Victoria - April 2020

A message from your Victorian Regional Committee Chair

Dear colleagues,

I am so proud to be a member of this profession and of our health system’s efforts in dealing with COVID-19. Thank you to each one of you and to your teams. Please be careful and support each other, while we wait and after the tsunami arrives. Please remember also that some of us may not make it, and that, for others, the worst will be afterwards. Again, I am so proud of the health system and this country’s response. Let’s hope that the strategies introduced to date have changed the course of the disease in Australia.

I have thought, what can we do to help? Firstly, we are changing how we practise medicine on the wards and in the clinics, and the College has held some incredibly popular sessions on telehealth. In addition, some of you will have time on your hands and might like to catch up on the Continuing Education Updates or sessions from our MBA in a Day or Opportunities in Retirement from the past 12 months. The latter are not just about retirement – they include talks on writing a book, undertaking a PhD in medical history, working in east Timor, teaching in a rural medical school, doing medical research part-time, or becoming a CMO or a Board member.

We will make available some more online talks in coming weeks. More updates in haematology and neurology; ‘What every physician needs to know about genetics’ and some genetics in individual specialities. And for our trainees ‘How to write a case report’ and hopefully some sessions on statistics for research.

This might also be a good time to register for the College Learning Series. As part of your membership, you have access to all the lectures provided for training program. You can just dip in and out – and catch up on topics such as what is happening with inflammatory bowel disease or cancer of the breast.

We aim to run half-day seminars later in the year on topics such as climate change and the future hospital hosted by the Committee of Chairs of Medical Colleges.

Please let me know if we at the Victorian Regional Committee can do anything to support you.

Thank you once again

Professor Judy Savige FRCP FRACP FRCPA PhD MSc Dip Mgmt
Victorian Regional Committee Chair


College Bodies expressions of interest open

Expressions of Interest (EOI) are now open across all of our College Bodies for various positions on councils and committees. View listings for more information on the positions on offer.

You are invited to express your interest in the below categories:

The future of digital health webinar

The Australian Digital Health Agency and RACP are co-hosting an interactive webinar on national digital health strategy priority initiatives on Saturday, 9 May from 11am to 12pm. Initiatives such as My Health Record, secure messaging, interoperability as well as the introduction of electronic prescribing will be covered. There will also be ample time allocated for Q&A and discussion with your peers.

Register


 

Practical points for management of direct oral anticoagulants (DOACs)

Although there is still a significant proportion of patients being treated with warfarin, use of direct oral anticoagulants has been steadily increasing. Dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis) are available in Australia for non-valvular AF, treatment of thromboembolism, as well as VTE prophylaxis. DOACs are not suitable for prosthetic valves. Although all have degree of renal excretion, dabigatran, in particular, should be used with caution in patients with renal impairment.

These medications are convenient for patients due to the lack of requirement for routine blood monitoring, fixed dosing, less drug interactions and effects from diet. Bleeding rates appear to be lower, particularly intracranial haemorrhage. However, menorrhagia appears to be more significant with DOACs compared with warfarin.

Although DOACs are easier for patients to manage than warfarin, regular reevaluation of the risks and benefits is still necessary. Although there are fewer interactions with other medications, there are still some to be considered, for example rivaroxaban interaction with azoles, carbamazepine and rifampicin.  Although management is not as complex as for warfarin, patients still need education.

Regular testing for warfarin can give an indication of compliance, whereas DOACS are usually not monitored and hence compliance is not known as objectively. It is reasonable to consider renal function at least annually. As dabigatran is the DOAC most prone to accumulation with declining GFR, clinicians have to be cognisant that many older patients have poorer renal function than suggested by creatinine levels or biochemically calculated GFR. Liver dysfunction is also a consideration, particularly for apixaban and rivaroxaban and severe liver disease may be a contraindication.

Unlike warfarin, if doses are missed, due to their direct action and half-life, the patient may become under anticoagulated within 24 to 48 hours. Like warfarin, if there is an accidental overdose, bleeding risk obviously increases, but the risk cannot be estimated with an INR. Patients need to be assessed for self-management of medications, whether dosette boxes are required and whether they need someone else filling them and/or whether medication administration has to be supervised. Because of the bleeding risk, it is important to determine when patients have become more at risk of bleeding, for example if they start having recurrent falls. Patients should also be reminded not to engage in risky behavior such as climbing ladders and/or onto the roof, which I have found is surprisingly prevalent. Patients and carers also need to be instructed to seek medical advice if significant bleeding occurs. For clinicians regularly prescribing DOACs, it may be useful to develop a fact sheet to give to patients. Sample patient information sheets in several languages are available online.

All DOACs will increase the APTT and PT in a non-linear fashion, not being useful for assessment of effective treatment. The thrombin clotting time (TCT) is very sensitive to dabigatran, which again is not helpful for monitoring unless normal, indicating no dabigatran effect. Dabigatran levels can be performed, but this testing is available in only a few laboratories and is rarely indicated. Rivaroxaban and apixaban levels can be estimated with their respective anti-factor Xa assays. As therapeutic ranges are poorly defined, testing is rarely indicated. Wearing my laboratory hat, I would like to emphasise that when requesting coagulation testing it is important to detail the anticoagulant being prescribed to allow result interpretation.

As there are three agents, it is difficult to commit to memory how to manage patient’s peri-procedure. In most instances, unless at very high risk of thromboembolism, patients do not require bridging therapy, provided guidelines for stopping therapy prior to the procedure are followed. The time to stop dabigatran prior to procedures or surgery is dependent on renal function. A useful resource which considers the bleeding risk of surgery and the thrombotic risk of the patient for each DOAC has been developed by the European Society of Cardiology, using a traffic light system. It gives access to the article: European Heart Journal 2018: 39: 1330-93 with peri-operative guidelines detailed in Tables 11 and 12. Similarly this article includes guidance for transitioning between agents. In general, DOACs can be commenced when the INR is less than 2.5, preferably closer to 2.0 when transitioning from warfarin.

Urgent reversal may be required for life-saving surgery or significant bleeding. Dabigatran is the only DOAC with an antidote available in Australia -idarucizumab. Idarucizumab is available in most major hospitals, with use requiring approval due to its expense.  It is rare for one dose to not be sufficient. If bleeding continues and thought to be due to coagulopathy a second dose may be required. The FDA has approved andexanet, which can be used for reversal for apixaban and rivaroxaban. Until this agent is available, if significant bleeding occurs with apixaban and rivaroxaban, Prothrombinex-VF may be administered with less predictable benefit compared to warfarin reversal. Doses are empiric. The benefit of prophylactic Prothrombinex-VF is unknown.

Dabigatran is associated with less menstrual loss than rivaroxaban and apixaban. Menorrhagia may require management with progesterone subcutaneous implants or intrauterine devices. Some clinicians add an oral contraceptive in low risk patients, but although data about the safety of this strategy is increasing, it is still limited. Tranexamic acid use has also been used anecdotally.

In addition to treatment of atrial fibrillation long term and DVT/PE short term, there are some studies with extended use treatment after DVT, particularly with unprovoked DVT where recurrence rates are higher than provoked. Some studies suggest reduced doses are effective and have less bleeding when given for an extended six months beyond initial three months of full dose therapy. This is useful in the context of Chest guidelines that suggest considering indefinite treatment for unprovoked DVT. Also, a recent study of warfarin for two years showed reduction of recurrence rates (ExACT trial) compared to no treatment.

Data is very limited about the use of DOACs with aspirin, but anecdotally clinicians have been using this combination. There are a few studies suggestive that the use of DOACs in patients with cancer is both efficacious and safe. The bleeding rate is not increased compared with heparin and warfarin, but with the current lack of robust data, clinicians need to balance the convenience for patients against risks in a group of patients where anticoagulant failure rates are high. Current evidence indicates that DOACs may not be sufficiently effective in antiphospholipid syndrome (APLS). Although early studies were favourable, inclusion criteria included patients that had positive antibody testing only on one occasion and may not have had APLS. A study including triple antibody positive APLS participants was stopped early due to increased events in the DOAC arm compared with warfarin. Pregnancy should still be managed with low molecular weight heparin and, in selected cases, mid-trimester warfarin supervised by a specialist centre.

Due to the complexity of managing DOACs, it may be useful to become familiar with one that suits most of your patient’s requirements.  It is useful to have access to local guidelines for peri-operative or procedural management or use the links above, as well as consulting a haematologist for tricky situations.

Carole Smith MD, FRACP, FRCPA


Online Supervisors Professional Development Program (SPDP) workshops

The Practical Skills for Supervisors workshop incorporates the overarching themes of developing trainee expertise and using coaching techniques to improve feedback practise. 

This workshop focuses on delivering feedback using two frameworks, the GROW model and the four areas of feedback. By using these models, supervisors can facilitate change and growth in trainees towards expert performance.

The session topics are:

  • developing a culture for learning
  • providing feedback and improving performance
  • delivering feedback in challenging situations

Register


We are preparing to deliver Congress 2020 to you online

So you can still learn from each other, engage with experts and your peers and contribute to the conversation we are now preparing to deliver Congress online. RACP Congress 2020 Balancing Medical Science with Humanity online program will explore the theme and deliver shared sessions and selected stream sessions for you to access from your computer or device.

You will be able to watch orations, interact with experts through webinars and listen and contribute to panel discussions via podcasts.

Details about the sessions and how you can access the program will be announced soon.


Pomegranate podcast: The art of telehealth

COVID-19 has left few people around the world unaffected, and health practitioners are among those at the top of the list. Their daily and intimate service to the public inevitably puts them at risk of catching the virus, while social distancing precautions can compromise the work they do. Dreadful as the viral disease is, the bigger consequences of the pandemic may be on the disruption to routine healthcare.

Consulting patients by video or phone can be a way to keep healthcare ticking over, but many doctors are nervous as they adopt it for the first time. In this podcast we go over some of the bureaucratic and tech support questions that clinicians have been asking during the current crisis. We also discuss the art of building trust with new patients, and conducting a physical examination through telehealth.

The guest speakers are oncologist Sabe Sabesan and paediatrician Michael Williams, who’ve been pioneering telehealth outreach to rural and remote Queensland for more than a decade.

Listen now


Discover your online learning options today

We understand you’re busy and on-the go, so discover our quality online education. Access a range of online learning courses, resources, lectures, curated collections and podcasts which have all been developed by members, for members. The interactive nature of our online learning resources enable you to learn from your peers. Accessible anywhere and optimised for mobile on-the-go learning, RACP Online Learning Resources are free for members and count towards CPD requirements

Access today


End-of-Life Q Stream

Fellows can claim CPD credits by completing the Online Professionalism Program (OPP)

Looking for another effective avenue to claim CPD credits? We recommend considering OPP. OPP is an evidence-based, spaced online learning program. The program has been demonstrated in randomised trials to improve knowledge acquisition, boost retention, change on-the-job behaviours and improve patient outcomes.

OPP delivers short and practical case studies right to your inbox, and feature multiple-choice questions. These case studies are created by a Working Group whose experience is in the relevant field or topic. Each multiple-choice question takes about five minutes to complete, with an opportunity to re-attempt each question if answered incorrectly.

These questions are framed in clinical scenarios and are designed to encourage critical thinking. Each question links to a discussion forum for participants to engage in conversation about each case study. This is in acknowledgement that there is not always a right or wrong answer.

On 16 March 2020, the RACP’s Continuous Learning team launched the End-ofLife Care OPP Course to over 40 participants. The End-of-Life Care Course is designed to enhance physician’s skills with end-of-life and advance care planning.

The End-of-Life Care Course is comprised of 11 multiple-choice questions which will take participants three to four weeks to complete. Participants can claim CPD credits (one credit per hour) in Category 1: Educational Activities, for the time they spend on this resource.

If you are interested in the current End-of-Life Care course or future OPP courses, please register your interest by emailing professionalism@racp.edu.au.


Insurance implications of genetic testing survey

In 2017, Monash University surveyed health professionals regarding their knowledge, experience and views regarding the life insurance implications of genetic testing. In 2019, policy in this area changed, and we are keen to understand whether, and if so how, things have changed. You are eligible if you are a qualified health professional (other than a general practitioner) working in Australia or Aotearoa New Zealand who has direct contact (by telephone or in person) with clients who are considering genetic testing.

Please complete this important survey. It should not take longer than 10-15 minutes to complete, and can be anonymous. The findings of this project will contribute to a policy response to the Australian government regarding the current situation, and your participation will assist with gathering critical data in this space. For any queries regarding this research, please contact Jane Tiller

Complete the survey


 

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