RxFiles Newsletters

 

 

Usually twice per year, RxFiles Academic Detailing takes a deep dive into the evidence surrounding a clinical area we think might be appreciated by our readers. We consult experts, read hundreds of articles, critically appraise the available guidelines, and consider multiple perspectives. We then put together documents that we hope will aid clinicians to make informed drug-therapy decisions. Below you will find links to all of our newsletters, dating back to 1997.

 

2019

Geriatrics

 

Diabetes

2019-geri

HIGHLIGHTS

  Nonpharmacological and pharmacological approaches can help prevent falls.

  Older adults require a unique approach to prescribing medications.

  Using the tools, tips, and strategies in the Geri-RxFiles book can help care for older adults.

 

coming fall 2019!

 

 

 

2018

Tapering Opioids

 

Cannabinoids

2018-opioid-taper

HIGHLIGHTS

  After tapering their opioid, patients with CNCP will often have pain that is no worse, and perhaps even improved.

  Motivational interviewing can help encourage patients to taper.

  Our Opioids: Q&A Patient Booklet is a valuable tool.

 

2018-cannabinoids

HIGHLIGHTS

  There are still many uncertainties with cannabis.

  At least 14% of Canadians use cannabis recreationally - routinely screen.

  Using THC roughly doubles the risk of a car crash.

  Our Cannabis: Q&A Patient Booklet is a valuable tool.

 

 

2017

Antibiotics: Part 2

 

Pain Management

2017-abx2

HIGHLIGHTS

  Nitrofurantoin is still effective in >95% of UTIs caused by E. coli in Saskatchewan.

  Urine cultures are not required for most symptomatic acute uncomplicated cystitis cases.

  Incision and drainage are key to successful treatment of skin abscess.

  Elevation of the affected limb is essential to successful treatment of cellulitis.

 

HIGHLIGHTS

  Nonpharmacologic therapy is first-line in chronic pain.

  Let opioid dose guidelines serve the patient - not the other way around.

  Our Pain Colour Comparison Chart provides guidance towards the benefits and harms of various options.

  If prescribing opioids, do so safely.

 

 

2016

DAPT

 

Antibiotics: Part 1

HIGHLIGHTS

  Antithrombotics are sometimes combined to reduce the risk of thrombosis.

  Combination antithrombotic use should be for a definite duration.

  Therapy that is too short or too long increases the risk of harm.

 

2016-abx1

HIGHLIGHTS

  Avoid antibiotics in infections that are predominantly viral (such as acute bronchitis, pharyngitis, sinusitis, and the common cold).

  Our viral prescription pad helps teach patients when they don't need an antibiotic.

  Antibiotic harms are underappreciated.

  Doxycycline covers the majority of community acquired pneumonia bugs.

 

 

2015

PPI Deprescribing

 

COPD

2015-ppi

HIGHLIGHTS

  PPI discontinuation is possible for 14-64% of patients.

  Attempt to discontinue PPI therapy at least once per year in most patients. Exceptions to this include patients with Barrett's esophagus, Los Angeles Grade D esophagitis, and gastrointestinal bleeding.

  Tapering a PPI is more likely to succeed than abruptly stopping.

 

2015-copd

HIGHLIGHTS

  Encourage smoking cessation.

  Ensure influenza and pneumococcal vaccinations.

  Pulmonary rehab of large value, especially following a COPD exacerbation.

  Assess inhaler technique regularly.

  Choose an inhalation device best suited for the patient.

  Reserve inhaled corticosteroids for after LAMA+LABA optimization.

 

 

2014

Dementia

 

 

2014-dementia

HIGHLIGHTS

  Cholinesterase inhibitors may be reasonable to trial in dementia, but supporting evidence is weak, tolerability is low, and benefits (if any) are usually small.

  Avoid combining cholinesterase inhibitors with anticholinergics - prioritize one or the other.

  Non-drug measures are valuable & improve quality of life in patients with dementia.

 

 

 

 

 

2013

Atrial Fibrillation

 

Older Adult Drug Therapy

2013-afib

HIGHLIGHTS

  Assess stroke risk in atrial fibrillation with the CHADS2 or CHA2DS2VASc scores. Assess bleeding risk with the HAS-BLED score.

  Rate control vs rhythm control - appears to be no difference in mortality or stroke risk.

  DOACs do not require INR monitoring and have fewer drug interactions, but have increased cost vs warfarin.

 

2013-olderadults

HIGHLIGHTS

  Insomnia: non-drug approaches effective; pain management may help; sedatives increase fall risk and benefits are small.

  UTIs: Avoid ordering urine cultures in those who are asymptomatic.

  Diabetes: Relax A1c targets in older adults at risk of hypoglycemia and subsequent falls.

 

 

2012

Peri-Pregnancy

 

 

2012-pregnancy

HIGHLIGHTS

  Start folic acid prior to pregnancy.

  Diabetes: insulin has the most safety data in pregnancy; metformin and glyburide may be continued.

  Hypertension: labetalol, nifedipine XL, & methyldopa are first-line in pregnancy.

  Hypothyroid: levothyroxine dose will require increase in pregnancy (e.g. 2 extra pills per week).

 

 

 

 

 

2011

Opioids

 

BPSD

HIGHLIGHTS

  Before initiating therapy, set pain and functional goals with the patient and document progress. Screen for opioid use disorder risk with the Opioid Risk Tool. Obtain informed consent and consider a treatment agreement.

  Use the Opioid Manager Tool.

  Take advantage of Rx monitoring programs.

  Use urine drug screening.

 

HIGHLIGHTS

  Assess for medical causes and drug causes (e.g. infection, constipation, urinary retention, anticholinergic load) in patients with behavioural and psychological symptoms of dementia.

  Non-drug therapy is first-line.

  Acetaminophen may help in unrecognized pain.

  Reassess need for antipsychotics after 3 months.

 

 

2010

Onychomycosis

 

Osteoporosis, Vitamin D, SMBG, Anti-Infectives

2010-onychomycosis

HIGHLIGHTS

  Not all abnormal nails are fungal; treat only if culture positive.

  Treat with terbinafine for 12-16 weeks (drug of choice for toenail onychomycosis).

  Mark nail at end of treatment to monitor treatment success.

 

2010-potpourri

HIGHLIGHTS

  Consider osteoporosis fracture risk, and whether a bisphosphonate is indicated.

  There is safety and efficacy evidence for Vitamin D 800-2000 IU per day for most osteoporosis patients.

  Self monitoring blood glucose is unnecessary if no therapy change will result.

  High dose amoxicillin can overcome Strep pneumonia resistance in AOM.

 

 

2009

Heart Failure

 

Gout

2009-hf

HIGHLIGHTS

  Gradually titrate ACEIs and BBs in heart failure to target doses to achieve mortality benefits. If low blood pressure, but asymptomatic, push on. Lowering diuretic dosing can help achieve target ACEI/BB dosing.

  Patients who monitor their daily weights can help prevent a hospital admission.

  Spironolactone is useful in stage 3-4 heart failure if renal function & K+ status permit.

 

2009-gout

HIGHLIGHTS

  Low dose colchicine (e.g. 1.2mg stat, then 0.6mg in one hour) can be used as initial therapy in gout and has improved GI tolerability.

  Indomethacin has never been shown to be superior to any other NSAID.

  Don't start, stop, or adjust allopurinol dosing during an acute gout attack.

  Weight loss for gout is likely more beneficial than a low-purine diet.

 

 

2008

IBS

 

Overactive Bladder

HIGHLIGHTS

  All patients with irritable bowel syndrome should receive reassurance that their symptoms are not life-threatening.

  Lifestyle modification can provide more relief than medications.

  Addressing psychosocial stress can help improve IBS symptoms.

  No single drug treats all IBS symptoms. Target drug therapy to specific symptoms.

 

2008-oab

HIGHLIGHTS

  Start oxybutynin at 2.5mg and titrate slowly in overactive bladder. PRN dosing is useful for some.

  Second-generation anticholinergics are better tolerated and more convenient than oxybutynin, but can cost more. Efficacy differences appear to be small.

  All anticholinergics can worsen cognitive impairment, especially in older adults.

ADHD

 

Diabetes

2008-adhd

HIGHLIGHTS

  Most ADHD patients will respond to stimulant therapy; alternatives include atomoxetine and other off-label non-stimulants.

  A stimulant treatment agreement can help protect both patients and doctors.

  Long-acting formulations may have less stimulant misuse potential.

 

2008-diabetes

HIGHLIGHTS

  Individualize glycemic control targets, considering patient and intervention factors.

  Metformin is first-line therapy, and should be continued indefinitely unless contraindicated.

  Discuss insulin use early on to gain patient buy-in for when it may be needed.

  A low dose of basal insulin at bedtime can make starting insulin safer and easier.

 

 

2007

Acne

 

PPIs

2007-acne

HIGHLIGHTS

  Acne medications require weeks of therapy before benefit.

  Topical therapies should be applied to the entire affected area - not just to specific lesions.

  Adding benzoyl peroxide to topical antibiotic regimens helps prevent bacterial resistance.

  Oral isotretinoin is the most effective acne medication.

 

2007-ppi

HIGHLIGHTS

  There are no clinically important differences between PPIs for most gastrointestinal conditions.

  Doubling the PPI dose typically does not provide additional efficacy over standard dosing.

  Periodically reassess PPI therapy - lower doses, tapering, or step-down to H2RAs may be indicated.

 

 

2006

Asthma

 

Smoking Cessation

2006-asthma

HIGHLIGHTS

  Asthma is often poorly controlled.

  Asthma action plans can help patients proactively manage their symptoms.

  It is critical for patients on long-acting beta-agonists to continue their steroid therapy.

  Inhaled corticosteroids are safe to continue in pregnancy.

 

2006-smokingcessation

HIGHLIGHTS

  Success in smoking cessation is seldom seen on the first attempt.

  Pharmacotherapy roughly doubles the chance of success.

  Combining nicotine gum with the nicotine patch is reasonable to help acute cravings.

  Support, counselling, and follow-up are essential, with or without drug options.

 

Weight Loss

 

2006-weightloss

HIGHLIGHTS

  Lifestyle and behavioural interventions are the cornerstone of weight loss.

  Weight loss drugs provide only a modest reduction in weight (<5kg at 1 year).

  No drugs with a weight loss indication are currently covered by Saskatchewan Health or NIHB.

  When possible, choose drugs with a low potential to cause weight gain.

 

 

 

 

2005

Fluoroquinolones

 

Parkinson's

HIGHLIGHTS

  Reserve fluoroquinolones to prevent antimicrobial resistance to this valuable class of antibiotic.

  Ciprofloxacin has anti-pseudomonal activity, making it particularly valuable.

  If treating community-acquired pneumonia with a fluoroquinolone, ensure use of a "respiratory fluoroquinolone" (e.g. NOT ciprofloxacin).

 

HIGHLIGHTS

  Levodopa is efficacious in Parkinson's Disease, but adverse effects are common.

  Chewing immediate-release levodopa speeds onset of action.

  Controlled-release levodopa at bedtime may be valuable in patients with early morning "off" episodes.

  Avoiding large levodopa doses helps prevent dyskinesia.

 

 

Opioids

 

 

HIGHLIGHTS

  Optimize both drug and non-drug interventions when treating pain.

  Carefully select patients for opioid use and use a treatment agreement in all patients.

  Avoid meperidine.

  Combination opioid/acetaminophen products are easily overused.

  Initiation of opioids doesn't always mean lifelong therapy.

 

 

 

 

 

2004

Intranasal Corticosteroids

 

Post-MI

2004-ics

HIGHLIGHTS

  Intranasal corticosteroids are potent and effective drugs for chronic sinusitis, nasal polyps, and rhinitis.

  Spray technique can reduce the risk of nasal bleeding with INCSs.

  INCSs with high systemic bioavailability may affect the growth of children.

 

HIGHLIGHTS

  Combination therapy with an ACEI, a statin, ASA, and a beta-blocker reduces cardiovascular risk in post-MI patients. This benefit is independent of lipid levels, blood pressure readings, or presence of LV dysfunction.

  Lifestyle management (e.g. diet, exercise, lifestyle) is also beneficial to all post-MI patients.

 

 

2003

Hypertension

 

Androgens, Topical Steroids, & AE Reporting

2003-htn

HIGHLIGHTS

  Low-dose thiazide diuretics remain the cornerstone of antihypertensive therapy.

  Most patients will require 2 or more drugs to adequately control their hypertension.

  Alpha-blockers should be avoided due to their increased risk of heart failure.

  ALLHAT showed CCBs to be safe and effective antihypertensive agents.

 

2003-androgen

HIGHLIGHTS

  Benefits of testosterone therapy are well accepted in symptomatic patients with hypogonadism; however, there is debate on their role in elderly men with partial, age-related decreases in testosterone.

  In general, only use low potency steroids on the face.

  51% of newly approved drugs have serious adverse effects undetected at approval.

 

 

2002

Lipid-Lowering Agents

 

Coxibs

HIGHLIGHTS

  Patients at the highest risk of a CV-event benefit the most from lipid lowering (i.e. greater effect size in secondary prevention than primary prevention).

  Statins are currently the only lipid lowering agent with a demonstrated mortality benefit.

 

HIGHLIGHTS

  Coxibs are not more effective than other NSAIDs.

  Coxibs have less GI-risk than other NSAIDs.

  Coxibs have similar renal risk to other NSAIDs.

  Coxibs may increase the risk of a cardiovascular event; caution is warranted.

 

 

Hormone Replacement Therapy

 

 

HIGHLIGHTS

  Hormone replacement therapy has benefits, but must be weighed against known long-term risks.

  Consider lifestyle changes for vasomotor symptoms where possible.

  If using HRT, use the lowest effective dose for the shortest amount of time.

  Vaginal moisturizers or vaginal hormone creams for genitourinary symptoms have a low risk of adverse effects.

 

 

 

 

 

2001

Community Acquired Pneumonia

 

Acute Otitis Media

2001-cap

HIGHLIGHTS

  Timely empiric treatment of community acquired pneumonia is crucial; tailor the antibiotic choice to the patient.

  Respiratory fluroquinolones are efficacious, but should be reserved to prevent resistance.

  Stepping down from IV to oral therapy when feasible facilitates earlier hospital discharge of CAP.

 

2001-aom

HIGHLIGHTS

  Acute otitis media is the most frequent bacterial infection of childhood.

  80% of AOM cases will resolve spontaneously without antibiotics. "Watchful waiting" for 48-72 hours may be feasible for select low-risk children.

  Amoxicillin is still the drug of choice in AOM.

 

Glaucoma

 

Psychotropics in the Elderly

2001-glaucoma

HIGHLIGHTS

  Therapeutic options for glaucoma effectively lower intraocular pressure.

  Many patients have poor eyedrop instillation technique. This compromises efficacy and can increase the risk of adverse effects.

 

2001-psych-elderly

HIGHLIGHTS

  Older adults are at high risk of drug-induced cognitive impairment.

  Use caution with TCAs, antipsychotics, benzodiazepines, and indomethacin in older adults.

  Nonpharmacological therapy is first-line for behavioural and psychological symptoms of dementia.

 

 

Diabetes

 

 

HIGHLIGHTS

  Metformin is first-line therapy in diabetes, especially in obese patients.

  Optimal diabetes care must also emphasize control of blood pressure, lipids, and other cardiovascular risk factors.

  Combination pharmacotherapy is usually required in most patients to achieve glycemic control.

 

 

 

 

 

2000

Hormonal Contraception

 

Coxibs

2000-oc

HIGHLIGHTS

  Low-dose oral contraceptives are highly effective with excellent safety.

  No single hormonal contraceptive is superior in efficacy, safety, or tolerability.

  Smoking, particularly after the age of 35, increases the risk of cardiovascular and thrombotic events in patients on hormonal contraceptives.

 

2000-coxibs

HIGHLIGHTS

  Coxibs are not more effective than other NSAIDs.

  Coxibs have less GI-risk than other NSAIDs.

  Coxibs have similar renal risk to other NSAIDs.

  Caution is warranted with coxibs due to a lack of long-term/published studies.

 

Asthma

 

Influenza

2000-asthma

HIGHLIGHTS

  Inhaled corticosteroids are the cornerstone of asthma therapy for all but the mildest cases.

  Daily or increasing use of short-acting beta-agonists is a sign to increase the steroid dose, or consider add-on therapy.

  It is critical for patients on long-acting beta-agonists to continue their steroid therapy.

 

2000-flu

HIGHLIGHTS

  Immunization is the most effective means of preventing and controlling the spread of influenza.

  The optimal time to immunize is October through mid-November.

  Antiviral agents in influenza are of little value if prescribed more than 48 hours after the onset of illness.

 

 

1999

H. Pylori Eradication

 

Acid Suppression

1999-hpylori

HIGHLIGHTS

  H. pylori eradication dramatically reduces ulcer recurrences in patients with duodenal or gastric ulcers.

  7-day triple therapies given BID are currently first-line for H. pylori eradication.

  Maintenance acid suppression therapy is not necessary following H. pylori eradication except in high risk patients.

 

HIGHLIGHTS

  PPIs are generally superior to H2RAs in treating acid-related diseases.

  There are few significant differences between PPIs.

  PPIs are most effective when taken just prior to a meal.

  Ranitidine has fewer drug interactions than cimetidine.

 

 

Postmenopause Pharmacotherapy

 

 

HIGHLIGHTS

  Long-term hormone replacement therapy carries several major benefits, but also risks. Evaluate on an individual and ongoing basis.

  Continuous estrogen replacement is appropriate for women without a uterus. Women with a uterus should receive a progestagen in addition to estrogen.

 

 

 

 

 

1998

Beta-blockers

 

Topical Steroids

HIGHLIGHTS

  Cardioselective beta-blockers may have improved safety and tolerability.

  Beta-blockers, unless contraindicated, are preferred agents in angina, previous myocardial infarction, and supraventricular arrhythmia.

  Carvedilol is beneficial in heart failure patients.

 

HIGHLIGHTS

  Topical steroids have potency ranging from Group 1 (Ultra High) to Group 7 (Low).

  Higher potency agents are useful in resistant conditions and thicker skin.

  Lower potency agents are useful in young children, where long-term use is required, and on thinner skin.

  Ointments are occlusive and effective in dry and hyperkeratinized skin conditions.

 

 

Antidepressants

 

 

HIGHLIGHTS

  All antidepressants have similar efficacy in depression. However, there are variations in cost, adverse effects, drug interactions, contraindications, and so on.

  SSRIs are first-line over TCAs for depression due to safety and tolerability.

  Nortriptyline has fewer side effects than amitriptyline.

 

 

 

 

 

1997

NSAIDs

 

ACEIs & ARBs

1997-nsaid

HIGHLIGHTS

  NSAIDs all have similar efficacy and adverse effects.

  Ibuprofen and naproxen are often preferred NSAID choices in low-risk patients.

  Acetaminophen is first-line in osteoarthritis.

  Misoprostol is approved for prophylaxis of NSAID-induced ulcers.

 

HIGHLIGHTS

  ACEIs all have similar efficacy and adverse effects.

  ACEIs are second-line to diuretics for hypertension.

  Lisinopril has cost advantages in Saskatchewan, and strong evidence of benefit.

  ARBs are alternatives when ACEIs are not tolerated.

 

 

Calcium Channel Blockers

 

 

HIGHLIGHTS

  CCBs are second-line to diuretics for hypertension.

  Short-acting CCBs are not recommended.

  Amlodipine may be OK in congestive heart failure (vs diltiazem and verapamil, which are contraindicated).