Aust Fam Physician
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Opioids have a critical, time-limited role in our management of acute and terminal pain and an open-ended role in our management of opioid dependency. They also have a use in the management of chronic non-cancer pain. ⋯ For chronic non-cancer pain, the evidence base for the long-term use of opiates is mediocre, with weak support for minimal improvements in pain measures and little or no evidence for functional restoration. Much research and professional education in this field has been underwritten by commercial interests. Escalating the prescribing of opioids has been repeatedly linked to a myriad of individual and public harms, including overdose deaths. Many patients on long-term opioids may never be able to taper off them, despite their associated toxicities and lack of efficacy. Prescribers need familiarity with good opioid care practices for evidence-based indications. Outside these areas, in chronic non-cancer pain, the general practitioner needs to use time and diligence to implement risk mitigation strategies. However, if a GP believes chronic non-cancer pain management requires opioids, prescribing must be both selective and cautious to allow patients to maintain, or regain, control of their pain management.
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Chronic refractory dyspnoea is defined as breathlessness daily for 3 months at rest or on minimal exertion where contributing causes have been treated maximally. Prevalent aetiologies include chronic obstructive pulmonary disease, heart failure, advanced cancer and interstitial lung diseases. ⋯ Dyspnoea is mostly multifactorial. Each reversible cause should be managed (Level 4 evidence). Non-pharmacological interventions include walking aids, breathing training and, in chronic obstructive pulmonary disease, pulmonary rehabilitation (Level 1 evidence). Regular, low dose, sustained release oral morphine (Level 1 evidence) titrated to effect (with regular aperients) is effective and safe. Oxygen therapy for patients who are not hypoxaemic is no more effective than medical air. If a therapeutic trial is indicated, any symptomatic benefit is likely within the first 72 hours.
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Renal function is an important prescribing consideration. On average, glomerular filtration rate declines by about 10 mL/min every 10 years after the age of 40. Renal impairment may cause medicines to accumulate or cause toxicity, especially if the medicine has a narrow therapeutic index. ⋯ Serum creatinine considered in isolation is not a reliable indicator of renal function. The estimated glomerular filtration rate provided in pathology reporting can alert prescribers to possible renal impairment and the need to consider dose adjustments. The Cockcroft-Gault equation should be used to adjust medicine doses. Renal function monitoring is recommended for patients using medicines that can impair renal function or cause nephrotoxicity (eg. NSAIDs, ACEIs, ARBs).
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Active surveillance, followed by delayed definitive treatment for those who develop evidence of significant cancer progression, is now a recognised management strategy for selected men with low risk prostate cancer. ⋯ A considerable proportion of men with low grade prostate cancer on biopsy may never progress to higher stage disease or develop symptoms from their cancers. These patients are suitable for active surveillance under the care of a urologist. Active surveillance involves initial stringent observation of the prostate cancer, with inclusion of monitoring biopsies rather than immediate active treatment in the form of surgery or radiotherapy. With careful selection, about 70% of men will not require any intervention for at least 5 years. Men with low grade disease should be offered active surveillance as a treatment option and provided with information about the risks and benefits of this approach.
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Familial hypercholesterolaemia (FH) is a relatively common inherited cause of premature coronary artery disease. However, a significant number of people remain undiagnosed. Several clinical guidelines on FH have been published recently, but these need to be placed in context for Australian general practitioners. ⋯ General practitioners are well placed to institute screening for FH in the general practice setting. Screening approaches could include opportunistic screening for family history, opportunistic screening of lipids, systematic searching of general practice electronic records, and universal screening of children. The role of specialist lipid clinics is important in the GP management of patients with FH.