Australian Prescriber最新文献

Calcitonin gene-related peptide (CGRP)-targeted therapies are the first medications developed specifically for migraine prevention. They block the actions of CGRP, a neuropeptide with a key role in migraine pathophysiology. There are 2 categories of drugs: monoclonal antibodies directed against either the CGRP ligand or receptor, and small-molecule CGRP receptor antagonists. CGRP monoclonal antibodies are available as self-administered subcutaneous injections or as an intravenous infusion, and are administered monthly or quarterly. Clinical trial and real-world data over the past 10 years support their effectiveness and safety in patients with episodic and chronic migraines, and research into long-term safety is ongoing. Patients must fulfil certain criteria, including prior treatment with nonspecific oral preventive medications, to receive subsidised treatment with these drugs on the Pharmaceutical Benefits Scheme (PBS) in Australia. Small-molecule CGRP receptor antagonists (known as gepants) are orally administered drugs that can be used for migraine prevention or acute treatment. There are no gepants listed on the PBS at the time of writing. Their role in the prevention and acute treatment of migraine is continuing to evolve.

Respiratory syncytial virus (RSV) is a common cause of respiratory tract infections in infants and young children, and adults over 60 years of age. Infants born prematurely, adults aged over 75 years, individuals with medical conditions such as chronic cardiac or respiratory disease, or obesity, and Aboriginal and Torres Strait Islander people are at increased risk of severe RSV disease. As the management of RSV disease is mainly supportive, routine testing for RSV in people with a respiratory illness is not recommended. In high-risk populations and individuals presenting with severe illness, respiratory virus testing should prioritise influenza and COVID-19, as there are specific antiviral drugs for these diseases. Recent approval of RSV vaccines and a new long-acting RSV monoclonal antibody has created opportunities to minimise adverse outcomes associated with RSV infection. Protection against severe RSV disease in infants can be achieved through vaccination of their mother between weeks 28 and 36 of pregnancy, or by administering an RSV monoclonal antibody after delivery. There is currently no RSV vaccine approved for neonates or infants. For older adults, at the time of writing there are 2 approved RSV vaccines available.

Vancomycin is an important antimicrobial for prophylactic, empirical and directed therapy of Gram-positive organisms. Therapeutic drug monitoring is recommended for all patients expected to receive vancomycin for more than 48 hours to optimise drug exposure. Monitoring the area under the concentration-time curve over a 24-hour period (AUC₂₄) for vancomycin is preferred over monitoring trough plasma concentrations. An AUC₂₄ of 400 to 600 mg.hr/L is recommended for infections other than central nervous system infections. Vancomycin may cause nephrotoxicity, ototoxicity, cutaneous reactions, hypersensitivity and haematological toxicity. Reducing the incidence of vancomycin-induced nephrotoxicity involves recognising and modifying risk factors where possible.

Australian health authorities recommend offering prenatal screening for fetal chromosome conditions, also known as aneuploidies (e.g. Down syndrome [trisomy 21]), to all pregnant individuals to support informed decision-making. Noninvasive prenatal testing (NIPT) is one of 3 types of prenatal aneuploidy screening tests available in Australia. NIPT requires a maternal blood test after 10 weeks gestation. Although it doesn't require an ultrasound, a 12- or 13-week ultrasound is recommended as it provides an opportunity for early diagnosis of major structural anomalies. NIPT is not subsidised by Medicare. It is important to take a patient-centred approach when discussing screening options. Patients should be encouraged to consider whether knowing the test result will impact their pregnancy decision-making or preparations. There are two main NIPT approaches: genome-wide and targeted. All currently available NIPT platforms perform well for detecting the common autosomal aneuploidies (trisomy 21, 18 and 13). NIPT has the highest true-positive rate (highest sensitivity) and lowest false-positive rate (highest specificity) among aneuploidy screening methods, however false-positive results can occur. Genetic counselling and confirmatory invasive diagnostic testing are recommended for patients with a high-probability NIPT result, especially if they are considering pregnancy termination.

Triple antithrombotic therapy or 'triple therapy' describes the combination of 3 oral antithrombotic medications - an anticoagulant drug (warfarin, apixaban, rivaroxaban or dabigatran) and 2 antiplatelet drugs (usually aspirin plus clopidogrel). Most commonly, triple therapy is indicated for patients who require both dual antiplatelet therapy following coronary stent insertion for acute coronary syndrome and long-term anticoagulation for atrial fibrillation. Current evidence supports shorter durations of triple therapy to mitigate bleeding risks without compromising ischaemic protection. Recent guidelines advocate up to 1 week of triple therapy for most patients, extending up to 1 month for those at high ischaemic risk. In practice, the approach to antithrombotic therapy is individualised by the patient's cardiologist, balancing bleeding and ischaemic risks. General practitioners and pharmacists have an important role in supporting patients in their step-down plan to dual therapy with the oral anticoagulant drug and one of the antiplatelet drugs, and then ongoing monotherapy with the oral anticoagulant drug.