Medication Cessation

Key points:

1. patients who are on 5 drugs or more are at an increased risk, up to 30 %, of experiencing an adverse drug-related event (ADE) over the next 6 months, which may lead to hospitalisation.

2. When reviewing medications for patients who are on multiple medications, the following issues need to be established:

• the current indications for each drug
• Patient and carer's perception of the efficacy and side effects Phyllis has experienced with each drug
• whether there are any drugs she is not taking and reasons for non compliance
• scientific evidence for the benefits and harms of each drug
• a shared understanding with patient of the likely future course of illness and what she values as the goals of care

3. The CEASE protocol includes a systematic method for appraising the utility of individual medications and deciding which ones may be worthy of discontinuation and in which order. The following 6 questions are there to help with the process:

• Is there a valid indication for each medication?
• right diagnosis? active disease?
• evidence to use those medications?
• Is the drug part of a prescribing cascade seeking to counteract side effect of other medicines?
• Is the drug, on balance, more likely to do harm than confer benefit over the medium to longer term?
• Is the drug being prescribed for disease or symptom control despite either being ineffective of where symptoms have completely resolved or are amenable to non-drug interventions?
• Is the drug a primarily preventive medicine, which is unlikely to confer any patient-important benefit over the patient's remaining lifespan?
• Is the drug imposing unacceptable treatment burden?

4. The drugs that should take priority in being discontinued are those with the lowest utility and least likelihood of being associated with withdrawal syndromes or disease rebound. (Figure 1 Algorithm for deciding the order and mode in which could be discontinued)

5. Cease one drug at a time so that harms and benefits can be attributed to specific drugs and rectified.

6. Wean, not abruptly cease, drugs that are more likely to cause adverse withdrawal effects. Instruct the patient on what to look for and report in the event of such effects occurring, and what actions they can self-initiate if these were to occur

7. Fully document the reasons for, and outcomes of, de-prescribing

Dysfunctional uterine bleeding

Condition

• Dysfunctional uterine bleeding

Definition

• Dysfunctional uterine bleeding is excessively heavy, prolonged or frequent bleeding of uterine origin which is not due to pelvic or systemic disease, or pregnancy
• It can only be diagnosed after other uterine and systemic causes have been excluded by history, examination and investigations

History

• Dysfunctional uterine bleeding is common in women aged 30-50 years of age
• Ovulatory dysfunctional bleeding, where cycles are regular, accounts for about 80% of cases and is most common in women who are in their 30s
• Excessive menstrual loss in women in their late 30s and early 40s is usually ovulatory and a result of fibroids, in particular sub mucous fibroids
• Irregular bleeding is associated with an increased incidence of underlying pathology, esp. in women > 40s, as the risk of endometrial carcinoma starts to rise at this stage.

Examination 

• Pelvic examination if 
• features in the history suggesting underlying pathology  (e.g. risk factors for endometrial hyperplasia or carcinoma)
• the patient has decided to go ahead with a levonorgestrel intrauterine device - a pelvic examination is performed to assess the uterus for suitability for the device 
• the patient is to be referred for further investigations such as ultrasound or biopsy

Investigation

• FBE
• TSH
• Serrum ferrtin (should not routinely be carried out on women with heavy menstrual bleeding)
• Female hormone testing should not be carried out on women with heavy menstrual bleeding
• Transvaginal ultrasound 

Management options

• Levonorgestrel intrauterine device
• Oral progesterone (days 5-25)
• Tranexamic acid
• Nonsteroid anti inflammatory drugs
• combined oral contraceptive pill 
• Danazol 
• Oral progesterone  (days 12-26)

primary dysmenorrhoea

Condition

• Primary dysmenorrhoea

Definition

• Primary dysmenorrhoea is the usual cause of dysmenorrhoea in adolescence

History

• Symptom onset at adolescence
• Duration: first 2-3 days of period
• No pain at other times of menstrual cycle
• No other types of pain 
• Risk factors for primary dysmenorrhoea 
• younger age at menarche
• long duration of menstrual flow 
• smoking 
• obesity 
• ETOH consumption 
• high levels of stress 
• anxiety
• depression 
• disruption of social networks

Management

• NSAIDs
• pain relief is achieved in approximately 70% of women
• Act to prevent pain rather than as an analgesic to treat pain 
• start taking the NSAIDs as soon as you know that period imminent, or as soon as the bleeding starts
• because these tablets prevent pain you need to take them at the correct dose on a regular basis for the first 1-3 days of period
• COCP is highly effective but 30 % users report no relief with use of the COCP

References:

- Check program 2011 

- eTG

Approach to breast pain

Mastalgia: diagnostic strategy model

Probability diagnosis

• Pregnancy
• Cyclical mastalgia
• benign mammary dysplasia 

Serious disorders not to be missed

• Neoplasia
• Inflammatory breast cancer
• Infection:
• mastitis
• abscess
• Myocardial ischaemia

Pitfalls

• pregnancy
• chest wall pain e.g. costochondritis
• Pectoralis muscle spasm
• Referred pain esp. thoracic spine
• Bornholm disease (epidemic pleurodynia)
• Mechanical
• bra problems
• weight change
• trauma
• Rarities
• hyperprolactinaemia
• nerve entrapment
• mammary duct ectasia
• sclerosing adenosis
• ankylosing spondylitis

Mastitis

Condition

• Mastitis

Definition 

• cellulitis of the interlobular connective tissue of the breast
• infection organism is usually S. Aureus, E. Coli or C. Albans

History

• A lump and soreness 
• A red tender area
• possibly fever, tiredness, muscle aches and pains

Management

• prevention: empty breast (keep feeding) and attend to breast engorgement and cracked nipples
• antibiotics: flucloxacillin 500 mg QID 

References:

• John Murtagh's general practice 

Costochondritis

Condition

• Costochondritis

Presentation

• pain can appear to be in the breast with intermittent radiation round the chest wall and is initiated or aggravated by deep breathing and coughing 
• pain is acute, intermittent or chronic

Examination

• normal breast examination 
• palpable swelling about 4cm from sternal edge due to enlargement of costochondral cartilage

Management 

• conservative 
• settles on its own 
• can use pain relief

References:

• John Murtagh's General Practice 

Cyclical mastalgia

Condition

• Cyclical Mastalgia

Definition 

• Pain prior to menstruation 

Presentation

• typical age 35
• discomfort and sometimes pain are present
• usually bilateral but one breast can dominate
• mainly premenstrual 
• usually resolves on commencement of menstruation 
• breasts diffusely nodular or lumpy
• variable relationship to the pill 

Examination

• as per normal breast examination 

Management

• reassurance
• proper bra support
• low fat diet, excluding caffeine
• ideal weight
• analgesia 
• Danazol in severe cases

Reference:

john murtagh general practice