May 2022 updates
Guidelines and topics reviewed
Practice-changing updates to other guidelines
The following practice-changing updates were included in Therapeutic Guidelines in May 2022.
Several functional improvements have been included in this release. The Therapeutic Goods Administration (TGA) pregnancy category and advice on drug compatibility with breastfeeding is now presented in a pop-up box when clicking on the pregnancy and breastfeeding buttons next to a drug recommendation, so users can access this information more directly. Links to the Pharmaceutical Benefits Scheme (PBS) schedule have also been updated, with the PBS button next to a drug recommendation now linking directly to the relevant section of the PBS website, so the latest information is always provided.
- The ventrogluteal site is preferred for administration of intramuscular benzathine benzylpenicillin because of reduced pain and risk of nerve injury. Instructions on intramuscular injection of benzathine benzylpenicillin at the ventrogluteal site have been included.
- Benzathine benzylpenicillin dosing has been streamlined for sore throat, impetigo, and prophylaxis for invasive group A streptococcal (iGAS) infection, with three weight-based bands recommended for dosing instead of five.
- Advice on compatibility with breastfeeding for trimethoprim+sulfamethoxazole has been updated.
- Based on new evidence, an early switch to oral therapy can be considered for Klebsiella pneumoniae liver abscess in patients who are not critically ill and do not have metastatic infection.
Antibiotic management of chronic obstructive pulmonary disease (COPD)
- Fever has been removed from the criteria for suspecting a bacterial cause of COPD exacerbation because it is not a sensitive marker for infection. The limited benefits of antibiotic therapy for bacterial exacerbations of COPD outside of the intensive care setting have been emphasised.
Prevention of infective endocarditis
- Studies have demonstrated that rheumatic heart disease is an independent risk factor for infective endocarditis and adverse outcomes from this disease. Therefore, infective endocarditis prophylaxis is now recommended for all patients with rheumatic heart disease undergoing certain procedures.
- A footnote has been added to clarify that obstetric procedures (eg caesarean section) are not considered to be genitourinary procedures when discussing procedures for which endocarditis prophylaxis is recommended for patients with a specified cardiac condition.
- Advice has been added on the management of impetigo in patients receiving benzathine benzylpenicillin for prevention of recurrent acute rheumatic fever.
- A quantitative test for assessing glucose-6-phosphate dehydrogenase activity to enable the safe use of tafenoquine is now available in Australia; the footnote about use of tafenoquine for radical cure of P. vivax malaria has been updated.
- A footnote has been added to explain that the quantity of famciclovir listed on the Pharmaceutical Benefits Scheme to treat shingles in patients who are not immunocompromised is not sufficient for the recommended course of treatment.
- The Lyme disease topic now includes more detail on clinical manifestations; links to international publications on the prevention, diagnosis and treatment of Lyme disease; and a link to the recently published clinical pathway on debilitating symptom complexes attributed to ticks (DSCATT).
Salmonella typhi and paratyphi A, B and C bacteraemia (typhoid and paratyphoid fever)
- Due to increasing resistance rates, we now emphasise that ciprofloxacin should not be used to treat typhoid or paratyphoid fever unless susceptibility is confirmed, regardless of the country of acquisition.
Bone and Metabolism guidelines
- The place of romosozumab (a new monoclonal antibody that increases bone formation and bone mineral density) in the management of osteoporosis has been addressed—it is usually reserved for patients who experience a fracture while on antiresorptive therapy.
- Empagliflozin has now been approved by the Australian Therapeutic Goods Administration for use in patients with an estimated glomerular filtration rate (eGFR) or creatinine clearance (CrCl) of 30 mL/min or more (previously 45 mL/min or more). The drug recommendation for empagliflozin for patients with type 2 diabetes has been updated.
Liver Disorders guidelines
- For treatment of hepatitis C in treatment-naive adults with compensated cirrhosis, the duration of therapy of glecaprevir+pibrentasvir has been shortened from 12 weeks to 8 weeks, based on new evidence.
- For bleeding gastro-oesophageal varices, the recommended dose of octreotide infusion (following a loading dose) is now 25 to 50 micrograms/hour. The dose at the lower end of the range has been included because atrioventricular block has been reported rarely in patients receiving higher doses.
- Several clinical studies have demonstrated that levetiracetam has similar efficacy to sodium valproate and phenytoin for treatment of status epilepticus. Levetiracetam is now recommended as an alternative first-line drug to treat status epilepticus in adults and children who continue to experience seizures after the administration of a benzodiazepine.
Oral and Dental guidelines
- The rationale for antibiotic choice for surgical prophylaxis for dental procedures has been clarified.
- Romosozumab (a new monoclonal antibody for the treatment of osteoporosis) has been reported to be associated with medication-related osteonecrosis of the jaw, but the magnitude of the risk is unclear. Most patients receiving romosozumab would have had at least 12 months of therapy with an antiresorptive drug, so this should be considered when assessing the risk of medication-related osteonecrosis of the jaw in a patient taking romosozumab. If a bone-invasive dental procedure is required in a patient taking romosozumab, the benefits of continued therapy outweigh the low risk of medication-related osteonecrosis of the jaw in most patients.
- The rankings for topical antifungals for oral candidiasis and angular cheilitis have been updated to reflect their similar efficacy; practical considerations on drug choice for oral candidiasis have also been included (eg amphotericin B lozenges may not be suitable for patients with a dry mouth).
Pain and Analgesia guidelines
- The Australian Therapeutic Goods Administration has added enhanced warnings to the product information and consumer medicines information for the gabapentinoids, gabapentin and pregabalin, to highlight the potential for misuse (pregabalin only), abuse and dependence. Advice on when to consider deprescribing gabapentinoids for chronic pain has been updated accordingly.
- New combination inhalers, mometasone+indacaterol and mometasone+indacaterol+glycopyrronium, have been added to the stepwise maintenance management of asthma for adults and adolescents.
- New triple therapy combination inhalers, beclometasone+glycopyrronium+formoterol and budesonide+glycopyrronium+formoterol, have been added as options for patients who continue to have symptoms and exacerbations of COPD despite dual therapy with a long-acting bronchodilator and inhaled corticosteroid.
- Dupilumab and omalizumab have now been approved by the Australian Therapeutic Goods Administration for use in adults with inadequately controlled chronic rhinosinusitis with nasal polyps. The role of biologics for patients with chronic rhinosinusitis with nasal polyps has been updated.