Consult 004 2008 by Virtual Medical Centre

consult The Australian Medical Magazine for Specialists and GPs Spring 2008

When drugs

ain’t drugs Fighting the scourge of counterfeiting

Vitamins and Cancer Therapy The Emperor’s New Clothes uncovered

Chronic Kidney Disease What does an eGFR <60 really mean?

Multiple Sclerosis Treatment and long-term care

Neuropathic Pain

Magazine

pantoprazole ®

A first choice for 24-hour symptom control

1–4§

PBS Information: Restricted Benefit. Gastro-oesophageal reflux disease; initial Before prescribing, please review Approved Product Information. Full PI available from Nycomed Pty Ltd, ABN 71095 610 870, 2-4 Lyonpark than with ranitidine 150mg bd (p<0.05).2 *Only Somac binds to cysteine residue 822 and the true clinical significance of this is unknown. †Half-life

Duodenal and gastric ulcers; gastro-oesophageal reflux disease (GORD), including symptomatic GORD and reflux oesophagitis; gastrointestinal lesions refractory to H2 blockers; Zollinger-Ellison non-selective NSAIDs in increased risk patients with a need for continuous NSAID treatment. CONTRAINDICATIONS: Hypersensitivity to ingredients; cirrhosis; severe liver disease. Combination therapy: malignancy; rare cases of Vitamin B12 deficiency reported; monitoring for long-term use; investigation if non-responsive symptomatic GORD; pregnancy; lactation; children; monitoring for patients on diarrhoea, severe eructation, constipation, flatulence, dry mouth, upper abdominal pain, metallic taste, psychiatric disorders; others, see full PI. DOSAGE AND ADMINISTRATION: Monotherapy: 20initial dose with mild liver disease. Date of preparation: 16 July 2007. Price: 20mg (30): Restricted Benefit - PBS/RPBS: fully dispensed $21.34; 40mg (30): Restricted Benefit - PBS/RPBS: fully Aliment Pharmacol Ther 2003; 18: 587-594. 4. Grass U et al. 10th United European Gastroenterology Week Congress, UEGW 2002, Geneva, 19-24 October. 5. Sachs G. Pharmacotherapy 2003;

Somac is unique among PPIs, it binds deep in the proton pump, at cysteine 822.5,6* Somac produces lasting acid suppression.6,7†

Somac reduces the chance of breakthrough nighttime symptoms.1# Somac: a first choice for 24-hour symptom control.1–4§

24 hr

1–4§

treatment of peptic ulcer; Zollinger-Ellison syndrome; scleroderma oesophagus. Road, North Ryde NSW 2113. §During 12 months, percentages of heartburn free days/ nights were significantly higher with Somac 40mg/day of acid inhibition approximately 46 hours as determined by PK/PD models in humans. #SOMAC 40mg vs placebo. SOMAC® (pantoprazole) INDICATIONS:

Syndrome; maintenance of healed reflux oesophagitis; eradication of H. pylori in peptic ulcer (combination therapy); prevention of gastroduodenal lesions and dyspeptic symptoms associated with Hypersensitivity to antibiotics; moderate to severe hepatic or renal dysfunction, atazanavir therapy. PRECAUTIONS: If suspected gastric ulcer or reflux oesophagitis, exclude coumarin anticoagulants; drugs with pH dependent bioavailability, including atazanavir. ADVERSE EVENTS: Most commonly reported: Fatigue, asthenia, sweating, headache, 40 mg once daily depending on indication (may be increased for Zollinger-Ellison Syndrome or reflux oesophagitis), see full PI. Combination therapy: 40 mg twice daily. Reduced dispensed $38.04. References: 1. Richter JE et al. Am J Gastroenterol 2000; 95: 3071-3080. 2. Richter JE et al. Aliment Pharmacol Ther 2004; 20: 567-575. 3. Scholten T et al. 23 (Suppl): 68S-73S. 6. Shin JM et al. Gastroenterology 2002; 123: 1588-1597. 7. Somac Product Information, July 2007. ®Registered Trademark 07/08 S&H NYCSO0110

POWERFUL BP REDUCTIONS from Morning to Morning

PBS information: General Benefit. FULL PRODUCT INFORMATION IS AVAILABLE ON REQUEST FROM THE MANUFACTURER. PLEASE REVIEW THE FULL PRODUCT INFORMATION BEFORE PRESCRIBING.

Reference: 1. White et al. Am J Hypertens. 2004;17:347-353. Boehringer Ingelheim Pty Ltd. ABN 52 000 452 308, 85 Waterloo Road, North Ryde NSW 2113. 速Registered Trademark. MICARDIS速 (telmisartan) Tablets 40 mg and 80 mg. INDICATIONS: Treatment of hypertension. CONTRAINDICATIONS: Hypersensitivity to any components of the product. Pregnancy. Lactation. Biliary obstructive disorders. Severe hepatic impairment. Rare hereditary conditions (fructose intolerance).* PRECAUTIONS: Primary aldosteronism; congestive heart failure; aortic/mitral valve stenosis; obstructive hypertrophic cardiomyopathy; ischaemic cardiovascular disease; renal artery stenosis, kidney transplant; patients whose vascular tone and renal function depend on the activity of the renin-angiotensin-aldosterone system; hepatic and/or renal impairment; combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory drugs and thiazide diuretics; volume and/or sodium deficiency; fructose intolerance, children. Interactions with Other Drugs: Other antihypertensive agents; digoxin; lithium, NSAIDs (including aspirin, COX-2 inhibitors and non-selective NSAIDs*), potassium-sparing diuretics, potassium supplements, other agents that may cause increased serum potassium levels. ADVERSE REACTIONS: headache, upper respiratory tract infection, diarrhoea, back pain, pain, influenza-like symptoms, sinusitis, erythema, syncope/faint, hypotension, bradycardia, abnormal hepatic function / liver disorder, renal impairment, hyperkalaemia, anaemia, eosinophilia, thrombocytopenia, weakness, dizziness, fatigue, angioneurotic oedema*, pruritus, rash, urticaria, others (see full PI). DOSAGE: Adults: 40 mg once daily. Increase to 80 mg once daily if necessary. The maximum antihypertensive effect is generally attained four to eight weeks after the start of treatment. No dosing adjustment is necessary in the elderly or in patients with renal impairment, including those on haemodialysis. Telmisartan is not removed from blood by haemofiltration. In patients with mild to moderate hepatic impairment, dosage should not exceed 40 mg once daily. PBS DISPENSED PRICE: MICARDIS速 40 mg $20.02, MICARDIS速 80 mg $26.96. *Please note changes in Product Information. TH MIC FP 6/08 CSANZ

medical director

consult

elcome to another edition of CONSULT Magazine! For the first time, our last issue of CONSULT Magazine included a mix of the relevant clinical articles prepared by medical specialists on our Editorial Advisory Board (which you are used to), and a new series of articles on practice management and lifestyle. The response has been overwhelmingly positive and so we are continuing with the balance of articles in this issue. We continue to receive positive feedback and praise from subscribers to the weekly e-newsletter of CONSULT Magazine. There are informative articles on best clinical practice, medical policy and politics, and lifestyle. Make sure you sign up to receive your free subscription online at www.consultmagazine.net. It also gives me great pleasure to introduce Virtual Medical Centre’s new initiative: our CME program, endorsed by the RACGP for 40 Category 1 points and by ACRRM for 12.75 points. There are over 600 topics to choose from! Please read the article on page 18 – your feedback would be very welcome. To help shape Australia’s busiest health site, Virtual Medical Centre, please email me (adean@virtualmedicalcentre.com) if you would like to join our Editorial Advisory Board or offer feedback on www.virtualmedicalcentre.com and CONSULT Magazine. Andrew Dean MBChB MRCP(UK) FRACP Medical Director Virtual Medical Centre

Magazine

COUNTERFEIT DRUGS 4

When drugs ain’t drugs

ROOM DESIGN 7

The experience of waiting and consulting rooms

PALLIATIVE CARE

10 Home-based palliative care

CHRONIC KIDNEY DISEASE

13 What does an eGFR <60 really mean?

Associate Professor Merlin C Thomas

MULTIPLE SCLEROSIS

contents

greetings from the

15 Focus on progressive multiple sclerosis Part II: Treatment and long-term care

Dr Jeremy Hallpike

ONLINE LEARNING

18 Virtual education reaches new heights

Dr Joe Kosterich

VITAMINS AND CANCER THERAPY 23 The Emperor’s New Clothes uncovered: Vitamins may hinder cancer therapy

Dr Andrew Dean

NEUROPATHIC PAIN

28 Using gabapentinoids to treat neuropathic pain

Professor Stephan A Schug

TREE CHANGE

30 Beating it to the bush We acknowledge the important contribution of the Medical Directors: • Dr Peter Bremner • Dr Andrew Dean • Dr Nick de Felice • Dr Clay Golledge • Dr Roger Goucke • Professor Jeffrey Hamdorf • Professor Graeme Hankey • Dr Andrew McQuillan

• Dr Brendan McQuillan • Dr Donald Ormonde • Dr Paul Snelling • Associate Professor Rob Will • Dr Garry Wilson • Dr Steve Wilson • Dr Joe Kosterich (Medical Spokesperson)

Published by Virtual Medical Centre.com Pty Ltd and Aspermont Ltd Managing Editor: John Feary Editor: Nick Evans (nick.evans@aspermont.com) Medical Editor: Elizabeth Tysoe (elizabeth@virtualmedicalcentre.com) Contributor Coordinator: Jen de Vos Production Team Leader: Mata Henry Production Coordinator: Kelly Somers Senior Layout Designer: Diane Igglesden Layout Designer: Catherine Hogan Senior Sub Editor: Sonja Moore Sub Editor: Sarah McCabe MEDICAL SUB EDITOR: Dr Emma Jaquet Advertising Sales: Peter Sinclair (peter.sinclair@aspermont.com, advertising@consultmagazine.net) Ph: (02) 9808 1890 Advertising Production: Isaac Burrows, Christine Lim, Janine Hoffman Subscriptions: subscriptions@consultmagazine.net Circulation: 20,000 copies Executive: Colm O’Brien – Chief Executive Officer, Chris Bond – Chief Operating Officer, Henry Thong – Chief Financial Officer Virtual Medical Centre PO Box 1048, Subiaco, Western Australia 6904 Ph: Perth (08) 9388 0344 Fax: (08) 9388 0611 Sydney office: Level 4, 201 Miller Street, North Sydney Ph: (02) 9025 3590 Fax: (02) 9025 3535 Email: consult@virtualmedicalcentre.com Website: www.virtualmedicalcentre.com Medical Director: Dr Andrew Dean Managing Director: Wayne Hughes General Manager: Thomas Maher General Manager Marketing: Barry Epstein Aspermont 613-619 Wellington Street, Perth, Western Australia 6000; PO Box 78, Leederville WA 6902 Ph: (08) 6263 9100 Fax: (08) 6263 9148 Website: www.consultmagazine.net COPYRIGHT WARNING: All editorial copy and some advertisements in this magazine are subject to copyright and cannot be reproduced in any form without the written permisson of the editor. Offenders will be prosecuted. DISCLAIMER: Virtual Medical Centre.com Pty Ltd and Aspermont Ltd (‘the publishers’), and each of its directors, employees and related entities do not make any warranty whatsoever as to the accuracy or reliability of any information, estimates, opinions, conclusions or recommendations contained in this publication and, to the maximum extent permitted by law, the publisher disclaims all liability and responsibility for any direct or indirect loss or damage which may be suffered by any person or entity through relying on anything contained in, or omitted from, this publication whether as a result of negligence on the part of the publisher or not.

Aspermont Limited Information for Industry

Production Management: Aspermont Limited (ABN: 66 000 375 048)

COUNTERFEIT DRUGS

When drugs

ain’t drugs By Ruth Callaghan

IT USED to be a problem confined to those with, ahem, size issues. Click on a dodgy advertisement for a pharmaceutical performance-booster and any little blue pill that turned up in the mail was bound to be fake. But the issue of counterfeit medication has gone far beyond Viagra, with the market for counterfeit drugs tipped to be worth up to $200 million a day by 2010. And while pharmaceutical companies safeguarding profits are the most vocal about the problem, it also threatens the health of hundreds of millions worldwide. The World Health Organization says counterfeit drugs are rampant, making up an estimated one in 10 medications worldwide.

They have left trails of death in countries such as Haiti, where children died after receiving cough syrup spiked with a chemical used in antifreeze, and in Niger, where fake vaccines failed to protect 2500 people from meningitis. Even if the medicine itself is not fatal, the lack of active ingredients renders many drugs useless. Up to 40% of anti-malarials may contain no active ingredient, for example, and in parts of Africa, Asia and Latin America as many as one in three medicines on sale is fake. WHO says determining the value of the counterfeit market is difficult, but points to estimates by the industry-backed US Center for Medicines in the Public Interest that it will be worth $75 billion globally by 2010.

Viagra and other genito-urinary drugs remain the top sellers, followed by antiinfectives such as anti-malarials and drugs for the central nervous system. The fastest-growing segment is among fake cardiovascular drugs, however, according to groups that monitor counterfeit seizures. Fakes range from drugs containing less – or more – than the required amount of active ingredients used in the real version, to products with the correct ingredients that were manufactured in unsanitary or unsafe conditions. In some cases, it is the packaging that has been altered, with genuine medicines reboxed to extend the expiry date. But while the rest of the world begins to tackle the growing threat posed by

Spring 2008 | Consult Magazine

COUNTERFEIT DRUGS

counterfeit medication, the issue has barely made it onto the radar in Australia. Protected by our isolation, regulated drug market and tight border security, Australia has one of the safest pharmaceutical supply chains in the world. The Therapeutic Goods Administration says that by working with border control agencies and manufacturers, “counterfeit drugs is not a big problem in Australia”. Yet that may be changing. In November, a report by the Organisation for Economic Co-operation and Development (OECD) noted that while Australia and other developed countries had very low counterfeit levels in the regulated supply, attacks were mounting. The report warned that “counterfeits are increasingly being detected as having entered the supply chain of some of the most regulated jurisdictions”. Those jurisdictions include the UK, where Pfizer says a recent recall of cholesterol drug Lipitor found 60% of returned packets were fake, and Canada, where deaths have been linked to counterfeit versions of bloodpressure drug Norvasc. Pharmacy Guild of Australia vicepresident Tim Logan said the odds of finding counterfeit drugs in Australian pharmacies were still remote, as the TGA strictly regulated the importation of medicine listed or unlisted by the Pharmaceutical Benefits Scheme. And while recent incidents such as the recall of seven contaminated batches of the blood-thinning drug Clexane raise questions about the safety of all supplies, he said the supply chain was carefully monitored.

The scale of the problem THE number of counterfeit drug seizures has surged in recent years, according to the Pharmaceutical Security Institute, a membership group for pharmaceuticals which has tracked cases since 2002. The institute counts counterfeiting alongside other criminal acts such as largescale drug theft and illegal diversion (in which medicines approved for one country are intercepted and sold elsewhere).

“Clexane was an isolated incident and it was picked up very quickly,” he said. “I guess any manufacturing process can have glitches and you just want to detect that sort of thing quickly.” But Mr Logan said Australians who decided to bring drugs into the country from overseas, usually through internet pharmacies, were at far greater risk. The TGA also points to personal importation as an entry point for fake drugs, although it allows individuals to bring in up to three months’ supply of medication at a time for their own use or that of an immediate family member. Individuals can access up to 15 months’ supply of a drug in a single year. There are exceptions to the rule – including a range of prohibited substances, such as anabolic steroids, drugs that require

In some cases, genuine medicines are reboxed to extend the expiry date.

In 2007, there were 1759 major incidents, mostly in Asia and Latin America, involving 639 different pharmaceutical products. Every therapeutic category was targeted, the group says, and some seizures found scores of different drugs being produced and marketed by criminal organisations. Worldwide, 1047 people were arrested.

injections or those that include material of human or animal origin – and many drugs require the importer to be in possession of a script. “There is really no need to buy things offshore,” Mr Logan said. “The PBS delivers quality drugs at quite a low cost and pharmacies can supply medications at good prices. I would be very careful about going outside Australian pharmacies.” The temptation to do just that can be strong, however. Dr Alex Broom, a sociologist at the University of Newcastle, has researched the use of the internet by patients both to inform themselves on health issues and to obtain medication directly. With the proliferation of online chat sites and the sharing of information across borders, it is easy to see how a drug being used in one part of the world to fight disease could be sought by patients elsewhere. “You might have a drug that is offered in the US and UK and in the context, say, of someone with cancer, they can’t afford to wait [for it to be available here],” he said. “In that case, they may be less concerned about the risk of it not being regulated in the way that it should be or that you might take it in a way that your physician would not like.” Dr Broom said the sense of independence the internet gave patients in seeking health care information and solutions was not something that would be easy – or desirable – to change. But helping them access better information about which sites to trust or which pharmacies were safest could help. “In the 21st century we have a democratic view of individual agency, and in a consumerist society this is quite good,” he said. “What we need is to be able to talk openly about these things; ensure they get time in a medical consultation to discuss things.” CM

Consult Magazine | Spring 2008

: n i a p c i h t a p d o e r t u Ne ica 1

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†Significant improvement compared to placebo by trials. #LYRICA may potentiate the CNS depressant

week 1 and sustained effect for up to 13 weeks in clinical effects of alcohol and CNS depressant medications. Before prescribing, please review Approved Product Information. LYRICA®* Indications Neuropathic pain in adults. As adjunctive therapy

in adults with partial seizures with or without secondary generalisation. Contraindications Hypersensitivity to pregabalin or excipients. Precautions Pregnancy; lactation; may cause dizziness and somnolence and therefore may affect the ability to drive and use machines and may increase accidental falls in elderly; congestive heart failure; galactose intolerance; withdrawal symptoms. Interactions: oxycodone, CNS depressants, ethanol and lorazepam. Adverse effects Dizziness, somnolence, blurred vision, weight gain, peripheral oedema, creatine kinase elevation, fatigue, dry mouth, ataxia, balanced impaired, diplopia. Dosage The dose range is 150 to 600 mg daily given as 2 divided doses. Neuropathic pain: Start at a dose of 150 mg per day, given as two divided doses. After 3 to 7 days, the dosage may be increased to 300 mg per day given as two divided doses. If needed, after an additional 7 day interval, the dosage may be increased to a maximum dose of 600 mg per day. Epilepsy: Start at a dose of 150 mg per day, given as two divided doses. After 1 week, the dosage may be increased to 300 mg per day given as two divided doses. If needed, after an additional 7 day interval, the dosage may be increased to a maximum dose of 600 mg per day. Dosage reduction in patients with compromised renal function must be individualised according to creatinine clearance. For patients receiving haemodialysis, in addition to the daily dose, a supplementary dose should be given immediately following every 4-hour haemodialysis. Treatment discontinuation should be done gradually over a minimum of one week. Use in children and adolescents (<18 years of age) have not been established. Further information is available from Pfizer Australia Pty Limited, ABN 50 008 422 348, 38-42 Wharf Road, West Ryde, NSW 2114. LYRICA®* Registered trademark of Pfizer. Date of most recent PI amendment: 3 September 2007. Pfizer Medical Affairs 1800 675 229. References: 1. LYRICA Approved Product Information. 2 Dworkin RH et al. Neurology 2003; 60: 1274-1283. 3. Rosenstock J et al. Pain 2004; 110: 628-638. 4. Lesser H et al. Neurology 2004; 63: 2104-2110. 5. Sabatowski R et al. Pain 2004; 109: 26-35. www.pfizer.com.au 04/08 PFXLY7394/A

PBS Information: This product is not listed on the PBS. RPBS Information: Authority required “For the treatment of refractory neuropathic pain not controlled by other drugs”.

ROOM DESIGN

Space

is what you make it The experience of waiting and consulting rooms By Laura Glitsos

Consult Magazine asked experts to share their views on creating the best environment possible, not only for patients, but for doctors to see patients.

e all share space. Our very thoughts can be dictated by the mood of our environment. The quality of our work and the dynamic of our interpersonal relationships are subtly manipulated by where we are. Theorists have torn apart the notion of post-modern space, only to put it back together in strange ways. In a zeitgeist of consumerism and haste, experts discuss a way to bring the human element back into the physician’s realm.

Getting personal “It took years to get the doctor out from behind the desk.” Flinders University associate professor of behavioural science and health Malcolm Bond said that since the mid1960s, research has shown a raft of issues impacting on the psychology of patients. A habit of previous years, in which a doctor sat behind a desk, is a classic example. This behaviour worked as a barrier between the patient and the physician. “Practitioners need to be aware that there should be no barrier between them and the patient. They should have the desk against the wall and have an open and inviting space,” Professor Bond said. “Though this may not be therapeutic, it helps get the most out of a consult for both doctor and patient.” Awareness and sensitivity of the “contraptions” doctors leave in view of patients is important, according to Professor Bond. © 2008 Virtual Medical Centre/ Aspermont Limited - Courtesy of CONSULT magazine

Consult Magazine | Spring 2008

ROOM DESIGN

“In more modern general practice settings, many of the contraptions aren’t in the consulting room anymore. In multidoctor practices, the contraptions are kept in treatment rooms, and doctors see patients in the consulting room. So that has freed-up the environment,” he said. “Now people don’t walk into a consulting room and see all these nasty things.” Professor Bond said research has explored ways to make rooms “more inviting”. Creating more space within the consulting room is a key element of invoking healthy communication. He advises pushing furniture to the perimeter to create an uncluttered space where patients, and the doctor, can relax.

Are you in the mood? Professor Bond said simple things can make massive differences, such as the colour of the walls. Both designers and psychologists generally agree green and blue hues are the most soothing. This is typically why backstage theatre rooms are labelled “green rooms”. Stark white is harsh on the eyes and should be avoided. Flinders University school of psychology research associate Maria Gardiner said it was not necessary to spend inordinate amounts of money – even small changes can have great impact. “Consulting rooms are an area of interest for me. As a psychologist I am interested in the difference between doctors’ rooms and my rooms, for instance,” she said. “When I have doctors come to my practice they often say they were not expecting this layout – we have coffee tables, soft chairs, plants and bookcases, flowers. “It’s not a fancy room and I haven’t spent large amounts of money on it. It’s just the way you set it up so that it’s more like a sitting room to take the air of formality out.” Ms Gardiner works in the staff development and training unit, and emphasised these environmental structures are just as much for the doctor as for the patient, because “that person must be there for eight hours a day”. “We ask doctors, when they are stressed, what would the ideal work situation be, and often they say natural light,” she said. “It definitely has an impact on their physical wellbeing. “I have spoken to doctors who have been much happier since they have moved to a practice with more light and windows.”

Bored to bits RMIT architecture and design lecturer Roger Kemp said that waiting rooms are an interesting area for designers to look at, both from a theoretical and practical perspective.

“I think the idea of the waiting room is very important for a designer to investigate,” Mr Kemp said. “We talk about these things especially for train stations and airports. Airports are at times referred to as non-places because there is not a sense of complete context. “A waiting room in this respect is comparable because ‘waiting’ can feel like a lifetime.” Mr Kemp said even the idea of waiting has loaded connotations. Referring to this space as a “patient area” or “patient room” instead may help people feel as though they belong. “Designers can combat a sense of ‘placelessness’ by creating distractions. Magazines are often used but they are such familiar processes now, so we should really try more novel ways,” he said. “Spatially, not even decoratively, people need to see what’s going on behind the desk rather than being shut out, so they can become involved in the space and processes and be engaged with the staff.”

Don’t cramp my style Ms Gardiner said the other important factor is crowding. From a psychological perspective and from what doctors have shared, people feel anxious and desperate if they are crowded. “The distances between chairs has been discussed and should be spaced out,” Ms Gardiner said. “When people are less crowded they feel less anxious. “Staff working in the waiting areas are possibly affected by this more than the doctors. They are caught between the doctor and the patient.” Ms Gardiner echoed the revelations of other experts and said bringing a sense of calm to the environment dynamic has a definite impact, not only on patient morale, but also on quality of work. “What we have seen from doctors is that because they are so rushed and stressed, an environment with a lot of noise exacerbates that sensation,” she said. “Then the doctors feel the patients are annoyed at waiting or are anxious and upset, which in turn upsets the doctors. “We need to keep in mind that everyone in the space is related. “If the reception staff and doctors feel the patients are more relaxed, it impacts on the quality of the job they are doing too.”

Music soothes the savage beast Everybody likes a good tune. Experts suggest adding soothing sounds to the environment to create an overall sense of calm. Imagine your patients to be guests at your dinner party. It is much harder to feel anxious when listening to baroque, for example.

Tips

Tricks

Crowding Create enough space for patients, doctors and staff to feel relaxed. Sounds What we hear is important too, so add soft, smooth music to your practice. Colours Stay away from dark, foreboding colour schemes. Try pastels and light reflecting shades. Lighting Bring in as much natural light as you can. Distraction Keep toys, magazines and things to look at in the waiting areas (but make sure they are new and exciting). Furniture Make sure chairs in all rooms are comfortable. Steer clear of hard seats. Space Try opening up the environment. Place seats facing other people and distractions, so everyone feels engaged with one another. Fish Experts often suggest adding fish tanks to create a sense of calm and to lessen anxiety. Plants Flowers and green plants make people feel at home and more willing to communicate. Contraptions Keep anything that may look intimidating to children (or adults) out of sight.

“Many doctors I have spoken to have spent time and money on sound systems because they did not want the aggressiveness of the radio. They felt the radio was just more noise. I know a practice in Adelaide invested substantial money into the rooms to put in sound,” Ms Gardiner said. “They were taking action for both doctors and patients.” We spend much of our lives in our working environment. Professional life is hard enough, but small changes to the immediate world around us can make a significant difference. We know that all people within a space engage with one another. As doctors, communication with both staff and patients is vital. And small things can CM change your reality.

Spring 2008 | Consult Magazine

“Wait, Mum – let me guess. Grass for dinner again, right?”

Sometimes it can be hard for parents to get kids to eat what’s good for them. Not anymore. The Kids Good Health Recipe Book shows parents that nutritious meals incorporating dairy foods can be fun and delicious. Simply fax back the order form below to get copies delivered to your surgery, for you to hand out to families in your practice. The recipe book was developed by Dairy Australia’s team of home economists and dietitians and is supported by Nutrition Australia.

For free recipe books, fax back on 1800 473 329 or email hpnutrition@dairyaustralia.com.au Please send __ copies of the Kids Good Health Recipe Book for me to distribute to families in my practice (max. limit of 10 copies). Name: Clinic Address: Postcode:

Dairy Australia, Level 5, IBM Tower, 60 City Road, Southbank, Victoria, 3006 Tel: 61 3 9694 3777 Fax: 61 3 9694 3733 www.dairyaustralia.com.au Dairy Australia Limited ABN 60 105 227 987.

PA L L I AT I V E C A R E

Home-based

palliative care By Anne Little

DEATH is incidental for palliative care nurse Maureen Langtry. Taking handover at the start of a shift, she does not focus on the ultimate fate facing her terminally ill patients. What Ms Langtry does find important is that her patients, and their families, are as comfortable as possible as they face the inevitable. Her measure of a successful day’s work is helping someone achieve the sometimes elusive “good” death – a comfortable and dignified end. “Palliative care is about keeping people as comfortable as possible so that the end stage of their disease process is not traumatic. You can’t do palliative care if all you see is death. The death is incidental,” she said.

Bringing the dying home As the Australian population ages, the current trend to medicalise and institutionalise dying means hospitals will face immense pressure in the coming years. As the Federal Government makes plans for increased home-based palliative care to ease the pressure on hospitals, more of the terminally ill will move out from behind closed hospital doors and into suburbia, with families bringing their dying home. As a palliative care nurse specialist at Canberra’s Calvary Health Care, Ms Langtry has seen an increase in demand for home-based palliative care service over the past 10 years. “I think we would all like to die at home if we could. No one wants to be in hospital when they don’t have to be,” she said. © 2008 Virtual Medical Centre/Aspermont Limited - Courtesy of CONSULT magazine

Spring 2008 | Consult Magazine

PA L L I AT I V E C A R E

Government initiatives Up to half a million Australians are touched by terminal illness each year as a patient, carer, family or friend. Chronically underfunded in the past, this is set to change with the Federal Government allocating $6.5 million in funding for the Palliative Care for People Living at Home initiative. Minister for Ageing Justine Elliot announced in May that $3.5 million would be allocated to a project that will look at ways to improve and bring together existing clinical and nursing services, in-home support, in-house respite and training of carers. The announcement was coupled with the re-launch of the $3 million CareSearch website that gives people with a terminal illness, their families and carers 24-hour access to practical information, support and advice.

Holistic approach This holistic approach by the Government to end-of-life care is reflected in Ms Langtry’s philosophy of caring for the whole family. In caring for the dying, the former midwife sees no difference from caring for a newborn. “The principles are all the same,” she said. “By that I mean the philosophy of caring for the whole family. It’s one end of life to the other and ensuring a safe arrival and a safe exit is part of that.”

Family affair Despite the Government’s focus on the much cheaper, family-focused, home-based palliative care, Ms Langtry is realistic about just how much families can do. “Families do really want to care [for the patient at home] and it’s devastating for them if they get to the stage that they are so exhausted that they can’t,” she said. “There has got to be a family doing it together. It can’t be one person on their own. “People need to get sleep at night – it’s just that basic. It doesn’t matter how many other services you get in place, there is a limit to services that are available in the community and no one does overnight care. “It’s worked occasionally where it’s just the partner without any help but usually it means that the patient hasn’t lived very long. If someone is out there for any length of time in the community there needs to be more than one person that’s the carer. “You need adult children that really kick in and help with the whole scenario. You really can’t do it otherwise. Unless the support is there, it’s not feasible for families to do it.”

Hospital-based palliative care

Support and education

For those patients who do not have a large and willing family to oversee their homebased care, hospital and hospice-based palliative care are the other options. “There are a lot of scenarios where homebased palliative care is not feasible. A lot of people live alone or are too sick for an elderly carer to care for them,” Ms Langtry said. “Someone who we are caring for at the moment is physically just too big for his wife to be a carer – he has a paralysis down one side. This person has a brain tumour and he is certainly going to die. He could take months to die with a brain tumour that has had some surgery. Those people die very slowly. For them it is appropriate that they are in hospital for their care at this point in time. He certainly couldn’t be at home.”

Home-based palliative care is not for everyone, but when the patient is suitable and the family willing that is when professional support, services and education are essential, according to Ms Langtry. “If the family is keen to do it then they usually do a beautiful job as long as we can educate and support them. It’s empowering for families,” she said. “As long as we can provide that education and support to help them through the process it usually works really well. But a lot of things have to go right for that to happen. “Palliative care is a process and how we can manage that for all concerned is what it’s all about. “Unless the support is out there, it’s just CM not feasible for families to do it.”

Consult Magazine | Spring 2008

Youâ&#x20AC;&#x2122;ll never miss a beat with

Consult brings a new standard of professional journalism to the coverage of the issues of importance to the medical community. Consult also covers the lifestyle issues and activities that are of interest to the medical professionals, such as travel and well-being. All of this is built around a solid base of papers on medical topics from members of the Virtual Medical Centreâ&#x20AC;&#x2122;s Editorial Advisory Board of more than 1000 national specialists across 12 disease specialty areas.

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ckd CHRONIC KIDNEY DISEASE

What does an eGFR <60 really mean? Associate Professor Merlin C Thomas

When you take a blood test for serum creatinine, your lab will report whether your patient has an estimated glomerular filtration rate (eGFR) of less than 60ml/min/1.73m 2. But what does this value really mean for your patient? This article shows that the risks associated with chronic kidney disease extend beyond the kidneys, and demonstrates how eGFR can be used to improve your practice. Associate Professor Merlin C Thomas MB ChB, PhD FRACP, NHRMC/Diabetes Australia Research Fellow at the Baker Heart Research Institute and Editorial Advisory Board member of the Virtual Renal Centre. mthomas@baker.edu.au

hronic Kidney Disease (CKD) is a common problem seen in Australian general practice. For the most part, the signs and symptoms of CKD are difficult to distinguish from diabetes, hypertension and a range of co-morbid conditions. Consequently, patient outcomes often depend on the general practitioner’s interpretation of routine biochemistry results and their subsequent choices about the type and intensity of therapy to employ.

The automatic detection of eGFR In 2005, a working group representing the peak bodies of Australian nephrology, pathology and biochemistry, plus Kidney Health Australia (KHA) recommended that whenever a request for serum creatinine measurement is made to a pathology service in Australia, an estimated glomerular filtration rate (eGFR) should be automatically calculated.1 If this value is less than 60ml/min/1.73m2, it is reported on the lab results form alongside, or in place of, the serum creatinine. A cutoff of 60ml/min/1.73m2 was selected for two major reasons. First, the formula used to calculate the GFR is most reliable at levels below 60ml/min/1.73m2.

Second, the risk of severe complications of CKD (detailed below) increases dramatically at levels of GFR below 60. The importance of this initiative is illustrated by the fact that at least half of all individuals who reported an eGFR <60ml/min/1.73m2 had a serum creatinine measurement in the normal range. Therefore CKD was frequently undetected until much later, rendering attempts at intervention less effective.

How common is an eGFR <60? Eleven percent of adult Australians (more than half of adults aged 65 and older) have an eGFR <60ml/min/1.73m2.2 Kidney function declines with age, so this increase in CKD may be part of the normal ageing process. However, an eGFR <60ml/ min/1.73m2 still identifies individuals at increased risk of adverse outcomes when compared to an individual of similar age with an eGFR >60ml/min/1.73m2. An eGFR <60ml/min/1.73m2 is also more common in individuals with diabetes hypertension and cardiovascular disease.2,3 In particular, if an eGFR was requested on every patient with type 2 diabetes seeing their GP today, 25% would show an eGFR <60ml/min/1.73m2.3 This has led to the recommendation that patients with

type 2 diabetes have their kidney function examined (by estimating the GFR and urinalysis) at least annually.

Why does an eGFR <60 matter? Kidneys are vital to overall health but their role is not always well understood. Kidney disease is often linked to the need to have dialysis or a kidney transplant. However, less than one out of every 20 patients with CKD will live long enough to receive dialysis or a transplant. Kidney disease contributes to other complications including cardiovascular disease, heart failure, and stroke (see Figure 1 overleaf). A patient with an eGFR <60ml/min/1.73m2 is at an increased risk for these complications that can lead to premature death if not immediately addressed. An eGFR <60ml/min in your patient means: • High risk of a heart attack or stroke. • In the case of a heart attack, survival is less likely. • Hospitalisation in the next 12 months is more likely. • Your patient has heart failure (diagnosed or undiagnosed). • Wounds will heal more slowly. • Ankle swelling and fluid retention are more difficult to control.

Consult Magazine | Spring 2008

CHRONIC KIDNEY DISEASE

Figure 1. Kidney disease means that your patient is at risk for heart disease, stroke, fracture, premature mortality and a range of other complications that may be prevented.

• BP targets are more difficult to achieve with vasodilators alone. • In the case of a fall, a fracture is more likely due to thinning of the bones. • Side effects to drugs are more common, including hypoglycaemia and fluid retention.

What can you do about an eGFR <60? Understanding that an eGFR <60ml/min/ 1.73m2 is a useful marker of risk for adverse outcomes allows you to take simple steps to reduce that risk. Screening for CKD is one simple way for a busy clinician to identify at-risk patients. For example, in a nursing home for octogenarians, reduced kidney function can predict those patients at risk of side effects from their medications, heart failure or hospitalisation. The knowledge that a patient’s eGFR is <60ml/min/1.73m2 allows you to make effective clinical decisions about the choice and intensity of therapy. For example, at this reduced level of function, the kidney retains salt and water. As a result, intravascular volume is expanded and vasodilator agents alone will not adequately lower the BP. Importantly, when an eGFR is <60ml/min/ 1.73m2, salt restriction becomes a powerful antihypertensive tool. Therefore directing your patients to lower salt intake is critical. Much of the salt consumed in diets is hidden in processed foods. Therefore, in addition to restricting the addition of salt to meals, it is important to encourage your patients to choose fresh food where possible, rinse

References 1. Mathew TH. Chronic kidney disease and automatic reporting of estimated glomerular filtration rate: a position statement. Med J Aust. 2005;183(3): 138-41. 2. Chadban SJ, Briganti EM, Kerr PG,

canned foods, read food labels and choose products lowest in salt. The addition of diuretics to an antihypertensive regimen will also help to lower the blood pressure in patients with CKD. However, it is important to remember that the diuretic efficacy of thiazides is attenuated when the GFR falls below <60ml/min/1.73m2. The efficacy of screening for CKD rests in providing an opportunity for preventive interventions that can be targeted to those patients at highest absolute risk. However, currently we are not taking those opportunities. A classic example is the use of aspirin for the primary prevention of cardiovascular disease. At present in Australia, a diabetic with an eGFR <60ml/ min/1.73m2, is no more likely to be on aspirin than a diabetic with an eGFR >60ml/min/1.73m2.4 However, the risk of heart attack in the next 10 years is 5-10 times more for an individual with CKD. It is worth remembering that the patient who has the greatest absolute risk stands to achieve the greatest absolute benefit from intensive risk factor management. Intensification or changes in patient management must follow from the identification of risk.

initiatives in patients with CKD are necessarily focused on preventing cardiovascular and heart disease. These initiatives are best conducted in the primary care setting where there is regular contact between patient and physician. Regular contact ensures that treatment targets can be optimised and the progress of kidney disease can be monitored. Patients with an eGFR <30ml/min/1.73m2 are at high risk of progressive deterioration of their kidney function and should be referred to a nephrology service for management of kidney failure. This is a relatively small group, as less than 3% of all Australians with an eGFR <60ml/min/1.73m2 also have an eGFR <30ml/min/1.73m2 (mainly because of the drop off due to premature CVD). Patients with rapidly declining kidney function or with clinical features to suggest that residual kidney function may decline rapidly (e.g. uncontrolled hypertension, proteinuria >1g/24 hours and Indigenous ethnicity) should be considered for referral to a nephrologist at an earlier stage.

A nephrologist can assist in the care of your patients with CKD. However, referral is not necessary for every patient with an eGFR <60ml/min/1.73m2. Management

Acknowledgements “Type 2 diabetes from the GP’s perspective” details the findings of the NEFRON study and other important diabetes management issues. It is published by Kidney Health Australia and is available free from Servier Laboratories (Aust) Pty Ltd, PO Box 196, Hawthorn, Victoria 3122. Tel: +61 3 8823 7333 or 1800 331 675. CM Website: www.servier.com.au

Dunstan DW, Welborn TA, Zimmet PZ, et al. Prevalence of kidney damage in Australian adults: The AusDiab kidney study. J Am Soc Nephrol. 2003;14(7 Suppl 2):S131-8. 3. Thomas MC, Weekes AJ, Broadley OJ, Cooper ME, Mathew TH. The

burden of chronic kidney disease in Australian patients with type 2 diabetes (the NEFRON study). Med J Aust. 2006;185(3):140-4. 4. Thomas MC, Weekes, A.J. Type 2 diabetes from the GP’s perspective. Melbourne, Victoria: Kidney Health Australia; 2007.

Which patients should I refer to a nephrologist?

Spring 2008 | Consult Magazine

EFFECTIVE AND AS CLEAN A S W E † C A N M A K E I T 1-3

N EW

HELPING YOU TREAT SCHIZOPHRENIA

Janssen-Cilag. Effective refers to efficacy as shown in clinical trials and clean refers to degree of tolerability exhibited in clinical trials.1-3 Please review full Approved Product Information before prescribing, available from the manufacturer on request. INVEGA™ Minimum Product Information. INVEGA™ (paliperidone) Prolonged-Release Tablets. Indication: Treatment of †

schizophrenia, including acute treatment and recurrence prevention. Dosage and Administration: The recommended dose is 6 mg once daily in the morning. Initial dose titration is not required but some patients may benefit from lower or higher doses within the usual range of 3 to 9 mg once daily. Dose increases above 6 mg/day should be made only after clinical reassessment and generally should occur at intervals of more than 5 days. When dose increases are indicated, small increments of 3 mg/day are recommended. If required, the dose may be increased to the maximum recommended dose of 12 mg once daily. The administration of INVEGA should be standardised in relation to food intake such that INVEGA should only always be taken in the fasting state or in the fed state. Swallow tablets whole with the aid of liquids. Tablets should not be chewed, divided, or crushed. Contraindications: Hypersensitivity to paliperidone, risperidone, or to any components in the INVEGA formulation. Precautions: Use in the elderly; use in elderly patients with dementia; QT prolongation; extrapyramidal symptoms; neuroleptic malignant syndrome; tardive dyskinesia, hyperglycaemia and diabetes mellitus; orthostatic hypotension; seizures; hyperprolactinaemia; dysphagia; weight gain; suicide; potential for cognitive and motor impairment including somnolence, sedation, impairment of judgment, thinking or motor skills; priapism; disruption of body temperature regulation; pre-existing gastrointestinal conditions or disturbances; antiemetic effect; use in patients with renal impairment; use in patients with hepatic impairment; use in patients with concomitant illness; use with alcohol. Interactions with other medicines: Centrally acting drugs; medicines known to cause QT prolongation, medicines containing risperidone; medicines that lower the seizure threshold; medicines that induce orthostatic hypotension; medicines that affect gastrointestinal transit time. Adverse Reactions: Commonly observed adverse events in controlled clinical studies – tachycardia; akathisia; extrapyramidal disorder. Dose dependent adverse events – somnolence, orthostatic hypotension; salivary hypersecretion; akathisia; dystonia; extrapyramidal disorder; hypertonia; Parkinsonism. Presentation: 3 mg, 6 mg, 9 mg and 12 mg prolonged-release tablets. PBS dispensed price: $247.93 (3, 6, 9 & 12 mg). Date of preparation 17 December 2007. 1. Kane J, et al. Schizophr Res. 2007;90:147-161. 2. Marder SR, et al. Biol Psychiatry 2007;62(12):1363-1376. 3. Davidson M, et al. Schizophr Res. 2007;93:117-130. Janssen-Cilag Pty Ltd, ABN 47 000 129 975, 1-5 Khartoum Road, North Ryde NSW 2113. INVEGA™ is a trademark of JANSSEN USA for paliperidone oral tablets. 07/08 JAN1102/CJB

PBS information: Authority required ( STREAMLINED ). Schizophrenia.

No 1589

M U LT I P L E S C L E R O S I S

Focus on progressive multiple sclerosis Part II:

Dr Jeremy Hallpike

Treatment and long-term care

An in-depth look at the disease-modifying treatments and frequently encountered management issues of chronic progressive multiple sclerosis (CPMS). Dr Jeremy Hallpike, MD(Lond.), FRCP(Lond), FRACP; Emeritus Neurologist, Royal Adelaide Hospital; Editorial Advisory Board Member; Virtual Neuro Centre. jhallpik@bigpond.net.au

here are major hurdles in evaluating disease-related treatments in MS. One hurdle is the well-known variability of the disease, which in its early stages is also characterised by spontaneous clinical remissions. Other confounding factors include its prolonged course, the extent to which both inflammatory and degenerative processes co-exist, the poor correlation between disability and diagnostic white matter abnormalities on MRI, and the absence of alternative laboratory markers. Key early trials of beta interferons in early MS, in which MRI was used as an objective marker, showed for the first time that these agents are effective in reducing the rate of increase of inflammatory white matter lesions on MRI and in reducing clinical relapse rates. However, the reasonable expectation that such effects would carry through to improved longer-term prognosis has not been borne out. The efficacy of beta interferon therapy may be compromised by the development of neutralising antibody activity in a high proportion of cases. It is important to know firstly whether treatment with beta interferons, or glatiramer acetate, in the relapse-remitting stage of MS (RRMS) will delay the onset of progression; and secondly whether progression, once established, is slowed. A recent comprehensive survey of the treatment trials of both these agents concluded that, while interferons reduced relapse rates in individuals with progressive disease who

continued to experience attacks, there was no evidence that clinical progression or MRI evidence of cerebral atrophy were inhibited by treatment with either beta interferons or glatiramer acetate.1 An emergent question is the need to explain why although inflammatory changes linked to acute and potentially recoverable neurologic episodes can be therapeutically suppressed, neurodegenerative changes continue to evolve. For the individual with MS, the modest treatment-related benefits in RRMS are tempered by the failure, thus far, to effectively postpone progression longer term and delay important disability end points. A review of corticosteroid treatment in MS pre-use of MRI in placebo-controlled clinical trials concluded that short-term treatment with high dose intravenous methylprednisolone (IVMP) accelerated recovery from acute exacerbations.2 IVMP was shown to reduce abnormal contrast enhancement on CT scanning and to suppress IgG synthesis within the bloodbrain barrier. However, it is generally accepted that long-term continuous therapy with corticosteroids is unhelpful. A recent study with MRI has shown that regularly repeated pulse therapy with IVMP followed by rapidly tapered oral prednisolone in ambulatory RRMS may be beneficial in reducing the rate of conversion from relapseremitting to CPMS and also in reducing loss of parenchymal brain volumes.3 If

confirmed, such findings may suggest a new treatment role for corticosteroids. Mitoxantrone (MX) is an antineoplastic agent used in cancer chemotherapy that has been reported to have a stabilising effect in rapidly progressive MS. Myelosuppressive and cardiotoxic effects of MX are well recognised, but these risks are held to be slight in MS and may be minimised by limiting cumulative dosage to less than 100 mg/m2. Benefit from MX is thought to be restricted to patients with aggressive disease who have active inflammatory lesions shown on contrasted MRI. The use of MX requires regular monitoring of cardiac function. A recent report of cardiotoxicity in four of 18 patients with MX-treated CPMS,4 as well as a report of delayed heart failure following MX in three patients, are a source of heightened concern about the use of this drug in MS. A recent comparison of MX and cyclophosphamide in 50 patients with CPMS found that the two drugs had equal stabilising effects.5 Much effort is being devoted to devising monoclonal antibody (mAb) treatments to achieve targeted immunological effects for treatment of MS. Natalizumab has been approved in Europe and the United States for treatment of RRMS.6 It has also been found to be effective in patients with CPMS who show inflammatory changes on MRI. However, a small number of patients treated with these agents have had serious side effects. Treatment with Natalizumab has been associated with

ÂŠ 2008 Virtual Medical Centre/Aspermont Limited - Courtesy of CONSULT magazine

Spring 2008 | Consult Magazine

Experience confirms that every person with MS will maintain a unique personal battle. The multiplicity of involved factors can relate as much to the make-up of the individual as to the statistics of the various aspects of the disease. Care programs, therefore, rely heavily on “bottom up” processes commencing with the sufferer. It is helpful to refer to Scheinberg’s classification of MS-related problems as primary, secondary and tertiary effects. Primary effects are the neurological deficits (e.g. weakness, spasticity, urinary distress), secondary effects are complications of these deficits (e.g. loss of ambulatory function, contractures, urinary tract infections) and tertiary effects refer to spouse and family relationship issues, loss of working capacity, dependence, anxiety, depression, isolation, and other ramifications.8 Various factors which are peculiar to MS can combine to defeat optimum comprehensive care. The emphasis that can be placed on the lack of a cure for MS engenders negative attitudes that cut across the spectrum of management.9 Everyone involved with MS carries the burden of knowing that no treatment has yet been devised that will reliably slow progression. However, effective treatments exist.

The functional implications of increasing loss of neurological function are generally very visible. As MS progresses, loss of manual dexterity, impairments of memory, difficulties with speech and other changes compound with the walking loss. “The most valuable adjunct to rehabilitation, we have learned, is a stable pre-morbid personality and supportive family.”9 In this setting, “adaptation” conveys a more accurate view of what is generally accomplished. The management of increasing levels of disability are reflected in EDSS scores. A level of 5.0 on the Expanded Disability Status Scale (EDSS) is the level at which disability becomes severe enough to impair full daily activities and frequently marks the first major lifestyle changes, such as having to retire from work. EDSS 6.0 implies an ability to walk up to 100 metres slowly, stopping if necessary, and using aids such as sticks or a frame. EDSS 7.0 means reliance on a wheelchair (wheelchair active) with ability to transfer without needing to be personally assisted. This is the range in which adaptive measures often contribute successfully to preserving functional capacity and mitigating tertiary effects. Leg spasticity is variably relieved by baclofen, a centrally acting inhibitor that is generally well tolerated. But care must be exercised in distinguishing between spasticity that serves to support residual walking function and spasticity that is symptomatic. Urinary distress symptoms are reported to occur in up to 90% of persons with MS. This primary effect contributes to social reclusiveness. Frequency and urge incontinence, or dyscontinence (inability to get to a toilet quickly enough), can be mitigated by regulating fluid intake and anticholinergics (e.g. oxybutynin). Further measures, e.g. self-catheterisation, depend on residual urine. The value of tailored exercise programs, for cardiovascular health, maintaining a healthy weight, preserving joint movements and checking osteopenia,

are self-evident. A normal vitamin D status should be maintained. Progression to EDSS 8.0 connotes passive wheelchair use for long periods, sitting in an upright position for maximum advantage for hand functioning. Transfers are likely to be by hoist unless the subject is very light. At this stage, attrition of selfcare functions resulting from neurological deterioration extending to the upper limbs and loss of manual dexterity is more likely to be reflected in needs-based disability scores than the EDSS. Immobility, whether as chair-bound or bed-bound, greatly increases the risk of pressure sores. Riskassessment protocols have been shown to be of value for predicting pressure ulcers and determining the level of prevention measures. If allowed to progress, pressure ulcers have debilitating consequences and can herald a terminal decline. Contractures from unopposed leg spasticity compromise sitting and lying, and add to the risk of pressure sores.

References 1. Noseworthy J, Miller D, Compston A. Disease-modifying treatments in multiple sclerosis. In: Compson A, editor. McAlpine’s Multiple Sclerosis. 4th ed. Churchill Livingstone Elsevier; 2005. p. 729-802. 2. Hallpike JF. Is there anything new for multiple sclerosis? Curr Ther. 1988;29:77-96. 3. Zivadinov R, Rudick RA, De Masi R, Nasuelli D, Ukmar M, Pozzi-Mucelli RS, et al. Effects of IV methylprednisolone on brain atrophy in relapse-remitting MS. Neurology. 2001;57:1239-47.

4. Paul F, Dörr J, Wüfel J, Vogel H-P, Zipp F. Early mitoxantrone-induced cardiotoxicity in secondary progressive multiple sclerosis. J Neurol Neurosurg Psychiatry. 2007;78:198-200. 5. Perini P, Calabrese M. Tiberio M. Mitoxantrone versus cyclophosphamide in secondary-progressive multiple sclerosis: a comparative study. J Neurol. 2006;253:1034-40. 6. Lutterotti A, Martin R. Getting specific: monoclonal antibodies in multiple sclerosis. Lancet Neurol. 2008;7:538-547. 7. Metz I, Lucchinetti F, Openshaw H, et al. Autologous haematopoietic

stem cell transplantation fails to stop demyelination and neurodegeneration in multiple sclerosis. Brain. 2007; 130:1254-1262. 8. Smith CR, Aisen ML, Scheinberg L. Symptomatic management of multiple sclerosis. In: McDonald WI, Silberberg DH, editors. Multiple Sclerosis. Butterworths International Medical Reviews. Neurology, 6; 1986. p. 166-183. 9. Scheinberg L, Holland NJ, Kirschenbaum M, et al. Comprehensive long-term care of patients with multiple sclerosis. Neurology. 1981;31: 1121-1123.

Approach to symptomatic long-term care

A new perspective An emergent theme in understanding is the apparently dichotomised pathology of MS. This is now seen to encompass neuroaxonal degeneration and immunoinflammatory demyelination. Neuroaxonal degeneration results in brain atrophy which can now be detected in early stage MS by employing the most up-to-date MRI techniques. Such atrophy also appears to characterise the ongoing pathology of the later progressive phase and explains why treatments that are effective in reducing inflammatory demyelination and reducing relapse rates have had such little impact on the longerterm prognosis. It is a perspective which can be expected to translate into new therapies for protecting the axon and its parent cell for use in conjunction with current agents. Acknowledgement To Jane for teaching me about MS.

Consult Magazine | Spring 2008

M U LT I P L E S C L E R O S I S

progressive multifocal leukoencephalopathy (PML). New guidelines should minimise the risks of PML and permit continuing use of Natalizumab in carefully monitored selected patients. Autologous haematopoietic stem cell transplantation has been practised in small numbers of patients with severe RRMS or fluctuating disease and progressing disability who cannot be stabilised. A recent neuropathological study of five patients with MS who had undergone this treatment found ongoing active demyelination and axonal degeneration, confirming continued disease progression.7

ONLINE LEARNING

learning

Virtual education reaches new heights Dr Joe Kosterich

Finally, a comprehensive range of 600 topics you can choose that are RACGP and ACRRM endorsed self-learning programs for you to work at your own pace in your surgery or at home that are facilitated by Australian medical specialists. www.VirtualMedicalCentre.com/cme_demo.asp Dr Joe Kosterich MBBS

o you sometimes find what’s on offer in GP education a bit dull? Do you sometimes think that the topics offered don’t really match what you see in your day-to-day practice? Do you sometimes wish that you could select topics that are of interest to you, learn new information about them, and do it at a time that suits you and in a way that is intellectually challenging and interesting? If your answer to any of the above questions is yes, then you need to be enrolling for Continuing Medical Education at virtualmedicalcentre.com (VMC). The Virtual Medical Centre is Australia’s leading online medical reference site for the medical profession and the public. It boasts an editorial advisory panel of over 1,000 Australian specialists in 19 different areas of medicine. For the current triennium, VMC is offering online active learning modules. The education offered is accredited by the RACGP as a Category 1 learning activity, which attracts 40 points, and by the ACRRM for 12.75 points for its CPD program. The VMC Continuing Medical Education Centre allows you to choose a topic that is of interest to you and learn about it as if you were a researcher. You will be facilitated in finding recent studies and information on the topic or topics of your choice by an Australian medical specialist. The learning can be done at a time that suits you from your home or office computer. For busy GPs this means you don’t have to drive to events at the end of a busy day when you might rather go home to see your family. continued on page 22 © 2008 Virtual Medical Centre/Aspermont Limited - Courtesy of CONSULT magazine

Spring 2008 | Consult Magazine

PBS Information: Restricted Benefit – Gastro-oesophageal reflux disease; Initial treatment of peptic ulcer. † Treatment of patients with healed or ulcerative GORD. At one year, 9 out of 10 patients on PARIET 20mg maintained healing of erosive oesophagitis and reduced relapse of heartburn.1 Please review full Approved Product Information before prescribing PARIET. PARIET® (rabeprazole sodium) Minimum Product Information. Use: Symptomatic treatment, prophylaxis of gastro-oesophageal reflux disease (GORD) including relapse;

ulcers treatment (duodenal and gastric); H. pylori eradication (peptic ulcer, chronic gastritis) in combination regimen. Contraindications: Hypersensitivity to rabeprazole sodium, other ingredients and proton pump inhibitors. Precautions: Exclude malignancy; severe hepatic dysfunction; pregnancy; lactation; children. Interactions: Ketoconazole; digoxin; gastric pH dependent drugs. Adverse Reactions: Headache; dizziness; diarrhoea; constipation; nausea; vomiting; flatulence; abdominal pain; asthenia; myalgia; pain (chest,

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back, non-specific); rash; insomnia; flu-like syndrome; infection; rhinitis; pharyngitis; cough. Post-marketing experience: Erythema; urticarial skin eruptions; acute systemic allergic reactions e.g. facial swelling; hypotension; dyspnoea. Rarely: interstitial nephritis; gynaecomastia; potential allergic reactions e.g. anaphylactic; blood dyscrasia e.g. thrombocytopenia, neutropenia, leukopenia, pancytopenia, agranulocytosis and bicytopenia; increased hepatic enzymes and serious hepatic dysfunction e.g. hepatitis and jaundice; and hepatic encephalopathy in patients with underlying cirrhosis. For others see full PI. Dose: GORD. Treatment: 20 mg once/day for 4-8 weeks; Prophylaxis: 10-20 mg once/ day; Symptomatic: 10-20 mg once/day for 4 weeks, maintain symptom control with 10 mg once/day when needed (on demand regimen, see full PI). Gastric ulcer: 20 mg once/day for 6-12 weeks. Duodenal ulcer: 20 mg once/day for 4-8 weeks. H. pylori eradication: 20 mg twice/day + clarithromycin 500 mg twice/day + amoxicillin 1 g twice/day for 7 days. See full PI. Presentation: 10 and 20 mg enteric-coated tablets. Date of TGA approval: 10 November 2004. PBS Dispensed price: $37.97 (10 and 20mg). Reference: 1. Caos A et al. Am J Gastroenterol 2000;95(11):3081-8. Product Information available upon request from Janssen-Cilag Pty Ltd. ABN 47 000 129 975. 1-5 Khartoum Rd, North Ryde NSW 2113. ÂŽ PARIET is a trademark of Eisai Ltd. JCPA1151/CM/3PP. 09/08. Ward6.

ONLINE LEARNING

continued from page 18

It also means you can select topics that are relevant to your day-to-day practice rather than hearing another talk on a pre-selected topic which you may have heard numerous times before. For example, when was the last time that you went to a CME event dealing with acne or alcohol-related problems? These are just two of the topics that you can select from 600 on the VMC site. This means the new knowledge you obtain will be immediately useful in dealing with your patients.

The active learning modules themselves are interesting and allow you to do your own research into a subject of relevance to your practice. However, it is done in such a way so that you are supported and facilitated and not left having to search through reams of paper or dozens of internet pages to find something of relevance and interest to you. The modules are also supported by the VMC editorial advisory panel. VMC is a fully independent education provider and

FREE Your best resource for healthcare information and education

there is no cost to you in undertaking the learning modules. So with 600 topics to choose from – and the capacity to learn at your own pace in your own time from the comfort of either your home or surgery, together with the RACGP or ACRRM points on offer – this is the triennium to do something different that is both enjoyable and educational. Visit www.virtualmedicalcentre.com soon and sign up to do your first active learning CM module. You’ll be glad that you did.

Online CME

600 relevant topics to choose Free, independent and Australian Approved by RACGP (40 points QA & CPD) Approved by ACRRM (12.75 points PDP) Study from your surgery or home at your own rate Facilitated by Australian medical specialists

Please visit www.VirtualMedicalCentre.com/cme.asp vmc-half_600topics_210508.indd 1

Exp08-16

Spring 2008 | Consult Magazine

vitamins

Vitamins may hinder cancer therapy

Dr Andrew Dean

Fad cures for cancer, in the form of vitamin supplements and herbal remedies, are peddled to often desperate and vulnerable patients. This article asks whether practitioners risk malpractice by turning a blind eye to their patients’ use of scientifically unproven treatments. Dr Andrew Dean MBChC MRCP(UK), Oncologist and Medical Director of the Virtual Cancer Centre.

ne of my colleagues has a reputation for intolerance of anyone taking anything other than his prescribed medication. Rumour has it that he has thrown down his pen in the midst of a consultation when one of his patients dared to inquire about vitamin C injections or herbal supplements. I, on the other hand, have probably been more tolerant of patients wishing to experiment with herbal remedies. However, in the light of recent media publicity, I must concede that my colleague could be right; a new study shows that people who take vitamin supplements have a lower life expectancy than people who don’t.1 This has attracted more attention than previous studies, which showed that lung cancer patients given supplemental vitamins A, C and E all experienced recurrence of their cancer sooner, which progressed more rapidly resulting in an earlier death.2 Indeed, both studies (one in the US and one in Scandinavia) were stopped early because of the enormity of the difference between the vitamin supplemented and the nonvitamin supplemented group. These studies suggest that vitamin supplements may be particularly harmful for cancer patients.

Vitamins and cell growth The word vitamin comes from the amalgamation of two words: vital and amines. Vitamins were supposedly chemicals that the body was unable to © 2008 Virtual Medical Centre/ Aspermont Limited - Courtesy of CONSULT magazine

Consult Magazine | Spring 2008

V I TA M I N S A N D C A N C E R T H E R A P Y

The Emperor’s New Clothes uncovered:

V I TA M I N S A N D C A N C E R T H E R A P Y

manufacture itself and thus it was vital that these were ingested. It is generally understood that vitamins are necessary for normal metabolism, cell growth and tissue repair. It is logical therefore that a gross excess of vitamins could encourage cell growth and division in the cells we least want it (i.e. cancer cells). As oncologists, we try frantically to arrest cancer cell growth, yet ironically by not taking a stand against vitamin supplementation, we may be letting our patients down.

That is not to say that in certain circumstances careful supplementation of certain vitamins is not helpful. A typical example is Pemetrexed (Alimta) therapy. In this instance, vitamin supplementation with folic acid and vitamin B12 has been shown to reduce side effects of chemotherapy and improve quality of life.3 However, this does not mean that blanket supplementation with these vitamins should be encouraged. Critically, in this instance there is significant scientific basis for supplementation. Another

example is the addition of folinic acid to 5FU chemotherapy. It is known that folinic acid significantly improves the response rate to chemotherapy with this agent.4 Again there is a significant scientific basis for its use.

The case against health supplements Certain cancer treatments (e.g. radiotherapy) rely upon the creation of free radicals to damage the DNA of cancer cells. Radiotherapy involves high-energy proton or electron beams, targeted directly at cancer cells in an effort to damage their DNA. Often they do so by the creation of toxic free radicals within the affected tissues, which then cause damage and kill the cancer cell. Using free radical scavengers such as vitamins C and E potentially reduces the creation of the free radicals and can decrease the effect of radiotherapy. Should radiation oncologists therefore be more vigilant about what supplements their patients are taking? Patients often take vitamin supplements to excess. It is known that excess vitamins can be harmful, regardless of whether or not the patient has cancer. Three examples are the excess use of Vitamin A, B and D. Hypervitaminosis A occurs when excess doses of vitamin A cause marked cutaneous and metabolic problems. In particular, Beta-carotene, a vitamin A derivative, has been shown to worsen the outcome in patients with mesothelioma and lung cancer.5 Excess vitamin D consumption (e.g. eating polar bear liver) can be rapidly fatal due to hypervitaminosis D. Happily, not many oncology patients eat polar

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Spring 2008 | Consult Magazine

V I TA M I N S A N D C A N C E R T H E R A P Y

bear! Excess doses of vitamin C have been known to cause inflammation of the kidneys, interstitial nephritis.6 However, purveyors of the Emperor’s New Clothes would encourage cancer patients (as indeed they do) to have high doses of intravenous vitamin C to “boost the immune system”. The charge to the patient is often ten times the cost of the vitamin C ampoule. How harmful are herbal remedies or mixtures of herbs? And indeed, what evidence is there of quality control or accurate knowledge of what the herbal preparations contain? There are many reports of lead and other heavy metal poisoning from herbal and mineral supplementation.7 In addition, one of the country’s most widely consumed herbal remedies, St John’s wort, is known to interact with virtually every prescription drug. It interacts with the enzymes that are responsible for drug metabolism and although there is no doubt that St John’s wort works reasonably well as an antidepressant, its use would be strongly cautioned in anyone who is taking any prescription medications.8 So what then if patients are on chemotherapy? In this case, herbal remedies are potentially anything but harmless. If they induce the body’s enzymes (i.e. make the body metabolise substances more efficiently) then it is possible that this reduces the levels of circulating chemotherapy. It is known that chemotherapy levels are very important in determining optimal cell damage. Reduction of the effective chemotherapy dose can reduce cancer cell death, potentially reducing the response and cure rate to the chemotherapy. If the herbal supplements

reduce the activity of liver enzymes, this could raise the chemotherapy levels, which could in turn be toxic. If we tell patients that “it’s okay to take herbal supplements” could we be guilty of malpractice?

Unproven therapies A number of doctors have joined a group called the Australian College of Nutritional and Environmental Medicine, practising full-time with alternative and unproven remedies. Does the fact that they have their own college give credibility to potentially harmful therapies? Should doctors who abide by the Hippocratic oath prescribe medications without any scientific validity? The medical history books are full of wellmeaning practitioners who passionately believed in a pathological or therapeutic

theory. Researchers have even gone so far as to inject themselves with the HIV virus, because they passionately believed that the retrovirus itself was not the cause of AIDS. Passionate belief does not necessarily equate to therapeutic efficiency. The only way we know that treatments work is through rigorously controlled scientific trials that make a fair assessment of the probability of chance affecting the results. Is mainstream medicine guilty of passive acceptance of a small group of colleagues’ use of unproven (and perhaps harmful) therapies? One medical practitioner, who practises heavily in this field, is known to charge large sums of money to people who can least afford it, i.e. patients who have been afflicted by cancer, are no longer able to work and are facing death. These patients often pay large sums of money in the hope that they may benefit from these unproven remedies. The ethics of this is surely questionable. Most of us in Oncology have seen repeated vogues in cancer supplements. Shark cartilage was first touted as a cure for cancer in the 1960s. When it was shown to be of little use, it disappeared only to resurface in the 1990s. Virtually every cancer patient coming to the clinic was taking shark cartilage and unfortunately none of them have seemed to benefit. The underpinning “scientific” theory being that no shark has ever been discovered to have cancer.9 Another wellmeaning and passionate theory is that the antihistamine Promethazine gets into cancer cell mitochondria and poisons their metabolism thus killing the cancer cells.10 Patients can take doses so large that they are rendered virtually comatose. Recently, the Cancer Support Association of WA sponsored a public evening in which a European oncologist, who is barred from practising in their home country, espoused

Consult Magazine | Spring 2008

V I TA M I N S A N D C A N C E R T H E R A P Y

a theory about using intravenous sodium bicarbonate as a cancer treatment. Patients flocked to the purveyors of the Emperor’s New Clothes, spending hundreds of dollars to hear from colleagues who have no specialist training and who are only too happy to dispense intravenous sodium bicarbonate (at quite a high price too).

Hope What then is the role of hope in cancer care? An excellent nursing paper addressed this. It recalled the story of Pandora’s box. Pandora, driven by curiosity, opened the forbidden box. Out of the box rushed all the evils of the world – anger, greed, despair, envy, sloth, etc. – but remaining in the bottom of the box was hope. Thus the question as to the nature of hope arose. Was hope the greatest evil in the world or was it actually the antidote to all the evils in the world? We all see hope as being essential to the human condition. Patients who have hope are more upbeat and have better quality of life than those whose lives are devoid of hope. Critically, it is important that the hope is kept grounded and realistic. When a patient gets a lump, they hope it’s not cancer. When that hope is dashed, it is important that that hope is replaced with something else, i.e. the hope that the cancer can be cured. When surgery and other treatments take place, the patient hopes they are cured. We hope they are cured. However, if they relapse, then it is important that the germ of hope is kept alive, i.e. it may not be possible to cure it but we can give some treatment which may shrivel the cancer into remission. The problem comes when the hope

is unrealistic and preyed upon by the purveyors of Emperor’s New Clothes. Rather than encourage the hope that patients may enjoy the best quality of life in their remaining time, certain practitioners encourage patients, often impoverished by their illness, to spend what money they can’t afford on an unproven remedy. What is the responsibility of the general medical community? Should we make official complaints to the medical board in each state about medical practitioners

who carry out unproven, potentially dangerous and expensive treatments? Should the Minister of Health, on behalf of the government, take action to prevent people being preyed upon? Should the government legislate that alternative and unproven remedies carry health warnings such as “warning, unproven remedies may do nothing at all” or “warning, these herbs can make you ill”?

References 1. Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Mortality in randomized trials of antioxidant supplements for primary and secondary prevention: systematic review and meta-analysis. JAMA. 2007 Feb 28;297(8):842-57. 2. Slatore CG, Littman AJ, Au DH, Satia JA, White E. Long-term use of supplemental multivitamins, vitamin C, vitamin E, and folate does not reduce the risk of lung cancer. Am J Respir Crit Care Med. 2008 Mar 1;177(5):524-30. 3. Scagliotti GV, Shin DM, Kindler HL, Vasconcelles MJ, Keppler U, Manegold C, et al. Phase II study of pemetrexed with and without folic acid and vitamin B12 as front-line therapy in malignant pleural mesothelioma.

J Clin Oncol. 2003 Apr 15;21(8): 1556-61. 4. Francois E, Berdah JF, Chamorey E, Lesbats G, Teissier E, Codoul JF, et al. Use of the folinic acid/5-fluorouracil/ irinotecan (FOLFIRI 1) regimen in elderly patients as a first-line treatment for metastatic colorectal cancer: a Phase II study. Cancer Chemother Pharmacol. 2008 Feb 14. 5. de Klerk NH, Musk AW, Ambrosini GL, Eccles JL, Hansen J, Olsen N, et al. Vitamin A and cancer prevention II: comparison of the effects of retinol and beta-carotene. Int J Cancer. 1998 Jan 30;75(3):362-7. 6. Rathi S, Kern W, Lau K. Vitamin C-induced hyperoxaluria causing reversible tubulointerstitial nephritis and chronic renal failure: a case report. J Med Case Reports. 2007;1:155.

7. Lynch E, Braithwaite R. A review of the clinical and toxicological aspects of ‘traditional’ (herbal) medicines adulterated with heavy metals. Expert Opin Drug Saf. 2005 Jul;4(4):769-78. 8. Kasper S, Gastpar M, Muller WE, Volz HP, Dienel A, Kieser M, et al. Efficacy of St. John’s wort extract WS 5570 in acute treatment of mild depression: a reanalysis of data from controlled clinical trials. Eur Arch Psychiatry Clin Neurosci. 2008 Feb;258(1): 59-63. 9. Ostrander GK, Cheng KC, Wolf JC, Wolfe MJ. Shark cartilage, cancer and the growing threat of pseudoscience. Cancer Res. 2004 Dec 1;64(23): 8485-91. 10. Jones GR. Successful cancer therapy with promethazine: the rationale. Med Hypotheses. 1996 Jan;46(1):25-9.

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NEUROPATHY

Using gabapentinoids to treat neuropathic pain

Professor Stephan A Schug

There is growing interest in use of gabapentinoids in the treatment of neuropathic pain. Although they were traditionally used as anticonvulsants, gabapentinoids such as gabapentin and pregabalin have been shown to both reduce pain and improve the quality of life of patients. Professor Stephan A Schug MD FANZCA FFPMANZCA, Chair of Anaesthesiology, Pharmacology and Anaesthesiology Unit, School of Medicine and Pharmacology, University of Western Australia, Director of Pain Medicine, Royal Perth Hospital and Editorial Advisory Board Member of the Virtual Pain Centre.

abapentin, the first representative of the group of drugs now called gabapentinoids, was introduced into clinical practice in 1993 for the adjunctive treatment of partial complex seizures. By 1995 the first case reports appeared which described this newly released anticonvulsant as dramatically successful in the treatment of neuropathic pain states.1 Over the subsequent years, the off-label use of

gabapentin for the treatment of neuropathic pain (and generalised anxiety disorder by psychiatrists) exceeded by far the use for its original indication.2 In May 2002, the US Food and Drug Administration (FDA) approved gabapentin for the treatment of post-herpetic neuralgia. For a long time, it was unclear how gabapentinoids worked in neuropathic pain states. The name implies that the substances are gamma-aminobutyric acid (GABA)

analogues, but subsequent research showed no effect on GABA receptors. More recently, research using autoradiography has shown that gabapentinoids bind to the laminae 1 and 2 of the dorsal horn of the spinal cord. In this research, the alpha-2-delta subunit of voltage-gated calcium channels in primary afferent neurons were identified as the major effect site.3 These alpha-2-delta subunits modulate calcium influx into nerve cells and indirectly regulate the amount of excitatory amino acids that are released into the synaptic cleft.4 In situations of hyperexcitations of neurons (such as after damage to neurons), gabapentinoids cause the alpha2-delta subunits to reduce calcium influx at pre-synaptic terminals, thereby reducing the release of excitatory amino acids such as glutamate. This reduced release of excitatory neurotransmitters leads to an analgesic, anxiolotyic and anticonvulsant effect. Pregabalin is a newer compound than gabapentin with the same mechanism of action. However, it has much improved pharmacokinetics. It has a higher and more predictable oral bioavailability with a nonsaturable absorption across its dose range. In addition, it has a higher efficacy and a longer half-life, permitting twice-daily dosing in contrast to three-times-daily dosing necessary for gabapentin.5 Gabapentin and pregabalin have been extensively tested in peripheral neuropathic pain states such as diabetic polyneuropathy and post-herpetic neuralgia. In these

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N E U R O PAT H I C PA I N

conditions, they show a dose dependent effect on pain intensity with a limited range of mainly minor adverse effects such as dizziness, somnolence and peripheral oedema. The numbers needed to treat (NNT) for 50% pain relief are in the range of 3-4 and are, therefore, not as effective as more classical compounds such as tricyclic antidepressants (TCAs), which have high NNT.6 An evidence-based review of the treatment of neuropathic pain suggests that if pain relief is used as the only criterion, then TCAs are superior to opioids, which are superior/comparable to tramadol and to gabapentinoids. However, if criteria for efficacy are based both on pain relief and quality of life measures, then the preference becomes gabapentinoids over tramadol

which, in turn fares better than opioids. In this context, TCAs are the least preferable treatment option.6 Pregabalin is also one of the only compounds tested in a large, double-blind, randomised trial in the treatment of spinal cord injury pain.7 Pregabalin showed a high efficacy, with few side effects and a limited number of patients who discontinued intake due to adverse effects. These results provide further support for the use of gabapentinoids in the treatment of spinal cord injury pain. There is also now data on the use of gabapentinoids in other states of central sensitisation, and recently the FDA has added fibromyalgia as an indication for the use of pregabalin, after trials showed clinically relevant effects.8

In conclusion, the group of anticonvulsants called gabapentinoids, which act as alpha-2-delta modulators of voltagegated calcium channels, are an important addition to the armamentarium for the treatment of neuropathic pain. They show relatively good efficacy and are preferred due to their lack of interactions with other medications and their limited, and usually not severe, adverse-effect profile. Recent meta-analyses also suggest a role for these compounds in acute pain states such as postoperative pain.

References 1. Mellick LB, Mellick GA. Successful treatment of reflex sympathetic dystrophy with gabapentin. Am J Emerg Med. 1995 Jan;13(1):96. 2. Steinman MA, Bero LA, Chren MM, Landefeld CS. Narrative review: the promotion of gabapentin: an analysis of internal industry documents. Ann Intern Med. 2006 Aug 15;145(4): 284-93. 3. Stahl SM. Mechanism of action of alpha2delta ligands: voltage sensitive

calcium channel (VSCC) modulators. J Clin Psychiatry. 2004 Aug;65(8): 1033-4. 4. Sills GJ. The mechanisms of action of gabapentin and pregabalin. Curr Opin Pharmacol. 2006 Feb;6(1):108-13. 5. Shneker BF, McAuley JW. Pregabalin: a new neuromodulator with broad therapeutic indications. Ann Pharmacother. 2005 Dec;39(12): 2029-37. 6. Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm

for neuropathic pain treatment: an evidence based proposal. Pain. 2005 Dec 5;118(3):289-305. 7. Siddall PJ, Cousins MJ, Otte A, Griesing T, Chambers R, Murphy TK. Pregabalin in central neuropathic pain associated with spinal cord injury: a placebo-controlled trial. Neurology. 2006 Nov 28;67(10):1792-800. 8. Owen RT. Pregabalin: its efficacy, safety and tolerability profile in fibromyalgia syndrome. Drugs Today. 2007 Dec;43(12):857-63.

Disclosure The author receives research funding and/or acts as a consultant for several pharmaceutical CM companies, including Pfizer Inc.

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Consult Magazine | Spring 2008

TREE CHANGE

Beating it to

the bush By Mary Ward

Lake Gairdner in the Gawler Ranges, Eyre Peninsula, South Australia. Photo courtesy South Australian Tourism Commission

Upping sticks and moving to the coast or an inland country area is becoming a national preoccupation. Most of us know someone who has either done it, is in the process of doing it or just daydreams about it.

ut the reality of a “sea” or “tree change” can turn out to be less than idyllic, with some retreating to the city at the earliest opportunity. For others, though, it will later become one of the best life decisions they ever made. This is a view shared by locals who welcome the intrepid souls who do the extensive research and planning necessary to make a success of a new life far from the hum of a city. Such a community is the 1500 population of Wudinna on South Australia’s Eyre Peninsula – 570km northwest of Adelaide. The thriving rural centre supports wheat and sheep farmers, granite quarrying and

tourism. This is where 28-year-old Dr Scott Lewis arrived last February and provided Wudinna with their first permanent doctor since 2005, and the town’s only Australiagraduated GP for more than 12 years. Residents now no longer need endure an arduous 200km round trip to see the nearest GP, nor the sporadic appearance of locums at their 21-bed hospital. “Everyone in the town made us feel so accepted and at home when we arrived, something which made what was a major transition in our lives so much easier,” said Dr Lewis, who made the move from Adelaide with his wife Karen. Now new parents, the couple have chosen

what some might consider a daunting prospect – life in the bush far away from the conveniences of an urban lifestyle. But fortunately having experienced life as a country doctor while a medical student in the town years earlier Dr Lewis knew what to expect. “I firmly believe that it is the early experiences in medical school that shape career directions and destinations. At the very least, they determine what you don’t want to do,” he told Consult. He does not believe financial incentives have as big an impact as some think on the rural doctor shortage. Although there are a number of financial inducements already to

Spring 2008 | Consult Magazine

TREE CHANGE

go bush, Dr Lewis pointed out few people chose to do so. “I feel that lifestyle is the most important incentive for new graduates, and unfortunately the current rural workforce actually serves as a disincentive as a result.” What students observe while on a training placement is vitally important, Dr Lewis noted. Too often they will see a group of tired, run-down and disillusioned doctors who have spent their working lives caring for patients, to the detriment of themselves, or their own family. “There aren’t too many people saying that you don’t need to be like that, you can work part-time, and we need a change in the perception that rural medicine is an allconsuming career that comes at a penalty to your life,” Dr Lewis said. Sage words from a medical leader who collected the 2007 Westpac Rural Doctor Australia Association, Rural Registrar of the Year Award and is now an RDAA vice-president with an education portfolio. The son of a rural bank manager, a country childhood strongly influenced his career path. “I lived in five different places in country South Australia before moving to Adelaide at age nine,” he explains. Living in a rent-free house would be an unlikely component of any citybased medical salary package. However, Dr Lewis now enjoys both this and the novel perk of lease-free land on which his aircraft hangar stands. “Too often when looking at working in rural areas people only look at monetary benefits and, unfortunately, the perceived negatives,” he said.

Wudinna District Council chairman Tim Scholz at the newly prepared site for the Wudinna Medical Centre, August 2008. Photo courtesy Wudinna District Council

There is opportunity for “many little fringe benefits”, when working in regional areas, that are not insignificant although not formally considered part of the job income. These may not become apparent until after a move and will be personal to the individual or their family. For example, flying removes the tyranny of distance for Dr Lewis who can go in a straight line at 300km per hour in the air. Without an aircraft, a trip to Adelaide would take six hours by road. By air, the journey is reduced to just 75 minutes. This makes day trips to Adelaide possible, which keeps his family happy.

Dr Scott Lewis (left) and Wudinna District Council chairman Tim Scholz at the Wudinna Hospital. Photo courtesy Wudinna District Council

Dr Lewis credits the newly renamed Wudinna District Council for their proactive approach to providing local healthcare. He suggested other rural local governments needed to take similar urgent action to recruit and retain health professionals. “You cannot just sit back and expect that there will be a doctor available to come in and work when you want one,” Dr Lewis said. A newly built health centre, worth an estimated $1 million, replaces the old tworoom surgery. It contains four consulting rooms, a treatment room, video link and allied health resources. Funding of $440,000 came from the Federal Government Rural Medical Infrastructure Fund and the remainder from the council. Attracting a doctor must be approached as a long-term process, beginning years before the incumbent doctor plans to leave, Dr Lewis pointed out. “My recruitment to Wudinna began two-and-a-half years before I started, long before I finished my registrar training. They [the council] turned away potential doctors in preference to waiting until I arrived.” It is that sort of long-term relationship that needs to exist to recruit a doctor, rather than the idea of “if we throw a few hundred thousand dollars at the problem it will fix itself ”, according to Dr Lewis. On a personal level there are few negatives about his new life in Wudinna. While there is no such thing as a quick trip to the shops, it is people rather than things that he misses most. “The friends that we left behind. Apart from that, nothing – I don’t miss the traffic, the congestion and the lack of appreciation CM at work,” he said.

Consult Magazine | Spring 2008

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