Deprescribing: a fancy word for ceasing?

DeprescribingWhat’s old is new again. Hipster beards are so in, they’re out, and where we used to simply cease medications—we now deprescribe them.

The art of commencing medicinal herbs dates back to Neolithic times. The art of stopping them began about a week later.

Probably why Hippocrates had to remind us to do no harm.

With this history, we gen-dinosaur GPs have recently been scratching our beardy chins wondering how we missed the memo that deprescribing is now a ‘thing’.

Mind you; old or new, learning how to stop medication is critical for patient care. And hopefully, now we have a word for it, tomorrow’s deprescribers will do it smarter and harder than we ever did.

Our generation received no explicit teaching, gleaning what we could from our mentors and, no doubt, from our mistakes.

A recent article in The Conversation highlights the dubious practice of using one medicine to counter the side effects of another. This is fine if the first medicine is vital and the second makes the first tolerable. But more often the medicine cabinet rivals a lolly shop, and vague side effects are ubiquitous.

For the 10 per cent of Australians over 65 years taking 10 or more medications, an antacid or antinauseant may just reflect that the stomach is coping with nine other pills. I’d argue sometimes even the antidepressant is a product of a similar prescribing cascade. Continue reading

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Eat like an Italian

Delicious  portion of  fresh salmon fillet  with aromatic herbs,

The jury is in: the Mediterranean diet saves lives, and plenty of them. Just this week at a cardiology conference in Rome (where else?) another large study confirmed it.

So why is it that I so rarely prescribe the Mediterranean diet for my patients?

To answer that, we must examine the dietary advice of GPs in general and, unfortunately, of me in particular.

But first, let’s look at the new evidence from the Moli-sani study.

A group of 1197 Italians with a history of cardiovascular disease were followed for eight years, and their degree of adherence to a Mediterranean diet was assessed on a 9-point score. The all-cause mortality was 37% lower in those who followed the diet (score 6-9) compared to those who didn’t (score 0-3).

That 37% is huge, by the standards of most medication interventions. In comparison, taking a statin (cholesterol medication) reduces mortality by around 25%.

Ah, but association is not causation, you rightly insist! The study can’t show that the diet is the actual cause of the reduction in deaths. Yet in this case, it probably is.

Continue reading

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Diagnostic health apps: coming soon to your smart phone.

illustration of latest smart phone isolated in white background.

In case you missed the news, last week saw the launch of the smartest medical investigation tool in the world. Or, if not that, then at least last week’s biggest health claim in the world.

Ada, a smart phone app designed in Europe but yet to be launched there, is being tested on New Zealanders and Australians first. The makers suggest it is more than just an app (not a literal claim – it is indeed an app), and instead describe their product as a virtual companion.

The underlying concept is clever. This app is the first to tackle health diagnosis on such a grand scale, and its market penetration will be closely watched by Google, Facebook and perhaps startup companies hoping to access a portion of the trillions spent by US medical insurers.

Everything about its design is big, from the team involved (said to include a hundred doctors) to its capacity to eventually integrate with medical video consultations. It even aims to build a picture of the user’s medical history over time, which will presumably adjust the weightings given to each branch of its diagnostic algorithm.

The RACGP and AMA have both issued warnings about diagnostic apps, pointing out the dangers of relying on their results. The app’s marketers have tried to pre-empt this criticism by building in a function where the app can send a copy of its output to the user’s chosen GP.

Technology enthusiasts may be tempted to dismiss RACGP concerns as doctors trying to keep robots off their turf, but the warnings are salient. The issue isn’t as simple as getting the diagnosis right or wrong.

In algorithmic approaches, the risks of both underdiagnosis and overdiagnosis are high. The former can lead to false reassurance with dangerous consequences for the individual, but the latter is the bigger risk at a population level.

Continue reading

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Paracetamol and pregnancy: what’s the fuss?

1. pregnancy

Could paracetamol be linked to ADHD? Photo by

Yesterday’s study linking paracetamol use during pregnancy with behavioural problems in childhood has hit news headlines around the world, and this morning ranked first among Australian health news stories, according to Google trends.

[Clarification: paracetamol brands include Panadol and Tylenol. In the US, the chemical name for the drug is acetaminophen.]

What is the fuss about?

A study published yesterday in JAMA Paediatrics analysed data from 7796 mothers from Bristol, England, who were part of a prospective birth cohort study in 1991-2. The self-recorded data included maternal use of paracetamol during pregnancy (at 18 and 32 weeks) and five years later, and the presence of behavioural issues when the child was seven years old.

The study found an association between antenatal paracetamol use at 32 weeks gestation and behavioural problems for the 7-year-old children, as measured by a high score on a conduct disorder scale (RR 1.42, 95% CI 1.25 – 1.62) and hyperactivity scale (RR 1.31, 95% CI 1.16 – 1.49).

A Relative Risk (RR) of 1.31 means that 7-year-old children in this study were 31 per cent more likely to score highly on an ADHD scale if their mother said she used paracetamol during pregnancy. Smaller RRs were found for paracetamol use at 18 weeks gestation.

The perfect media storm?

Continue reading

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Does complementary medicine equal anti-vax?


Do any complementary practitioners defend Castle Vaccine?


Ever since Wakefield’s flawed MMR-autism study was published in the Lancet – surely that journal’s biggest regret – attitudes to vaccination seem to have become a litmus test for ‘science’ versus ‘non-science’.

The opposing camps are broadly assumed to lie on either side of a river, with mainstream medicine’s castle on one bank battling alternative health practitioners on the other.

But just how clean is that divide?

A review in the latest Vaccine (by Wardle et al. University of Technology Sydney) looks at all studies that examine vaccination attitudes of complementary medicine practitioners and their clients.

Results from the 39 papers reveal a mixed bag of results that mire the waters; the imaginary river turns out to be more a muddy meeting ground.

The authors point out, “There is no default position on immunisation by complementary medicine practitioners or parents who use complementary medicine themselves, or for their children.”

Attitudes vary depending on different populations, but also on what question is being asked.

A UK survey found that, when asked for email advice, no homeopath and only 5% of chiropractors actively recommended MMR.

In contrast, a Canadian study found that two thirds of all chiropractors in Alberta with children had arranged for their own child to be vaccinated. While this is considerably lower than the national average, clearly not every alternative practitioner is helping fortify the anti-vaxxer camp. Continue reading

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Pharmacy business model: consumers at risk

conflict of interestAustralia’s first comprehensive pharmacy review in two decades, released this week, asks the important question:

“Is it confusing for patients if non-evidence based therapies are sold alongside prescription medicines?”

Let me save the reviewers some trouble: the answer is “yes”.

The harder question, of course, is “What, if anything, should be done about it at a regulatory level?” I don’t pretend to have an answer, but doing nothing at all will be a poor outcome for consumers.

The Review of Pharmacy Remuneration and Regulation (the ‘King review’) can be found here (pdf).

I spend a lot of effort highlighting potential conflicts of interest when it comes to doctors’ prescription decisions being swayed by marketing rather than evidence. But this is merely fine-tuning within a system already ensuring most doctors gain no direct financial reward.

The community pharmacy model is, necessarily, far more prone to financial conflicts of interest. Arguably, this could loosely apply to any business with a cash register, but the health industry requires particularly careful oversight. Continue reading

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Does high antibiotic use prevent serious complications?

pill bottle

BMJ article yesterday provided strong evidence that doctors who prescribe antibiotics at high rates for respiratory tract infections are not, in fact, protecting their patients from serious bacterial complications such as meningitis.

This finding negates the ‘patient safety’ claim repeatedly pulled out by some high-prescribers to justify their practice of using antibiotics for colds. They typically recall an awful case of mastoiditis (ear-bone infection) they once treated, then suggest that the researchers must be heartless not to want to prevent it.

I have always resisted the urge to point out that, logically, the more anecdotes these high-prescribers produce, the less it would appear that their prescribing practices actually prevent these bacterial complications!

I resist that urge because, of course, fighting anecdote with anecdote is not how good evidence works. Happily, this study now provides the missing evidence.

Please note: the antibiotic problem certainly doesn’t lie with GPs alone – quite rightly, we need to look at antibiotic use in hospitals, specialists’ rooms, the agricultural industry, and third-world countries with minimal regulation etc. And of course, thousands of GPs do the right thing, and our profession deserves credit for talking about the issue openly.

But who am I to hold back when writing for a GP audience?

Article published in Medical Observer today:

Every medical media article highlighting antibiotic over-prescription of for respiratory tract infections (RTIs) seems to attract at least one doctor’s comment about Continue reading

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World’s best video animation about pharmacists in GP-land

Disclaimer; my claim of ‘world’s best’ relies heavily on the supposition that this is also the ‘world’s only’ such video animation.

It introduces the novel concept of embedding a pharmacist within a general practice (in addition to the pharmacy business owner down the road). This in-house pharmacist would consult from the GP’s rooms, and would not sell or dispense medications.

Besides the obvious benefits to patients in terms of fewer medication errors and misadventures, the appeal to me is that the in-house pharmacist has no conflict of interest.

Because they are non-dispensing, there is no gain or loss to them whether a patient takes one more pill or one less. If a vitamin is of no use to you, they’ll say so. These pharmacists don’t have anything to sell – their role is to advise, educate and oversee.

My video was commissioned by academic pharmacists Debbie Rigby and Chris Freeman, and launched at their AACP Consultant Pharmacy annual conference last weekend.

They tell me that around 25 Australian general practices currently have in-house pharmacists.

Let’s get more.

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We doctors must lift our game on antibiotics

ab'c prescribing report

Today’s major report on Australia’s antibiotic prescribing makes fairly grim reading. The Antimicrobial Use and Resistance in Australia (AURA) report reveals the following:

  1. Almost half (46%) the population was prescribed an antibiotic in 2014.
  2. More than half of patients with colds, flu and respiratory illness who received antibiotics did not need one.
  3. Acute upper respiratory tract infections (colds) resulted in antibiotic prescription 47% of the time (data taken from a sample of 180 GPs).
  4. Prescribing rates for sinusitis, bronchitis and middle ear infection massively exceed evidence-based recommendations.
  5. A fifth of nursing home residents who receive antibiotics have no signs of infection.
  6. Of the 38% of hospitalised patients who receive antibiotics on any given day, a quarter of prescriptions were inappropriate.
  7. Of those receiving antibiotics as a preventative measure around the time of their surgery, 40% of prescriptions were inappropriate.

When this sort of stuff hits the medical media, the response of a few doctors is to dig in, defend our position, and blame the messenger.

I pre-empted this with my own response below, which I have just sent out to GPs via my Medical Observer column. The main message is that we must do something to change.

Antibiotic overprescribing

It’s not hard to feel that GPs are under the pump, with rebate freezes and various reports suggesting we are using medical interventions too much or too little. Continue reading

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Weight-loss surgery: really the most radical treatment in a century?


I spend a lot of time highlighting the commercial forces that promote expensive medical interventions. So yesterday, when I read a lead author describe his new guidelines as “the most radical change in the treatment of type 2 diabetes for almost a century,” my first thought was, “why the hype?”

Francesco Rubino, who made this extraordinary claim in Nature, was describing not a new type of intervention, but a new consensus statement which argued we should be funding bariatric (weight-loss) surgery for more people, and at lower degrees of obesity. Yesterday’s Sydney Morning Herald article gives further background.

Now, we all agree that bariatric surgery has its place, but what are we to make of this statement which potentially expands that place from a niche into a town square?

First, we can dismiss the hype: a bunch of experts recommending surgery does not constitute a radical change in treatment, much less the biggest in a century. Continue reading

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