The Royal Australian College of General Practitioners
Recommendations from the Royal Australian College of General Practitioners (RACGP) on treating hypertension or hyperlipidaemia, prescribing benzodiazepines, self-monitoring of blood glucose, proton pump inhibitor therapy and screening for vascular disease. The Royal Australian College of General Practitioners (RACGP) is Australia’s largest professional general practice organisation and represents urban and rural general practitioners. We represent more than 30,000 members working in or towards a career in general practice. There are more than 125 million general practice consultations taking place annually in Australia.
1.
Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
PPIs are very effective and widely used medications for treating gastroesophageal reflux disease (GORD) and peptic ulcer disease. However, there is evidence of inappropriate prescribing, with a high proportion of patients kept on maximal doses long term. After initial symptom control, the lowest dose and frequency that provides ongoing symptom control should be reached by ‘stepping down’, and the medication ceased when no longer required. This reduces the risk of possible adverse effects to the individual, and the costs of long term treatment.
Adverse effects of long term use include increased risk of GI infection (incl. clostridium difficile), community acquired pneumonia, osteoporotic fractures, interstitial nephritis, and nutritional deficiencies (B12, Fe, Mg), particularly in the elderly or immunocompromised. Exceptions, for which prolonged treatment may be necessary, include Barrett's oesophagus, high grade oesophagitis, and GI bleeding.
The cost of anti-acid medication was $450 million in 2013–14, with prescription volume increasing 9% annually.
Recommendation released April 2015
Supporting evidence
- Hughes JD1, Tanpurekul W, Keen NC, Ee HC. Reducing the cost of proton pump inhibitors by adopting best practice. Qual Prim Care. 2009;17(1):15-21.
- www.nice.org.uk/guidance/cg184/chapter/1-recommendations
- A. S. Raghunath, C. O’Morain & R. C. McLoughlin. Review article: the long-term use of proton-pump inhibitors. Aliment Pharmacol Ther 2005; 22 (Suppl. 1): 55–63.
- T Ali, DN Roberts, WM Tierney. Long-term safety concerns with proton pump inhibitors. The American journal of medicine, October 2009 Vol 122, Issue 10, Pages 896–903
- Reimer C. Safety of long-term PPI therapy. Best practice & research Clinical gastroenterology. 2013;27(3):443-54.
How this list was made
Recommendations 1 - 5 (April 2015)
All RACGP members were invited, and five GPs selected, to join the Choosing Wisely panel. They raised 28 issues, researched these and voted on a shortlist of 10. The voting for this shortlist was based on the amount of supporting evidence available, the degree of importance for patients, and the frequency of the test or treatment being used by Australian GPs. Opinion from the entire College membership was then sought via online survey, to choose five of the shortlisted 10. Additional free-text comment was encouraged, with good response rates. This national vote determined the final five topics.
Following an NPS Representatives meeting, two on that list were found to duplicate other Colleges' choices, and it was felt the RACGP could endorse these rather than replicate them. Therefore the next two highest voted options were selected instead.
Recommendations 6-10 (March 2016)
The RACGP Working Group established for Wave 1 of Choosing Wisely identified 32 candidate topics for Wave 2, then shortlisted fifteen, spread across four categories – screening, imaging, pathology and treatment. The shortlisting criteria were: quality of supporting evidence; importance for patients; and number of Australian GPs using the test or treatment. A dedicated workshop was held at the RACGP Annual Scientific Meeting, ‘GP15’, and the entire RACGP membership was asked to vote for their ‘top five’ via online survey. Additional free-text comment was encouraged, with good response rates. The top five topics from this national vote were written up by the Working Group and reviewed by the RACGP Expert Committee – Quality Care.
- 1 Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
- 2 Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
- 3 Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- 4 Don't screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
- 5 Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
- 6 Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead.
- 7 Don’t order chest x-rays in patients with uncomplicated acute bronchitis.
- 8 Don’t routinely do a pelvic examination with a Pap smear.
- 9 Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
- 10 Don’t test thyroid function as population screening for asymptomatic patients.