RxFiles Newsletters

Acute Otitis Media & Other Respiratory Tract Infections

May 2024

HIGHLIGHTS

· Raise antibiotic awareness via 5 Clinic Posters and other resources.
· Review common questions related to amoxicillin in acute otitis media (AOM).
· Consider opportunities to reassess penicillin allergies and de-label when appropriate.
· Updates to 3 Respiratory Tract Infections: Acute Bronchitis, Acute Pharyngitis, & Acute Rhinosinusitis.

Visit: www.rxfiles.ca/antibiotics

Menopause

October 2023

HIGHLIGHTS

· Weigh the harms and benefits of hormone replacement using our quick reference tool.
· Systemic exposure of low dose vaginal estrogen is minimal, and it has not been linked to cardiovascular disease, dementia, or breast cancer.
· Initiating systemic hormone therapy at a low dose (e.g. PREMARIN 0.3mg, ESTRACE 0.5mg, or the 25mcg transdermal patch) is often reasonable.

Visit: www.rxfiles.ca/menopause

Anxiety

April 2023

HIGHLIGHTS

· The non-drug option for anxiety with the most evidence is cognitive behavioural therapy (CBT). Our CBT patient handout helps encourage patients to give it a try.
· SSRI non-response can be overcome by optimizing dose and duration, or by switching therapy.
· In patients who have difficulty tolerating SSRI titration, a benzodiazepine can help overcome SSRI-related agitation during the first 1-2 weeks.

Visit: www.rxfiles.ca/anxiety

Depression

November 2022

HIGHLIGHTS

· Guide patients to the non-drug therapy that best suits their lives using our psychotherapy prescription pad.
· Allow time when trialing an antidepressant (e.g. 6-8 weeks) before switching.
· Direct switching between SSRIs (without tapering) is often an option.
· Our depression colour comparison chart helps individualize therapy selection.

Visit: www.rxfiles.ca/depression

Migraines

April 2022

HIGHLIGHTS

· Typically try at least three triptans before giving up on the class.
· Combination therapy (e.g. a triptan plus an NSAID) is more effective in acute migraine than either agent alone.
· Candesartan is effective for migraine prophylaxis and well tolerated.
· Often recommend NSAIDs on an empty stomach to treat migraines quickly, as food slows their absorption.
· Starting prophylaxis for medication overuse headache can help facilitate stopping the offending medication.

Visit: www.rxfiles.ca/migraine

Adult Asthma

November 2021

HIGHLIGHTS

· Around half of patients have sub-optimal inhaler technique.
· Filling a prescription for more than 2 asthma reliever canisters per year is a flag for poorly controlled asthma.
· Budesonide-formoterol prn is an option for mild asthma, but for most patients a scheduled ICS is preferred.

Visit: www.rxfiles.ca/asthma

Prescribing Bup-Nal

May 2021

HIGHLIGHTS

· Microdosing buprenorphine-naloxone is a way to help avoid precipitated withdrawal during initiation.
· Traditional initiation of buprenorphine-naloxone is appropriate when patients are in acute withdrawal.
· If precipitated withdrawal occurs during buprenorphine-naloxone initiation, pushing through the withdrawal is preferred over abanonding the inititation attempt. Medications for opioid withdrawal can help.

Visit: www.rxfiles.ca/oud

HIV & PrEP

April 2021

HIGHLIGHTS

· All sexually active adults are reasonable candidates for HIV screening.
· Significant drug interactions with common HIV meds include metformin & dolutegravir; chelation & INSTIs; and tenofovir disoproxil fumarate & NSAIDs.
· Pre-exposure prophylaxis is effective and available for anyone at risk.

Visit: www.rxfiles.ca/HIV

Heart Failure

November 2020

HIGHLIGHTS

· Some medications can reduce heart failure mortality: specific beta-blockers, ACEIs, ARBs, MRAs, and SGLT2 inhibitors, as well as sacubitril/valsartan.
· There is no target blood pressure in patients with heart failure.
· Hyperkalemia, hypokalemia, hypotension, bradycardia, and worsening renal function are common in heart failure, but can be managed.
· Diuretics do not change mortality in heart failure and should be regularly reassessed.

Visit: www.rxfiles.ca/heartfailure

Buprenorphine-Naloxone

September 2020

HIGHLIGHTS

· Buprenorphine-naloxone is effective for opioid use disorder.
· Buprenorphine-naloxone is safer than methadone.
· Buprenorphine-naloxone is easier to prescribe than methadone.

Visit: www.rxfiles.ca/oud

Insulin

Spring 2020

HIGHLIGHTS

· Biosimilar insulins, such as insulin glargine BASAGLAR, have equivalent outcomes to their brand name counterparts.
· All prandial (meal-time) insulins have equivalent outcomes; consider cost and convenience when selecting.
· Basal insulin selection can have a small impact on hypoglycemia risk, but there are many other higher-impact ways to reduce risk other than switching insulins.

Visit www.rxfiles.ca/diabetes

Diabetes

Winter 2019; updated October 2020

HIGHLIGHTS

· Physical activity of any kind improves insulin sensitivity (see our Exercise Rx pad).
· Hold SADMANS medications when patients with diabetes are at risk of dehydration.
· Some SGLT2 inhibitors and GLP1 agonists have shown cardiovascular benefits, but predominantly in patients with established cardiovascular disease.

Visit www.rxfiles.ca/diabetes

Geriatrics

June 2019

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.

Visit: www.rxfiles.ca/geri

Cannabinoids

Fall 2018

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 resource when having conversations about cannabis with your patients.

Visit: www.rxfiles.ca/pain

Tapering Opioids

Spring 2018

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 can help motivate patients to taper their opioid.

Visit: www.rxfiles.ca/pain

Pain Management

Fall 2017

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.

Visit: www.rxfiles.ca/pain

Antibiotics: Part 2

April 2017

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.

Antibiotics: Part 1

October 2016

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.

DAPT

March 2016

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.

COPD

September 2015

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.

PPI Deprescribing

April 2015

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.

Dementia

October 2014

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.

Drugs in Older Adults

October 2013

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.

Atrial Fibrillation

January 2013

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.

Peri-Pregnancy

April 2012

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).

BPSD

October 2011

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.

Opioids

March 2011

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.

Osteoporosis, Vitamin D, SMBG, & Anti-Infectives

October 2010

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 of blood glucose is unnecessary if no therapy change will result.
· High dose amoxicillin can overcome Strep pneumonia resistance in acute otitis media.

Onychomycosis

April 2010

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.

Gout

October 2009

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.

Heart Failure

May 2009

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 & potassium status permit.

Diabetes

October 2008

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.

ADHD

August 2008

HIGHLIGHTS

· Most patients with ADHD 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.

Overactive Bladder

March 2008

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.

IBS

February 2008

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.

PPIs

September 2007

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.

Acne

March 2007

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.

Weight Loss

October 2006

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.

Smoking Cessation

October 2006

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.

Asthma

March 2006

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.

Opioids

October 2005

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.

Parkinson's

June 2005

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.

Fluoroquinolones

February 2005

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).

Post-MI

October 2004

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.

Intranasal Corticosteroids

January 2004

HIGHLIGHTS

· Intranasal corticosteroids are potent and effective drugs for chronic sinusitis, nasal polyps, and rhinitis.
· Proper spray technique can reduce the risk of nasal bleeding with INCSs.
· INCSs with high systemic bioavailability may affect the growth of children.

Androgens, Topical Steroids, & AE Reporting

May 2003

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.

Hypertension

February 2003

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.

Hormone Replacement Therapy

September 2002

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.

Coxibs

May 2002

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.

Lipid-Lowering Agents

February 2002

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.

Diabetes

October 2001

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.

Glaucoma

July 2001

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.

Psychotropics in the Elderly

May 2001; updated September 2011

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.

Acute Otitis Media

February 2001

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 acute otitis media.

Community Acquired Pneumonia

January 2001

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.

Influenza

September 2000

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.

Asthma

May 2000

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.

Coxibs

January 2000

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.

Hormonal Contraception

January 2000

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.

Postmenopausal Pharmacotherapy

September 1999

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.

Acid Suppression

May 1999

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.

H. pylori Eradication

March 1999

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.

Antidepressants

October 1998

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.

Topical Steroids

May 1998

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.

Beta-blockers

April 1998

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.

Calcium Channel Blockers

December 1997

HIGHLIGHTS

· Calcium channel blockers (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).

ACEIs & ARBs

October 1997

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.

NSAIDs

July 1997

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.