC 35mg tablet and 6 calcium 500mg tablets. The recommended dose in adults is 1 Actonel EC 35mg tablet on the first day, followed by, beginning on the next day, 1 calcium 500mg tablet daily for 6 days. This 7 day sequence is then repeated each week. Actonel EC Combi D: Intended of patients for whom the amount of calcium and cholecalciferol included is considered to provide adequate supplementation. The recommended dose is 1 Actonel EC 35mg tablet on the first day, followed by, beginning on the next day, 1 calcium carbonate/cholecalciferol sachet daily for 6 days. This 7 day sequence is then repeated each week starting with the Actonel EC 35mg tablet. Date of most recent amendment 6 February 2015. Name and Address of the Sponsor: Actavis Pty Ltd, 5/117 Harrington St, The Rocks, NSW 2000. References: 1 Eastell R et al. Osteoporos Int. 2000; 11;4:331-337. 2. Roux C et al. Curr Med Res Opin 2004;20:433–39. 3. Harrington JT et al. Calcif Tissue Int 2004;74:129–35. 4. Blake GM and Fogelman I. Postgrad Med J. 2007; 83(982): 509–517. 5. Osteoporosis Australia. Bone density testing in general practice. Available at: http://www.osteoporosis.org.au/sites/default/files/files/Bone%20Density%20Testing%20in%20General%20 Practice.pdf. Accessed on: 15.2.16. Allergan Australia Pty Ltd. ABN 85 000 612 831. 810 Pacific Highway, Gordon, NSW 2072. AU/0267/2015a. Date of preparation: January 2016. Job number: ACT3083_AD. ™ Trademark of Allergan, © Allergan Inc. 2016. ® Registered trademark.

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• With adequate folate intake, the effect of MTHFR genetic variants are usually mitigated. • Regardless of MTHFR status, all women planning a pregnancy should take 0.4mg FA/day, starting one month before conception and continuing at least until the 12th week of gestation.1 • When a patient presents with an existing MTHFR result it can be an opportunity to reinforce the importance of eating a healthy, folate-rich diet.

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Gut Feelings

GP training can’t rely on goodwill alone

T

Guest Editorial Dr Jon Fogarty

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| Australian Doctor | 27 May 2016

HE brave new world of GP training is emerging onto a shrouded and uncertain stage. The decision to wrest training from General Practice Education and Training and hand it to the Department of Health was done with little, if any, negotiation with the GPs who are actively involved in the process. No evidence was presented to convince the players involved that the new order would produce better GP training or a more equitable environment. It is true that the chronic shortage of GPs a decade ago has abated, but the new risk is that the government, having largely assumed control of training, will meet its own political agenda of more GPs at the cost of sustaining quality training. There are political parallels between the morphing of Medicare Locals into primary health networks with the shift of GP training from GPET to fewer, larger, regional training operators under government control. The move form Divisions of General Practice (remember them?) to Medicare Locals and then to PHNs was partly defended with the argument that healthcare was not all about GPs, and a more comprehensive health hub was appropriate to drive community health. In the process, many GPs felt marginalised, and the shift to more centralised, government-controlled GP training risks creating the same sense of disconnect.

With that, comes the prospect of practices involved in training departing the field, and experienced GP educators looking for other challenges. Communication from the health department has been an opaque process. There are recurrent whispers of corporates playing a more active role, but the department’s communication with GP representatives on this matter is hidden behind confidentiality agreements. There are corporates and there are corporates, and no doubt there

According to my practice manager, practices are being paid less for their contribution to teaching. I recently attended a ‘train the trainer session’ at night for which I was not paid, but would have been previously. Further, trainees are now required to do less face-to-face learning, with an increase in use of online training. This is no doubt cost-effective, and not without advantages, but it is more effective for some disciplines than others. Much of general practice involves subtle skills of commu-

The new risk is that the government, having largely assumed control of training, will meet its own political agenda of more GPs at the cost of sustaining quality training. are some excellent and content GPs working in such centres. But the major corporate players have a duty to their shareholders that will not sit easily with the provision of unhurried teaching. Inherent in this move is the prospect of financial incentives for corporates to undertake training, for which there would be a clear conflict of interest and the prospect of new GPs unhappily bonded to an unloved employer. As a long-time GP supervisor, I get the feeling there is now less money available for GP training under the new regime. www.australiandoctor.com.au

nication and patience, as well as core knowledge. Some of the latter can be taught online. The former can’t. There also appears to be more focus on tick-box assessment, where a doctor is satisfactory, or not satisfactory, leaving less room for nuanced assessment. For individual trainees, there is less capacity to take time out from training. This, at a time in life when many doctors are trying to combine career development with establishing a family, is a particularly insensitive and short-sighted decision. GPs involved in teaching are

simultaneously in a position of weakness, and strength: weakness because they have little control over the present teaching paradigm, strength because they can walk away at any time. This is not our core business. It certainly doesn’t fill the coffers. A survey conducted for the General Practice Supervisors Australia in March suggested that 44% of GPs found that hosting term 1 registrars cost the practice money, and term 2 registrars were at best revenue neutral. Almost 60% of GP supervisors who responded to the survey said they believed they would still be training registrars in three years. Put another way, that’s about 40 % who felt that they would cease training registrars within three years. The same survey revealed that, by a large majority, GP supervisors taught because they enjoyed watching the development of younger GPs, and by implication, being part of that process. Maintaining such goodwill is essential to providing good practices in which registrars can work. In structuring training, the health department and GP representative colleges need to know that goodwill cannot be assumed. Its maintenance is dependent on appropriate communication, remuneration, support and recognition. The present regime has some distance to travel in all these areas. Dr Fogarty is a GP on the Central Coast, NSW.


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College chiro call heavy-handed Celebrity chefs more hygienic than takeaway

Letters Your Views EDITOR This recommendation from the RACGP appears to be a rather heavy-handed approach to a specific issue (‘College urges GPs to stop referring to chiropractors’, 27 April, australiandoctor.com.au). As a GP, I asked my own GP to refer me to a chiro after trying all other non-invasive treatments for chronic neck pain. Some mutual interdisciplinary trust is needed here, not a knee-jerk reaction.

EDITOR How to justify getting caught watching FoodTV at work? Write a paper about ‘perhaps’ and ‘maybe’ and ‘could’ (‘Celebrity chefs a public health menace: study’, 2 May, australiandoctor. com.au). Of course, if the chefs encourage folks to actually cook, they may save countless thousands from the hygiene nightmare that is takeaway food.

Dr Mike Seah GP, Canberra, ACT

EDITOR As per Harrison and Lawton, “In Australia, estimates suggest undesired harmful effects from medication or other intervention such as surgery, known as ‘adverse events’, occur in around 17% of hospital admissions. This results in up to 18,000 unnecessary deaths and 50,000 temporarily or permanently disabled patients each year.”1 I never treat infants and rarely treat under-sixes, because I do not believe my craft has anything to offer them. I, too, am concerned about what was revealed on ABC’s Background Briefing last month.2 But my profession has a magnificent and admirable safety record when compared with hospital care.

Dr Carole Castles medical officer Canberra, ACT

John Drinkwater chiropractor, Taylors Lakes, Vic 1. Harrison R, Lawton R. Blaming individual doctors for medical errors doesn’t help anyone. The Conversation 2016; online. See bit.ly/23DJtjo 2. Green, J. Crack a baby’s back. Background Briefing. ABC. 2016 See: ab.co/1U74rGo

EDITOR We could probably say the same for any hospital-based programs too — perhaps washing hands doesn’t make for popular TV viewing. However, your point about Jamie Oliver being a public health menace is unfounded, given the whole focus of his work is about healthy eating and simple cooking, encouraging people to feed real food to themselves and their families. This goes a long way in my public health book.

Have your say All letters should contain the sender’s title, address and daytime phone number. Letters should be exclusive, no more than 250 words and may be edited. Letters should be sent to: Fax: (02) 8484 0800 or email: mail@australiandoctor.com.au

Jennifer Smith clinical nurse specialist Grafton, NSW

FROM THE WEB

australiandoctor.com.au antiseptic techniques used by staff. The other factor to consider is did the superantibiotics not work because of the patient’s depleted clinical state?

More GP bashing?

TWEET OF THE WEEK “Big Tobacco wont stop defending ‘right’ 2 kill ppl. Court condemns Philip Morris over secret bid 2 sue Australia” — Associate Professor John Mendoza @johno0910

(GPs lag on absolute risk approach to CVD, 2 May) I forgot, it’s always the GPs’ fault. Excuse me, while I call the next mindless automaton into my consulting room.

Tamiflu efficacy

Dr Raj

If a patient has 15% or more CVD risk, yet does not meet PBS criteria for statins, what does Professor Paul Glasziou suggest we do? Write a script a pensioner won’t fill or pay for? How is that my fault? Rural GP

Actually, I think Professor Glasziou has come out in defence of GPs here. He is not the author of the reported study. What he points out is that PBS prescribing does not take absolute risk into consideration. This article is yet another example of ‘recommended’ vs PBS criteria that leaves GPs in an ethically difficult position. Dr M Gunhouse

No surprise

Follow us at @australiandr

Hypocrites GP

(Q&A: College responds to questions on KFP fail rates, 18 April) Why is there an outcry that IMGs and practice-based pathway candidates are failing at higher rates than Australiantrained and Australian General

Practice Training pathway candidates? Surely this is to be expected? David

Australian GP training takes only three years postgrad, while international doctors need at least five years postgrad before even coming here. Often they have 10 years, and another 4-5 years working here as GPs. The significantly increased medical and clinical experience in Australia and abroad should be reflected in significantly higher or at least equal pass rates. Really?

“I can only speak from my time as the censor-in-chief [since 2014],” says Dr Miller. I think that is very disingenuous.

He has been a censor with the RACGP for longer than I have practised medicine. He is in an excellent place to see why these numbers have plummeted. He has been able to access and influence this data for decades. Dr Phil 42

Nosocomial bugs (Fatal superbug defeats all antibiotics, 18 April) This is a problem created in hospitals. The history indicates the Klebsiella infection was introduced to the pancreas probably via intranasal tubing, inactivity in hospital dropping the patient’s resistance, or innumerable other causes including questionable

www.australiandoctor.com.au

(Tamiflu ineffective in nursing home flu outbreaks, 19 April) I have never been impressed with Tamiflu. It is often vomited back up before being absorbed and its efficacy is questionable. By contrast, I have been quite impressed with the effectiveness of Relenza, which is easy to inhale. It goes in predictably, and by the same route the virus does, and does seem to lessen symptom intensity and shorten recovery time. Just my personal observations, but reinforced frequently and over quite some time. But I would never use it as prophylaxis — just get it started as soon as possible.

Australian Doctor team Editor-in-chief: Clifford Fram (02) 8484 0765 Editor: Jo Hartley (02) 8484 0741 Deputy editor: Paul Smith (02) 8484 0795 Medical editor: Dr Linda Calabresi MBBS FRACGP (02) 8484 0903 Therapy Update/Grand Rounds editor: A/Prof Amanda McBride MBBS MHPol (02) 8484 0879 How to Treat editor: Dr Claire Berman MBBCh (02) 8484 0749 Clinical news editor: Michael Woodhead (02) 8484 0674 Reporter: Tessa Hoffman (02) 8484 0789 Chief content producer/ Smart Practice editor: Cheree Corbin (02) 8484 0860 Deputy chief content producer: Gita Sankaran (02) 8484 0806 Content producers: Gill Canning (02) 8484 0786 Sophie Attwood (02) 8484 0606 Photo editor: Stacey Shipton (02) 8484 0799 Graphic designers: Edison Bartolome (02) 8484 0872 Antony Mazzaferro (02) 8484 0894 CEO: John King Sales and marketing inquiries: (02) 8484 0603 Classified pages bookings: Classifieds Manager gpclassifieds@cirrusmedia.com.au Production co-ordinator: Eve Allen (02) 8484 0764 @EMAIL US:

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Subtractor

Terrified, not bored (‘A bit boring’ — life as a GP on the after-hours helpline, 28 April) If I had to pick migraine over meningitis over the phone, I wouldn’t be bored. I’d be terrified. Iliya Englin 27 May 2016 | Australian Doctor |

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Guest Views IN MY EXPERIENCE

DR PAM RACHOOTIN

Life is a house of cards

A

It is a question of asking when to fold.

S a child, I enjoyed building towers of cards. It required steady hands, a bit of daring and a certain amount of luck that there was no breeze blowing through the room. I didn’t realise then that such play would offer the perfect analogy years later to

help me guide patients confronting difficult healthcare decisions. Over the course of my career, I have witnessed a fair share of the triumphs and disasters of medical care. I remember an elderly patient with diabetes, ischaemic heart disease and a 99% stenosis of one carotid artery.

Never mind the statistics. We trusted our instincts and put our faith in the remarkable homeostatic mechanisms of the human body over medical intervention. As it turned out, the decision was correct. I felt vindicated years later when my patient died of an entirely unrelated disease. Recently, another patient

The cardiologist hand-balled him back to me, wishing me the best of luck. I had to explain to my patient that I knew of a man who had died after an otherwise successful endarterectomy. My patient also knew of a person who had gone blind, albeit temporarily, after the same procedure.

SIGNS of the ALWAYS TIRED

1,2

Inability to concentrate

Dizziness

Fatigue during pregnancy

Constant irritability

Recommend Ferro-Grad C ® to the 1 in 5 Australian women under 50 years, who 3* may have some form of iron deficiency. Only Ferro-Grad C contains 105 mg of elemental iron plus 500 mg of vitamin C to aid absorption.4† *Defined as serum ferritin <20 micrograms/L.3 †Of the commercially available forms of iron therapy suitable for the treatment of iron deficiency anaemia. Ferro-Grad C contains dried ferrous sulphate 325 mg (equivalent to 105 mg elemental iron) and sodium ascorbate 562.4 mg (equivalent to 500 mg Vitamin C). For the prevention and treatment of iron deficiency. References: 1. Brittenham GM, et al. Disorders of Iron Homeostasis: Iron Deficiency and Overload. In: Hoffman R, et al. Hematology: Basic Principles and Practice. 6th ed. Elsevier; 2013. Available at: https://www.clinicalkey.com. Accessed 11 Feb 2015. 2. Digestive Health Foundation/GESA. Iron Deficiency. Clinical Update. First Ed 2008. Available at: www.gesa.org.au. Accessed 17 December 2014. 3. Ahmed F et al. Asia Pac J Clin Nutr 2008; 17:40–7. 4. Brise H & Hallberg L. Acta Med Scand 1962;171(Suppl 376):51–83. BGP Products Pty Ltd., trading as Mylan EPD. ABN 29 601 608 771. 299 Lane Cove Road, Macquarie Park NSW 2113. Ph: 1800 225 311. Ferro-Grad C is a registered trademark of Mylan. AU-FERR-2014-20(1) May 2015. ABB3201.

consulted me. He has a bowel loop within an inguinal hernia. Initially, I was alarmed. When he becomes uncomfortable, he pushes on the mass and the pressure is relieved. He has lived this way for several years now. The surgeon has recommended definitive treatment. But the patient is in his mid80s, on warfarin, with previous TIAs and the knowledge that a number of his friends who have had various elective surgeries have come out with “disappointing outcomes”, including loss of independence and cognitive deficits. We had a discussion about the house of cards analogy. Yes, he is at risk of bowel obstruction, peritonitis and death from septicaemia, but there are also risks of elective surgery. Is it a case of “a stitch in time saves nine” or

Hospitals are dangerous places and we should do everything we can to keep people out of them. “don’t rock the boat”? The older I get, the more I lean towards one of the golden rules presented in The House of God, the wonderful novel that should be required reading for all interns: “Do as much nothing as possible.” It chimes with the local hospital network’s sentiment: “Hospitals are dangerous places and we should do everything we can to keep people out of them.” The 90-year-old with a history of a benign bowel polyp and lapsed follow-up due to comorbidities presents feeling under the weather. She asks: “Well, how do you know I don’t have bowel cancer?” Then she demands: “I want to see the gastroenterologist.” In my letter to the specialist I ask, “Isn’t there a cut-off date to further screening?” Apparently not. The next thing I hear she is getting a colonoscopy, requiring preadmission the day before to monitor potential side effects of the bowel prep. She survives the colonoscopy and doesn’t have bowel cancer. She won’t die of bowel cancer. But inevitably, even in this day and age, she will die. ● Dr Rachootin is a GP in Adelaide.

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OPINION

DR RACHAEL DUNLOP (PhD)

Supplements a lucky dip The supplement industry is more opaque than we realise.

T

HE vitamin and supplement industry is big business in Australia. Around 75% of the population use some form of complementary medicines, including vitamins, minerals, herbs, aromatherapy and homeopathic products. But some vitamin supplements and protein powders at best don’t work and, at worst, can cause harm. Last week, ABC’s Four Corners program aired a PBS Frontline investigation exploring the complex issues surrounding supplements in North America. It’s an eye-opening report that details a web of lobbying and legislation designed to protect the industry, but which ultimately leaves patients at risk. The issue of harm is covered upfront with a group

of patients in Hawaii who suffered liver failure following the ingestion of a dietary supplement. Many required transplants. At the other extreme is the revelation that 60% of supplements analysed for the active ingredients didn’t contain what was stated on the label. In a random sample of 44 popular herbal supplements purchased from North American stores and analysed for their DNA fingerprints, onethird showed outright substitution, meaning there was no trace of the plant advertised on the bottle. Others contained undisclosed fillers such as soybean, wheat and rice. If you’re thinking that “what happens in North American doesn’t affect me”, you might be wrong. Herbal supplements bought online

have been linked to at least six Australian organ transplants since 2011. This includes the recent case of a Perth man who was given two weeks to live and required an emergency liver transplant after taking a protein powder containing green tea extract and a supplement containing garcinia cambogia. Australia’s regulatory authorities responded by saying they’re “continuing to

investigate the report” and “the results will be made public if there is sufficient evidence of a safety issue”. But Australia’s regulations when it comes to supplements are woefully inadequate. If a product is intended to be used as a supplement, it must be listed with the TGA. However, this only requires the registrant to fill out an online form, choose from a list of pre-approved ingredients (indicating low risk and

tested for safety in isolation) and state they hold information to substantiate their product’s claims. They are not required to present it. What is missing from this picture is testing each batch of supplement for the concentration and safety of indicated ingredients that are actually in the bottle. Importantly, the ingredients should be tested for safety in combination. What’s also missing is checks that the claims made on the bottle can be substantiated. While compliance checks do occur, each TGA review covers only a fraction of the total products listed on the Australian Register of Therapeutic Goods. However, each time a review is carried out, dozens of products are cancelled for reasons ranging from unsubstantiated claims on the label, to unacceptable quality, safety or efficacy of the goods.

And that doesn’t even cover products that are not listed on the register, such as traditional Chinese medicine products. Australian supplement manufacturers are also required to adhere to good manufacturing practice, and their sites are inspected and licensed by the TGA. But, beyond that, does the product do what it says? Is there any active ingredient in the bottle? We may never know. ● Dr Dunlop is visiting associate in the faculty of medicine and health sciences at Macquarie University, NSW. Disclosure: Dr Dunlop has a patent pending for L-serine use as a supplement in the treatment of neurodegenerative disorders.

This article is an edited version of an article on The Conversation website. See: bit.ly/1NxwWfr

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27 May 2016 | Australian Doctor |

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This Week PIC OF THE WEEK

QUOTES OF THE WEEK

VENEZUELA Jugs and soda bottles are rigged by doctors at Luis Razetti Hospital to treat patients in Puerto la Cruz last month. According to a New York Times report, some hospitals have no X-ray or dialysis machines, cancer medicines can only be found on the black market and patients languish on the floor “in pools of their blood”. The economic crisis in the country has exploded into a public health emergency, part of a larger unravelling that has become so widespread it has prompted President Nicolas Maduro to impose a state of emergency, raising fears of a government collapse.

“There is no doubt in my mind that everything is going to work. And I mean everything.”

Photo: NY Times/Headpress

Ovarian cancer screening no panacea Journal Talk Michael Woodhead

JUST before Christmas, the media excitedly reported that screening may cut ovarian cancer deaths by one-fifth. The “encouraging” findings came from a 14-year UK study of annual screening of 200,000 asymptomatic women using serum CA125 levels. The findings, published in the Lancet from a trial that cost almost $100 million, suggested there was a 20% reduction in ovarian cancer deaths. The results were hailed as a ‘landmark’ by usually reliable media outlets such as the BBC. However, oncologists who have had more time to pore over the data have since come to the conclusion that screening for ovarian cancer is unfortunately not justified by the questionable reductions shown in the study. Writing in the British Journal of Obstetrics and Gynaecology this month, Dr Nick Johnson, a gynaecological oncology surgeon, says that at best, the trial showed

that screening might prevent one life per 3000 women screened over 10 years. Aside from this marginal benefit, screening would also result in many false positives and mean that thousands of women would undergo unnecessary surgery to evaluate the ovary. Such surgery has a complication rate of 3-15%. “It seems obvious that some women will be harmed if a screening test puts her through an operation to remove a nodule that turns out to be irrelevant,” he writes. According to Dr Johnson, a notable finding of the trial was that screening only started to show an impact on survival after 7-10 years. This suggested that a genuine screening benefit on ovarian cancers was biologically implausible. Screening might be picking up unusual, slow-growing tumours, he postulated. He also highlighted the negative findings of another major ovarian cancer screening trial from the US. This study, involving more than 78,000 women, found that there

were actually more ovarian cancer deaths in the screened cohort compared with the unscreened group of women. The conflicting results suggested that the differences in ovarian cancer rates in the two landmark screening trials probably arose by chance. In any case, a further weakness for screening would be the cost, Dr Johnson wrote. With the test used in the UK trial costing around $300, that would translate to a cost of $6 million per life saved even assuming the most optimistic estimates from the UK trial. He concluded that currently screening asymptomatic low-risk women would have minimal impact on ovarian cancer survival rates and may cause significant harm. “It seems that any future improvements to ovarian-peritoneal cancer survival will not be made by early diagnosis.” Lancet 2016; 387:945-56. British Journal of Obstetrics and Gynaecology 2016; online.

PRINCIPAL DIAGNOSES FOR HOSPITALISATION

Common principal diagnoses:

There were almost 10 million hospitalisations in Australia in 2013-14, with digestive problems being the major cause.

3. Cancer

5. Circulatory

total admissions

total admissions

total admissions

978,000

616,000

481,000

Gall stones (65,000) Reflux (69,000) Hernia (94,000)

Skin (114,000) Bowel (28,000) Breast (25,000)

Heart attack (54,000) Angina (51,000) Heart failure (54,000)

2. Injury and poisoning

4. Musculoskeletal

6. Genitourinary

total admissions

total admissions

total admissions

624,000 Fracture (200,000) Poisoning (33,000) Burns (8,000)

521,000

Arthritis (138,000) Knee disorders (64,000) Back pain (63,000)

Reference: Australian Institute of Health and Welfare 2015; online.

“I wouldn’t want members of the public thinking they can treat their own depression by picking their own magic mushrooms.” Dr Robin Carhart-Harris, a researcher at Imperial College in London, commenting on a study he led into the use of magic mushrooms to treat patients with severe depression.

“What we are seeing now is just the tip of the iceberg.”

SNAPSHOT

1. Digestive system

Thomas Manning, the 64-year-old who last week became the US’s first penis transplant recipient, tells reporters he is looking forward to leaving hospital a “complete” man.

Construction, Forestry, Mining and Energy Union spokesman Steven Smyth warns the number of diagnosed cases of black lung is rising week by week.

“They made clowns of themselves trying to oneup each other’s promises.” The NT News takes aim at both political parties over their separate pledges to fund a $15 million PET scanner for Darwin, an important region in the upcoming election.

457,000

Kidney stones (41,000) Urinary tract infection (55,000) Kidney failure (27,000) MAZ

www.australiandoctor.com.au

27 May 2016 | Australian Doctor |

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NSW 592877_16_05_27

Privately owned, well equipped, ultra modern practice, 15 mins from Canberra CBD Full time nurse support Pathology on-site 70 / 75% Busy DWS location Call Peter 0412-224-824

• For accredited, computerised practice with RN support. • Excellent facilities with full allied health team. • Pathology on site. • Prime location, opposite train station. • Min or 70%.

Gladesville, Marrickville, Bankstown, Hurstville, caMpBelltown area vr Gp

TEM

N0416 S W_ 1 2 0 1 6 - -0 5 - 1 9 T 1 6 : 0 7 : 5 4 + 1 0 P: 251 5 0809 2 8 9 2 _ 1 6 _ 0 5 _ 2 7E: ian.marshall@sydney.edu.au A/Professor Ian Marshall E: contactjphan@gmail.com

P: 0403 865 934 - Peter P: 0416 276 808 P: 0403 534 486 E: efmc@bigpond.net.au N S W_ 5 9 2 8 7 7 _ 1 6 _ 0 5 _ 2 7 1 2 0 1 6 - 0 5 - 1 9 T 1 6 E:: rashid@centrehealth.com.au 1 3 : 5 4 + 1 0 : 0 0 E: mail@hopehealth.net.au W: www.centrehealth.com.au

VR GPs wanted - Tuggeranong

EPPING FT/PT VR GP

CO CON

Come and help us make a difference - and make a difference for your future as well.

P: 0413 586 802 - Edward E: elim@healthfirstmedical.net.au

P: 0413 587 693

Petersham / syd metro Ft/Pt/Locum

Kurri is just 10 minutes from Newcastle on the freeway and is an area with a huge population growth. You will be working with a friendly, experienced, professional and committed team of administration and clinical staff.

State of the art facility with on site pathology and specialty nursing support (chronic disease, women’s health, immunisation). Other onsite service include dietitian and exercise physiologist. Experienced, efficient nursing staff help the GP to maximise billings whilst still providing high

NSW 592531 16_05_13_RN

· Relocation and accomodation support if required.

For the right candidate, excellent terms and conditions are available.

quality bulk billed care. Kurri Kurri is a community with a great need for more good doctors.

NSW 592872 16_05_27_RN

· Optional after hours and weekend work if desired.

VR GPs for full time or sessional work at our brand new clinic in a huge growth area. VR / fellowship essential as Kurri is RA1 and DWS.

NSW 592035 16_04_15_RN

NSW 592511_16_05_13

· Great variety of work within the role.

NSW 592675 16_05_20_RN

KURRI KURRI COMMUNITY HEALTHCARE

• Mixed Billing Practice. N S W_ 5 9 2 5 1 1 _ 1 6 _ 0 5 _ 1 3P: 0401 154 989 / 0403 003 324 1 2 0 1 6 - 0 5 - 0 6 T1 5 : 0 7 : 0 4 + 1 0 : 0 0 P: 0407 244 548 - Dr Rapson • Pathology, Radiology, Pharmacy, Allied E: parramedicalcentre@outlook.com Health, Dental, Audiology and Cafe on site. • Huge Community Support and Anticipation. • Farm and Horse Lifestyle Packages available.

GP Opportunities in Australia (Some DWS)

VR GP

NSW 592892_16_05_27

Dws after-hours available. Busy, well-established, bulk billing. Modern teaching practice. Non-corporate friendly team environment. Free secure parking. Nursing, Pathology & Allied Health on site.

NSW 592518 16_05_13_RN

• • • • • •

NSW 592491 16_05_06_RN

Non corporate/no restrictive contract. Onsite GP support. Established practice 40 years. Bulk Billing. Allied Health / Fully Computerised. Partnership Option / Excellent Facilities.

NSW 592588 16_05_13_RN

• • • • • •

Parramatta Flexible hrs gP vr Ft/Pt

NSW 592011 16_04_01_RN

Greystanes Ft/Pt Vr GP required

NSW 592589 16_05_13_RN

For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

WHAT WE CAN OFFER Excellent earning potential Genuine work-life balance Guaranteed patient stream Commitment to ongoing education Flexible hours and locations Contact Joanne Stewart jo.stewart@sundoctors.com.au Doctor Relationship Manager 02 9455 1111

27 May 2016 | Australian Doctor |

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Classifieds For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

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jobs

• Currently seeking a full-time GP to join our friendly clinics. • For well established patient base. • Registered nurse and allied health services. • Pathology & Pharmacy next door. • Open 7 days 8 am to 10 pm.

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QLD 592477_16_05_06

QLD

KINGSTON & INALA GPs REQUIRED

-

QLD 592474 16_05_13_RN

QLD 591058 16_05_13_RN

QL D_ 5 9 2 4 7 7 _ 1 6 _ 0 5 _ 0 6

Bridgeman downs Vr gP required Required for a non corporate family practice in a pleasant Northern Brisbane suburb. Terms Negotiable.

QLD 592831 16_05_20_RN

P: 07 3808 8888 E: rosita@allcaremed.com.au

QLD 592881 16_05_27_RN

Burleigh Waters Weekend doctor required • Busy, established practice in modern facility • Private billing • Open 7 days • Allied Health and Pathology onsite

A

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Locums and OTD with FRACGP are encouraged to apply for 6 month locum placements. Call or Email for more details and to arrange a visit.

5 0418 8 3884 3 9 1 Bell 6 _ 0 1 _ 2 2 P: 8895- _ June E: june@ils.com.au

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Doctor Required General Practice Townsville

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Tropical North Queensland Keep 70 -100% of the money you earn

70%

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New Equipment, modern extremely busy practice Good solid earning potential Oxley Great support team including Team Care, JINDALEE - BRISBANE FT/PT VR GP RequiRed pap smear Nurses • Friendly Family Owned Accredited Practice. PT VR GP REquIRED • Established patient base. • Interest in Skin & Procedural • Mixed Billing. Call or email today for more details Medicine Preferred • RN & Admin Support. • Busy, established, accredited, Dr owned. • Pathology / Radiology / Visiting Specialists Sharyn Ph 0409 24 24 24 • RN support, high remuneration. on site. • Canossa Hospital/Nursing Home on site. P: 0416 201 222 - Dr Damodar Cherie / Wendy Ph 07 4035 8004 E: doc_damodar@yahoo.com.au Q L D _ 5 9 2 8 5 5 _ 1 6 _ 0 5 _ 2 7P: 07 3259 6900 - Paula 1 2 0 1 6 - 0 5 - 1 9 T1 6 : 1 1 : 1 3 + 1 0 : 0 0 Email - recruitment@iig.com.au E: ox-manager@bywatermedical.com.au   䘀愀洀椀氀礀 倀爀愀挀琀椀挀攀  䴀攀搀椀挀愀氀 䌀攀渀琀爀攀猀

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GP Opportunities Available − QLD Due to continued growth, IPN is currently looking for GPs to practise in several of our QLD Medical Centres. All positions are flexible with both part time and full time roles available:

S

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T

Brisbane

Gold Coast

• Browns Plains Family Practice – After Hours (DWS) • Everton Plaza Medical Centre (Women’s Health) • Ipswich Medical Centre (Women’s Health) • Kedron Park 7 Day Medical Centre • Kenmore General Practice – Skin Cancer Clinic (DWS) • Middle Park Medical Centre (Men’s Health) • Morayfield 7 Day Medical Centre (DWS) • Redcliffe GP Super Clinic

• Highlands Health Centre (DWS) • Highlands Health Centre – After Hours (AMDS) • Mermaid Beach Medical Centre As a valued GP working with IPN, you will enjoy freedom, flexibility and clinical sovereignty. For all confidential enquiries contact Fiona James on 0447 006 846 or fiona.james@ipn.com.au

With IPN, we’re looking after you.

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| Australian Doctor | 27 May 2016

QLD 592642 16_05_13_RN

䄀礀爀Ⰰ 䈀甀渀搀愀戀攀爀最 ☀ 䈀爀椀猀戀愀渀攀 䰀漀挀愀琀椀漀渀猀

The surgery is fully computerized and has mixed billing with a broad patient demographic.

www.australiandoctor.com.au

ORMEAU GP REQUIRED • Doctor Owned Bulk Billing. • Practice halfway between Brisbane & Gold Coast. • 3 minutes to the Pacific Highway. • District Workforce Shortage and Area of Need. • Friendly support staff, including a Registered Nurse. • Allied Health Professional onsite • Fully computerised and well equipped modern practice. For any inquiries please contact our Practice manager. E: cmitchell@ormeaumedicalcentre.com.au

QLD 592855_16_05_27

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QLD 592646 16_05_13

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QLD 592639_16_05_13

Cleveland P: 07 3166 9653 E: admin@bridgemanfamilypractice.com.au P: 0439 761 921 - Kim Pryce-Lunt FT / PT vR GeneRal W: Q bridgemanfamilypractice.com.au L D _ 5 9 2 6 3 9 _ 1 6 _ 0 5 _ 1 3E: kpl@eastbrooke.com.au 1 2 0 1 6 - 0 5 - 0 6 T 1 5 PRaCTiTioneR : 0 6 : 0 1 + 1RequiRed 0 : 0 0 W: www.eastbrookemedical.com.au For busy Cleveland Practice. GP Owned & Operated. We are an Accredited, modern, well equipped facility supported by experienced Nursing and admin staff.

QLD 592821 16_05_27_RN

W

AD_040___27MAY_15


AD_041___27MAY_15

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For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au -

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2 0 1 6 - 0 5 - 2 0 T1 4 : 1 2 : 5 0 + 1 0 : 0 0

QLD 59296_16_05_27

QL D_ 5 9 2 9 6 _ 1 6 _ 0 5 _ 2 7

VR GP Required for Flagship Medical Centre

A

Unique opportunity to join our GP Super Clinic in Sippy Downs. Enjoy full nursing support with a mixed billing policy, located in a superb location on the Sunshine Coast. In the role you will enjoy:

• A rapidly growing medical centre with extended scope of services • Accredited training centre hosting GP Registrars and Medical Students • Onsite Pharmacy, Imaging, Fracture Clinic and HITH Program • Open term agreements and flexible work arrangements.

CO CON

SEEKING GENERAL PRACTITIONER

Full or part-time opportunity Successful doctor owned Medical Centre Flexibility in working hours Low staff and doctor turnover provides an excellent work environment

P: 07 54921044 - Practice Manager E: pm@goldenbeachmedicalcentre.com.au’ W: www.pelicanwatersfamilydoctors.com.au

E: info@ehmc.com.au - Louise

• FT/PT VR GP for immediate start. • Established, friendly, 30 year old, family practice. • Pathology and Chemist on site. 65% of billing.

JOB DESCRIPTION: Due to the high demand on our various courses, we are looking for qualified doctors who can tutor RACGP (AKT, KFP & OSCE) and train students one-on-one, via Skype so as to equip the students with what it takes to pass their exams. Tutors can work from home, within any state in Australia, and schedule sessions in their free time.

BlackBurn South P/t F/t Vr GP Required for busy Family Owned Practice. Join a team of dedicated doctors, allied health and excellent support staff. Well-equipped surgery with full time nursing and on site pathology. Mixed billing, Flexible hours and excellent remuneration. Registrars may also apply P: 03 9890 0031 E: itzefronis@bsmedical.com.au

VIC 592201 16_04_22_RN

jobs

the Latest How to Treat yearbook

OUT NOW!

P: 07 3351 4455 E hillssurgery@gmail.com

IMG SOS is the number one provider of one-on-one AMC/RACGP/PESCI preparation courses. We specialise in online tutoring and role playing delivered mainly via Skype. We support the IMGs in their exams preparation by offering individualised courses that address each candidate’s specific needs.

SELECTION CRITERIA: • You have passed the RACGP examination. • You are a RACGP examiner. • You are a Medical Educator. • You can teach AKT, KFP and OSCE. • You can develop your own curriculum. • You have a relevant local experience.

• You like teaching and have a passion towards the role. • You have previous tutoring/mentoring experience. • You have excellent communication skills. • You are an academic or hold a PhD. • You can spare 6 hours per week for tutoring with us.

WHAT’S ON OFFER? • Excellent pay rate. • Flexible and enjoyable working environment. • A real enhancement to your CV

• Immediate start • No hassle in joining our firm; with only a ten-minute phone interview required if you are shortlisted.

TO APPLY FOR THIS JOB, PLEASE SEND YOUR CV TO ADMIN@IMGSOS.COM.AU

www.australiandoctor.com.au

Other features include: • Theatre & Treatment rooms. • Visiting Specialists & Allied Health Providers. • Pathology on-site. • Private & Bulk Billing. • Close to large Public Hospital (with 24hr A&E dept.) and Private Hospital. • Fully computerised and accredited. • 20 Mins from CBD & Adelaide beaches. • Flexible hours ( Open Mon-Fri. 8am - 7pm & Sat 8am to 12pm).

Order today from $99 hardcover and $79 eBook

Please email through your resume.

RACGP TUTOR DOCTOR

VIC

The Clinic is GP owned and has full-time RN nursing support (inc. Chronic Disease Clinics).

For start at end of July 2016. P: 08 8278 1111 E: rhicks@russellclinic.com.au

www.australiandoctor.com.au/httyb or call 1300 360 126

WESTFIELD SOUTHLAND VR GP PARTNER Urgently required for newly renovated modern medical clinic located in busy major shopping centre. GP partner will receive a cut of the profit with long term passive income. Minimal equity required. Free dedicated all day car park provided. P: 0402 455 664 - Dr Cora Wong E: cora.wong@myhealth.net.au

VIC 592829 16_05_27_RN

• • • •

Ferny Hills Vr GP

QLD 592471 16_05_06_RN

SUNSHINE COAST FEmAlE VR GP REqUIREd

VIC 592834 16_05_20_RN

Non corporate family practice. Well established, accredited, mixed billing, computerised. Experienced RN & other support staff. Please email your CVC.

Friendly, supportive, hills based practice with teaching links is looking for a FT VR GP for busy, well established, modern, purpose built surgery.

Phone: 07 54452928 / 0400 680164 - Anna Dann (Team Leader) Email: anna.dann@freshholistichealth.com.au Web: www.freshholistichealth.com.au

QLD 592591 16_06_13_RN

QLD 592590 16_05_13_RN

Excellent Opportunity for GPs in DWS area. 15 km from Brisbane CBD (Experienced Overseas Trained Doctors Welcome to apply!)

Blackwood / adelaide Hills FT VR GP

If you want to be at the forefront of Professional Integrative Medicine and can see yourself working in our environmentally sustainable clinic, then we invite you to contact us.

Please contact our Practice Manager Amanda Challenger on 0418 188 977

EVERTON HILLS FT/PT VR GP DWS

• Multi-modality supportive team with naturopath, physiotherapy, counselling, midwifery clinic, QML, treatment room. • Large Yoga/Pilates studio and meeting room, workshops. • Staff wellbeing, work/life balance a priority. • We are not AON or DWS.

Mount Martha GP rEQuIrED GP required for Mount Martha Medical Centre. • Fully computerised. • Friendly staff • Busy location. • High percentage remuneration. P: 0416 355 042 - Joe

Middle Park Vr GP required • • • • • • • •

Private billing. Modern facility. Fully computerised. Online bookings. Busy clinic. 5km from the CBD. Practice nurse. Flexible hours.

SA 592458 16_05_06_RN

• Hours are negotiable (full time and part time available). • 65% billings (mainly private) plus initial retainer. • Well-equipped Award winning eco-friendly ‘Green Facility’. • Longer appointment times with patients. • Integrative approach to medicine. • Registered with AGPAL accreditation

PR &S

• • • • • • • •

Family Medicine. Travel Clinic. Women’s Health. Children’s Health. Men’s Health. Counselling. Dietitian. Pathology.

VIC 592841 16_05_20_RN

• High Income Opportunity • F/T, P/T, VR Drs • Non – Corporate, well established practice • Mixed Billing • 65% of billing • Accredited, computerised, modern facilities • Nurse support • Excellent admin support • In-house education program (CPD)

SA jobs

For privately owned family practice in award-winning facility

VIC 592835 16_05_20_RN

GPs REQUIRED FOR A BUSY BRISBANE INNER NORTH PRACTICE

SUNSHINE COAST, QLD

QLD 592900 16_05_27_RN

Newmarket 7 Day Medical Centre

QLD 592869 16_05_27_RN

To register your interest, please contact Jimmy Bosmans on +61 407 897 416 or jbosmans@ochrehealth.com.au ochrehealth.com.au

P: 03 9699 4333 - Dr Noel Leon E: jobs@armstrongstreetmedicalcentre.com.au

27 May 2016 | Australian Doctor |

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Classifieds

We are looking for either restricted or unrestricted General Practitioners who are committed and will uphold the standards in place to provide outstanding healthcare.

BRISBANE VR GP REquIREd Practice is located 20KM South from Brisbane CBD and 45KM from Gold Coast. Preferably VR GP with surgical/skin interest.

P: 03 9246 0466 - Naya Lutu E: practice@arrowhmc.com.au

Carnegie Vr general PraCtitioner • • • • •

Required urgently for immediate start. Bulk Billing. On Site Pathology and Pharmacy. 70%, Flexible Contract Option. Fully accredited, excellent support, Practice Nurse, GP owned practice. • Growing Practice with fantastic earning potential.

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P: 0403 532 896

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Coburg After Hours gP • Required for Modern, Accredited Bulk Billing Practice open 7 days. • Nurse support and onsite allied health and Pharmacy. • Female GPs also required, we offer a great hours and flexibility. • Bonus will be offered to successful applicant.

SALE / LEASE

T

Ready to go-Modern set up with 2 consultation rooms,2 procedure rooms, reception and waiting room. Goodwill established in this position by previous Doctors. Pharmacy next door. Very reasonable rent. P: 0418 187 778 - Susan Cooper

P: 0452 275 782 E: khurshidinvestment@gmail.com

P: 03 8790 2111 - Julie / Neecia E: info@parkhillmedical.com.au

POSITION AVAILABLE

VR GENERAL PRACTITIONER

Ingleburn nSW ProfeSSIonal roomS New rooms available in this fast growing south-west area of Sydney, suit GP, Pathology centre or Specialist. For use either full-time or on a sessional basis. For further details please call. P: 0403 776 650 - George

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| Australian Doctor | 27 May 2016

VIC 592819 16_05_20_RN

P. 0413 019 841 E: medjobs263@gmail.com

Ringwood VR gP / gP RegistRaR For private billing, well-regarded, GP-owned group practice. Excellent remuneration, fully accredited. Friendly, happy place to work. Full time nursing & admin support. Pharmacy on-site. Hours/days flexible; no A/H. 25 mins from CBD. P: 03 9870 9000 - Philip McKenzie W: wrclinic.com.au/jobs E: pmk@wrclinic.com.au

• 70% of billings • DWS location • GP owned • Patient-focused team Active Medical is seeking a VR • Well equipped rooms General Practitioner to join our team • High profile location at our practice in Caroline Springs. • 30 mins from Melbourne Ongoing full time position available, CBD and Airport conveniently located in a high • Modern practice exposure area adjacent to a major • Experienced team of shopping centre. Division 1 nurses and This position would ideally suit a VR GP support staff looking to join a highly experienced • Onsite radiology, pathology team focused on quality patient care. and allied health

Camberwell, melbourne mediCal Centre site available for lease • • • •

Plans approved. Located within a pharmacy. Offering plenty of off-street parking. Easy access it has excellent signage with high visibility to the road. • Close to Shops / Railway Station. P: 0404 031 866 - Jayesh

42

VIC 592664 16_05_27_RN

VIC 592661 16_05_20_RN

Good remuneration. Brand new practice in a busy shopping center. Nursing support. DWS/AoN available.

For established practice located within busy Parkhill Plaza Berwick. Open seven days. Large patient base. RN support. Dietitian, Podiatrist & Pathology on site with Pharmacy next door. Immediate start with excellent remuneration.

We are looking for VR GPs to work in our medical (with on site dental, cosmetic, spa, allied and body and mind medical centre). Part time sessions are also available.

P: 03 8339 4555 - Practice Manager E: schatterjee@craigieburncmc.com.au

Berwick P/T F/T Vr Or GeNerAL reGiSTereD GP

Melbourne Vr GPs

DWS available for a full time GP.

vermont F/t or P/t vr GP reQUIreD For friendly GP owned, well established mixed billing clinic:: • Fully accredited, Fully computerized. • Full time Clinic Nurse. • Onsite pathology. • Diabetes Educator. • Mental Health Nurse. • Administration support. • Excellent remuneration. • Hours negotiable.

To apply, or for more information contact the manager: (03) 9363 0954 or jobs@activemedicalcentre.com.au

P: 03 9386 6680 - Megan Cartwright E: jskmedicalgroup@gmail.com

Cairns YOrKEYs KnOB FOr LEasE

Flexible hours, fully computerised, modern, well equipped practice. Great location in busy shopping centre. Will consider Non VR GP’s (non-resident or with 19AA exemption).

• Attractive percentage offered

GENERAL PRACTICE 30 MINUTES FROM MELBOURNE IN A DWS LOCATION

P: 0407 621 606 - Malcolm

VIC 592663 16_05_20_RN

s

• Opportunity for GP to establish a new Medical Clinic • Premises available from the 1st June • Rare vacancy in the only Shopping centre in Newport • An Established Area with considerable future growth underway

• Teaching practice for registrars and medical students

www.australiandoctor.com.au

P: 03 9874 2422 - Susan E: manager@vermontmedical.com.au

HOXTON PARK - NSW GP PRACTICE FOR SALE Busy solo GP Practice for sale in Hoxton Park (South Western Sydney)Large patient base. Next door to chemist. Seeing more than 50 patients per day P: 0422 830 392 - Tam E: thamle2001@yahoo.com

FOR 592876 16_05_27_RN

• Accredited Practice, supported by on-site chemist, • Pathology, Allied Health, Practice Nurses • Friendly staff. • We open 7 days including public holidays.

NEWPORT REDCLIFFE PENINSULA GP REQUIRED

Criagieburn FT PT Vr gP’s (non DWs)

VIC 592874 16_05_27_RN

POINT COOK FT Or PT GPs (Vr & NON Vr)

VIC 592529 16_05_13_RN

s

VIC 592480 16_05_06_RN

PLEASE CONTACT Phone: 0401 477 860 - Arun Email: admin@bcmedical.com.au

• Visiting specialists

VIC 592837 16_05_20_RN

P: 03 9887 0211 - Geoff E: accmed@accessmedical.com.au

• Purpose built facility with numerous co located services including pathology, radiology and a wide variety of allied health professionals

VIC 592888 16_05_27

A great opportunity exists for an experienced General Practitioner to join Balwyn Central Medical. Our team of Doctors aim to deliver good quality, affordable healthcare to all. We are a GP owned practice, modern and purpose built with on-site pathology, pharmacy and full time nursing support.

Opportunities are also open for VR GPs interested in locum work. Our practice offers flexibility, diverse work, attractive remuneration, a fully computerised system and a great team environment.

A

Busy, Doctor-owned, Modern Practice Doctor-centred, Non-corporate. Flexible Working Conditions. After-hours available but not required. High Grossing: 65–75% of Billings. Mixed Billing. X-ray, Pathology, Nursing Support

• Great location, near public transport and large shoppingcentre.

VIC 592865 16_05_27_RN

» Modern bulk billing practice co-located with a Pharmacy. » Open 7 days, Full / Part Time positions with flexible rosters. » Excellent support from experienced clinical and admin staff. » Relocation incentive is offered.

• • • • • •

• Rewarding work environment within a diverse community.

For 30 years Dianella has cared for the people of Hume; providing high quality services to people of all ages, ethnic backgrounds and socio-economic circumstances. Across multiple sites in Melbourne’s northern suburbs – including Broadmeadows, Craigieburn, Meadow Heights and Roxburgh Park – our services are designed to deliver high quality health care and health promotion to the local community. For further discussion please call Kaye Phillips on 03 8301 8888 or email to pm@dianella.org.au

P: 0416 355 042 - Joe

Knox and Wheelers hill GP reQUired

• Professional nursing and administrative support.

FOR 592817 16_05_20_RN

VR GENERAL PRACTITIONERS REQUIRED FOR BALWYN

• Fully accredited and computerised.

VIC 592826 16_05_20_RN

P: 0424 190 155 / 0405 557 589 - Practice Manager E: practice.medical14@yahoo.com.au

P: 0451 114 171 – Jonathan Blake E: jb@eastbrooke.com.au W: www.eastbrookemedical.com.au

GP required for our medical centre. • Fully computerised. • Friendly staff • Busy location. • High percentage remuneration.

VIC 592840 16_05_20_RN

• DWS available • 457 Sponsorship available • Pharmacy, pathology, radiology onsite

BENTLEIGH GP REQUIRED

VIC 592456 16_05_06_RN

Established, busy mixed billing practice Great admin & nursing support Pathology onsite Competitive remuneration split

VIC 592527 16_05_13_RN

C

• • • •

western suburbs GP required

• Part of a well established community Health Service.

Dianella GP Super Clinic are seeking expressions of interest from VR GPs to work at our Broadmeadows site.

E: pilar.pascua@abcardi.com.au

VIC 592493 16_05_06_RN

Noble Park FT/PT Vr GeNeral PracTiTioNer required

• Radiology, Pathology, Pharmacy and Day Surgery on-site. • Flexible full-time hours, Attractive Remuneration. • Training Practice with EVGP Training. • Easy access from Eastlink Freeway.

• Expanding patient numbers.

VIC 590584 16_04_01

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