Statins (or HMG Co-A reductase inhibitors) are the most effective class of cholesterol-lowering medications, also significantly reducing the risk of developing cardiovascular disease in those patients at high risk.

Between 2004 and 2009, the number of patients diagnosed with high cholesterol has doubled, with statins currently the most prescribed of all drugs, in both quantity and cost, on the Pharmaceutical Benefits Scheme in Australia.

In late February 2012, the U.S. Food and Drug Administration (FDA) approved safety label changes for this class of medication. The expansion of advice on the risks of statins relating to memory loss and increased risk of type two diabetes was reported widely in the Australian mainstream media, resulting in concern amongst patients.

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Postural hypotension is defined as a drop in systolic blood pressure of 20mmHg or diastolic blood pressure of 10mmHg within three minutes of standing. Not only is postural hypotension dangerous because of an increased risk of falls, but it is also a risk factor for stroke and myocardial infarction.

Postural hypotension is commonly experienced in the elderly, due to decreased baroreceptor activity, reduced salt and water conservation, increased arterial stiffness, diastolic dysfunction, and also reduced parasympathetic response.

The elderly are also more likely to be affected by diseases that are associated with postural hypotension, such as Parkinson’s disease and diabetes. Likewise, they are also more likely to be taking medications that can contribute to postural drop, including diuretics, antihypertensives, alpha adrenergic blockers, antipsychotics, and vasodilators.

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Ticagrelor is an oral antiplatelet drug that is a reversible, direct-acting inhibitor of the adenosine diphosphate receptor P2Y12: it has a more rapid onset and produces more pronounced platelet inhibition than clopidogrel. Unlike clopidogrel and prasugrel which are prodrugs, ticagrelor does not need to be metabolised to become biologically active.

The efficacy of ticagrelor was studied in the PLATO study, a multi-centre, double-blinded and randomized trial,comparing ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) and clopidogrel (300 – 600 mg loading dose, 75mg daily thereafter) for the prevention of cardiovascular events in 18,624 patients admitted to the hospital with an acute coronary syndrome, with or without ST-segment elevation. All patients also received aspirin at a dose of 75 – 100 mg daily unless not tolerated.

At 12 months, the findings of the PLATO study were that ticagrelor in combination with aspirin lowered the incidence of a composite outcome of death from vascular causes, MI or stroke more than the
combination of clopidogrel and aspirin. There were slightly more strokes among the group taking ticagrelor compared to those taking clopidogrel, but this was not a statistically significant difference.

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Bullous Pemphigoid (BP) is the most common autoimmune, blistering disease encountered in the western countries. The prevalence is approximately equally for both genders, and although more common in the elderly this condition can occur in younger adults and children.

The clinical presentation involves the appearance of tense blisters on normal-looking or erythematous skin, with mucous membranes involved in about 50% of cases. The degree of associated itch can range from none, through to intense itching, and this may precede the appearance of the blisters by weeks, or in some cases, years.

Bullous Pemphigoid is generally self-limiting and usually remits within five years. Given that most people affected are elderly, with many co-morbidities and a susceptibility to drug-interactions and adverse drug effects, treatment is aimed at arresting the disease progression, reducing itch and the healing of blisters

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Bobby McLeod from Wreck Bay Village, Jervis Bay Territory died May 30 2009 aged 62 years. Here is his song “Wayward Dreams”

In an effort to reduce the potential for in-hospital drug-related problems, RGH and many other hospitals have established a preadmission clinic (PAC) patients are assessed prior to admission for elective surgery. This approach has now become a routine service at RGH, aiming to provide anaesthetic and surgical assessments of patients prior to surgery.

The clinic serves as an opportunity to educate patients, to allow access to allied health professionals, to obtain patient information relevant to the surgery, to anticipate any problems and to plan for a smooth discharge.

Historically, pharmacists have a very limited involvement in PAC. In recent years, it has been reported that having a pharmacist in PAC can be beneficial. The roles undertaken by PAC pharmacists can include taking a complete medication history, and clarifying discrepancies by reviewing notes, contacting general practitioners, community pharmacists, patient’s carers or relatives and residential care facilities

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Dopaminergic replacement therapies such as laevodopa and dopamine agonists are a mainstay in the treatment of Parkinson’s disease. As well as motor symptoms such as motor fluctuations and dyskinesias, dopaminergic drugs can cause behavioural adverse effects such as mood fluctuations, psychosis, and impulse control disorders.

Dopamine Dysregulation Syndrome (DDS) is a recently described complication of long-term dopaminergic therapy for Parkinson’s disease. Patients with DDS develop a pattern of addictive and excessive use of dopamine replacement therapy. Medication use is often escalated by the patient without doctor’s advice and the doses taken are in excess of those required to control motor symptoms.

Hoarding of medication and attempts to purchase additional dopaminergic treatment through the internet or by ‘doctor shopping’ is common. It has been suggested the compulsive medication use is due to sensitization of dopamine receptors, causing a progressive increase in the rewarding effects of dopaminergic drugs.

However, unlike psychostimulant users, patients with DDS do not recognize the pleasurable effects from their medication.

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Clostridium difficile is a bacterium that can cause diarrhoea that does not improve. Symptoms include watery stool, abdominal pain, and fever. Patients may develop electrolyte imbalance, malnutrition and pressure sores. They may go on to develop more serious abdominal conditions.

Most people colonised with C difficile remain asymptomatic. Research as demonstrated that the organism can be cultured from the stool of 3% of healthy adults and 35% of hospital inpatients. When normal gut flora is disrupted, usually by antibiotic exposure, clinical disease develops in C. difficile colonised people under conditions that favor C. difficile proliferation within the colon.

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Age-related macular degeneration (AMD) is the leading cause of blindness and severe visual impairment in adults over the age of 50. Neovascular AMD (nAMD) is caused by the growth of abnormal blood vessels under the macular which can cause haemorrhage and scarring, leading to severe vision loss. One of the mediators in the pathogenesis of neovascular AMD is vascular endothelial growth factor-A (VEGF) which facilitates the growth of these leaky blood vessels. New treatments have been developed to target the inhibition of this growth factor.

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The Australian Advisory Committee on the Safety of Medicines (ACSOM) have received few reports of renal
impairment/failure with IV pamidronate, or oral bisphosphonates risedronate and alendronate, but a significant number with zoledronic acid (31 from a total of 268 reports) are reported. Deterioration in renal function with IV bisphosphonates due to a rapid infusion rate has been suggested, but the reports did not appear to be related to a rapid infusion rate.

Interstitial nephritis was described in three reports. It is important to bear in mind that those who received zoledronic acid were probably more likely predisposed to renal failure secondary to existing co-morbidities (many patients had pre-existing renal impairment or multiple myeloma).

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The new guidelines for Chronic Disease Management in General Practice (Australia) are now available.

They are available as PDF to download or you can order a hard copy.

A haunting song by Kutcha Edwards and The Black Arm Band “Is This What We Deseve?”

I’m a bit late with this as it occurred on 24th April.

However their video “Meningitis: Two Lives, Two Different Outcomes” may be of interest as it explores the disease, symptoms and treatments that are available. More information on the day can be found here.

Diarrhoea is characterised by increased volume, fluidity or frequency of faecal discharges. Acute diarrhoea is commonly infectious and can be viral (e.g. rotavirus, norovirus), bacterial (often causing food poisoning) or parasitic and is usually associated with nausea & vomiting. In some health service jurisdictions, infections with specific organisms are notifiable (e.g. salmonella). The issue of diarrhoea due to Clostridium difficile has been addressed in a previous RGH e-bulletin.

The use of antimotility agents for infectious diarrhoea is not routinely recommended, because the infectious agent and associated toxins will remain in the GI tract longer. Rehydration and electrolyte replacement are the mainstays of treatment. Oral rehydration solutions contain sodium, potassium, glucose and water plus alkalinising agent; a sachet is given after each loose bowel motion.

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Indacaterol is an ultra-long-acting β-2 adrenergic agonist which can be administered once daily for the treatment of Chronic Obstructive Pulmonary Disease (COPD). In Australia, indacaterol has recently been listed for subsidized supply under the auspices of the Pharmaceutical Benefits Schedule (for this indication only).

The pharmacological effects of β-2 adrenoreceptor agonists can be partly credited to the intracellular stimulation of adenyl cyclase. This enzyme catalyzes the conversion of adenosine tri phosphate (ATP) to cyclic 3’,5 adenosine monophosphate. These raised cyclic AMP levels cause relaxation of bronchial smooth muscle. In vitro studies have shown that indacaterol has more than a 24-fold greater agonist activity at β-2 receptors compared to β-1 receptors, and a 20-fold greater agonist activity compared to β-3 receptors. This degree of selectivity is similar to that observed with eformoterol.

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Clickity click 66. Here’s the 66th remote desert wreck of the week with plenty more to come

It’s been a few months but in case you missed it here is the Prime Minister’s Closing the Gap speech delivered to Parliament on 9th February 2012. Following that is a copy of the report.

2011 Closing the Gap

Citalopram is a selective serotonin reuptake inhibitor (SSRI) indicated for major depression. Previously, the usual dose was 20 mg daily, gradually increasing after 2-4 weeks, if necessary, up to 60 mg once daily. The Australian Therapeutic Goods Administration (TGA) recently followed the U.S. Food and Drug Administration (FDA) recommendation to limit the maximum daily dosage of citalopram to 40 mg once daily.

This decision followed evidence from a post-marketing study that demonstrated a significant QT prolongation effect at doses of 60 mg. The FDA suggests that studies have not show a benefit in the treatment of depression at doses higher than 40 mg once daily. The QT interval is a measure of ventricular depolarisation and repolarisation.

QT measurements corrected for heart rate (QTc) over 450 msec for men and 470 msec for women are considered prolonged. Prolonging the QT interval can lead to arrhythmias and in some cases result in Torsades de Pointes (TdP). TdP usually terminates spontaneously but can be life threatening.

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Avoiding the use of high-risk and inappropriate drugs is a simple and cost-effective way to reduce medication-related problems in older people. Several methods have been developed to help identify potentially inappropriate medication (PIM) use in elderly populations.

These can be either criteria-based (explicit) or patient specific (implicit). The Beers criteria, first published in 1991, are the most studied explicit measure of medication use in the elderly. They were first used to assess medication use in nursing home residents in the USA, and were revised in 1997 and 2003 to permit more general use.

The 2003 criteria were divided into two classes; PIM use independent of diagnosis or condition, and PIM use due to drug-disease interaction. The criteria also classified each PIM as having either low or high significance.

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These stories were developed and mostly filmed, animated by young people in Warburton and Warakurna. They have identified ways of health seeking, appropriate services, supporting each other, problem solving and identity through these stories. Young people really engaged and enjoyed the workshops and processes involved in the development and provided fantastic learning opportunities around problem solving.

Lost Zac from Ngaanyatjarra Health on Vimeo.

Kungkaku Yangapalaku from Ngaanyatjarra Health on Vimeo.

Carlston’s Love Song from Ngaanyatjarra Health on Vimeo.

Kulila Kangyima from Ngaanyatjarra Health on Vimeo.