Updates

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Other practice-changing updates:

Antibiotic prescribing in primary care: summary table

• The freely available Antibiotic prescribing in primary care summary table has been updated to include temporary advice on alternative recommendations to first-line antibiotics for use in shortage situations. The listed alternatives should only be considered if first-line treatment is unavailable as the alternatives may be less efficacious, have a suboptimal spectrum of activity and have a less favourable harm–benefit profile.
• Shortage of oral liquid formulations of some antibiotics is particularly an issue. To enable the preferred antibiotic to be used in children when an oral liquid formulation is not available, the summary table also includes temporary advice developed by The Society of Hospital Pharmacists of Australia, from Don’t Rush To Crush, on the suitability of crushing or dispersing oral solid-dose formulations. 
• For more information about the development of the table, see the news article.

Antibiotic guidelines 

• The pneumonia topics have been updated to indicate that pneumonia can be a feature of coronavirus disease (COVID-19), and to provide links to the COVID-19 topic for resources on diagnosis and management. 

Diabetes guidelines 

• Following the discontinuation of the modified-release formulation of exenatide in Australia in 2021, the immediate-release formulation was discontinued in December 2022; there are now no formulations of exenatide available in Australia, so use of alternative glucagon-like peptide-1 (GLP-1) receptor agonists (dulaglutide, liraglutide, semaglutide) should be considered for type 2 diabetes in adults. 

Fatigue guidelines 

• New links to updated National Institute for Health and Care Excellence (NICE) guidance and advice on energy management have been added to help clinicians support patients with myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS). 

Pain and Analgesia guidelines 

• The Role of analgesics in chronic noncancer pain topic has new links to the revised Addiction Guidelines to support management of patients who may have a disorder of opioid use. 
• Advice on take-home naloxone has been updated to include information about eligibility and availability. 

Sexual and Reproductive Health guidelines 

• Advice has been added on new contraceptive pill formulations—the drospirenone-only progestogen only pill (Slinda) and the estetrol-drospirenone combined oral contraceptive pill (NextStellis).
• A revised printable table on switching between contraceptives includes new pill formulations and expands on advice for switching from combined hormonal contraceptives to other formulations.
• Rufinamide has been added to the list of antiepileptic drugs that interact with contraceptives and advice on lamotrigine’s interactions with hormonal contraception is expanded.
• Vaping is included the section on tobacco smoking and eligibility to use hormonal contraception.
• New advice for patients aged 50 years and older explains which contraceptives can be combined with cyclical combined menopausal hormone therapy. 

Toxicology and Toxinology guidelines 

• Ranitidine injection and tablets are currently suspended for use in Australia; alternative histamine H₂-receptor antagonists (famotidine or nizatidine) are now recommended in combination with promethazine for the treatment of mild to moderate scombroid poisoning. 

Cardiovascular guidelines

• The alteplase recommendation for haemodynamically unstable pulmonary embolism has been amended to clarify that the total daily dose (including initial intravenous bolus dose) for patients less than 65 kg is 1.5 mg/kg. 

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Other practice-changing updates:

Antibiotic guidelines

• The Australasian consensus guidelines for the management of invasive fungal disease and use of antifungal agents in the haematology/oncology setting were updated in 2021; all links to these guidelines have been updated.
• All mentions of the bacterium, Clostridium difficile, have been updated to its new name, Clostridioides difficile.
• In response to user feedback, printable summary tables of the indications and regimens for surgical antibiotic prophylaxis have been developed for most groups of procedures. A link to the summary table is included in each relevant section of the Surgical antibiotic prophylaxis for specific procedures topic, and a collation of all the summary tables is available via the ‘Quick links’ drop-down menu at the top of each page in Therapeutic Guidelines.
• Advice on diagnosing and managing COVID-19 changes frequently. To improve access to the most up-to-date advice, a list of the most relevant Australian resources has been collated.
• Primary prophylaxis for Mycobacterium avium complex (MAC) is no longer recommended for adults with HIV infection who immediately start antiretroviral therapy. See here for further information.
• The section on Management of neonates born to mothers with tuberculosis (TB) has been extensively revised following updates to a number of key state and international guidelines. Presumptive therapy for latent TB is now only recommended for neonates born to mothers with pulmonary TB if the mother is still considered infectious at the time of birth. Presumptive therapy for latent TB now includes the option of a 4-month rifampicin regimen.
• Flucytosine injection is no longer available for induction therapy of cryptococcal meningitis and pulmonary cryptococcosis. Recommendations for these conditions have been updated—use oral flucytosine (or consider administration via a nasogastric tube), or seek expert advice for other treatment options.

Pain and Analgesia guidelines

• The modified-release morphine recommendation for chronic noncancer pain has been updated to clarify dosing for the 12-hour and 24-hour formulations.
• Following updates to international guidelines, duloxetine is now the preferred drug for the management of painful chemotherapy-induced peripheral neuropathy.
• Paracetamol is a first-line analgesic in children. Information on paediatric-specific formulations has been added to support paracetamol use in this group.

Respiratory guidelines

• The new combination inhaler, fluticasone furoate+umeclidinium+vilanterol, has been added to the stepwise maintenance management of asthma for adults and adolescents for patients who continue to have uncontrolled asthma despite optimised dual therapy with an inhaled corticosteroid plus long-acting beta₂ agonist. In these patients, therapy consists of either increasing the inhaled corticosteroid dose or adding a long-acting muscarinic antagonist. The role of type 2 airway inflammation in selecting appropriate therapy has been updated.

Rheumatology guidelines

• Advice on NSAID use during the perinatal period has been updated to reflect current evidence. In general, NSAIDs should be avoided in pregnancy and must be avoided after 30 weeks’ gestation.

Toxicology and Toxinology guidelines

• Updated intravenous calcium drug recommendations throughout Therapeutic Guidelines to address change in labelling of calcium gluconate and to emphasise mmol dosing.

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.

Antibiotic guidelines

General

• 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.
• The primary care summary table has been updated to include the changes to management of sore throat.

Liver abscess

• 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.

Impetigo

• Advice has been added on the management of impetigo in patients receiving benzathine benzylpenicillin for prevention of recurrent acute rheumatic fever.

Malaria

• 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.

Shingles

• 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.

Lyme disease

• 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.

Diabetes guidelines

• 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.

Neurology guidelines

• 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.

Respiratory guidelines

• 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.

The following practice-changing updates were included in Therapeutic Guidelines in February 2022. 

Antibiotic guidelines:

• Antibiotics with activity against Pseudomonas aeruginosa are included in empirical regimens for severe diabetic foot infection. When intravenous ciprofloxacin is used to treat P. aeruginosa, it must be dosed 8-hourly (not 12-hourly). 

The following practice-changing updates were included in eTG complete in September 2021. 

Antibiotic guidelines:

• Based on new evidence, residence in a correctional facility has been included as a risk factor for methicillin-resistant Staphylococcus aureus (MRSA) infection.

The following practice-changing updates were included in eTG complete in July 2021. 

Antibiotic guidelines

• The empirical antibiotic regimens for children 2 months or older with community-acquired sepsis or septic shock have been updated in line with current Australian practice. The addition of gentamicin is recommended for children with septic shock to ensure adequate treatment of bacteria not susceptible to cefotaxime and ceftriaxone, but is not required for children with sepsis. Vancomycin has been added to ciprofloxacin for children with severe penicillin hypersensitivity to ensure adequate treatment of Gram-positive bacteria. 
• The nitazoxanide drug recommendation for children with recurrence of or ongoing refractory Clostridium difficile infection has been updated to include specific dosing for children 12 years or older. 
• Separate advice is given for dilution of benzylpenicillin for intramuscular and intravenous administration for management of suspected meningococcaemia in the community setting. 
• The graphic to support shared decision making discussions for patients with acute rhinosinusitis has been updated to clarify that decongestants should not be used for children younger than 6 years. 

Sexual and Reproductive Health guidelines 

• Rhesus antibody testing and anti-D immunoglobulin use is no longer recommended for medical abortion before 10 weeks’ gestation based on updated advice from the National Blood Authority and RANZCOG. 

Guidelines reviewed

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Practice-changing updates to other guidelines

As well as including a comprehensive update to the Developmental Disability and Psychotropic guidelines, the March 2021 release of eTG complete also includes the following practice-changing updates to other guidelines. With each release, we are also continuing to implement drug name changes in line with the Therapeutic Goods Administration.

Antibiotic guidelines

• In patients undergoing surgical abortion, age is one of several criteria for assessing the risk of concurrent sexually transmitted infection. Criteria have been amended in the topic ‘Surgical antibiotic prophylaxis for specific procedures’ to clarify that individuals aged 20 years or younger are at higher risk than those older than 20 years. 

Gastrointestinal guidelines

• Patients taking an SGLT2 inhibitor are at increased risk of euglycaemic diabetic ketoacidosis (DKA) when undergoing a procedure, and this risk is increased if the patient has been fasting, has very restricted dietary intake or has undergone bowel preparation. The topic ‘Preparation for gastrointestinal procedures’ has been updated to highlight this risk; it now includes links to the Diabetes guidelines for more detail on management, and links to alerts issued by the Australian Diabetes Society and Australian Therapeutic Goods Administration. 

Respiratory guidelines

• Beclometasone+formoterol has now been approved by the Australian Therapeutic Goods Administration (TGA) for use in adults with asthma who require Step 3 maintenance and reliever therapy, or Step 3 or Step 4 maintenance therapy. Drug recommendations for beclometasone+formoterol have been added.  
• A link has been added to the recently published Thoracic Society of Australia and New Zealand position statement on diagnosis and management of connective tissue disease–associated interstitial lung disease.

Sexual and Reproductive Health guidelines

• Serum human chorionic gonadotrophin (hCG) measurement helps guide the timing of an ultrasound scan to confirm intrauterine pregnancy before medical abortion. Detail has been added to clarify how to use hCG measurements to guide timing of ultrasound for very early gestations (less than 5 to 6 weeks). 

Practice-changing updates

The March 2020 release of eTG complete includes a new topic on coronavirus disease (COVID-19), with links to useful resources, and the following practice-changing updates to specific guidelines. With each release, we are also continuing to implement drug name changes in line with the Therapeutic Goods Administration.

Antibiotic guidelines

• To help users navigate the sepsis topics, the categories applied in these guidelines to antibiotic regimens for sepsis or septic shock have been defined. A new table summarises the empirical regimens for sepsis or septic shock when the source of infection is not known. A list summarising the pathogen-specific regimens for bloodstream infections has also been added.
• In the topic on ‘Pneumonia diagnosis and follow-up’, the statement on repeat chest X-ray has been reworded to clarify that a repeat chest X-ray is only recommended 6 to 8 weeks after the episode of pneumonia for patients in whom there is a clinical suspicion of lung malignancy (eg elderly, smokers).
• The intravenous dose of trimethoprim+sulfamethoxazole for add-on empirical therapy for meningitis and encephalitis in patients with risk factors for Listeria infection, and for directed therapy of Listeria meningoencephalitis, has been updated to align with standard references.
• The oral dose of trimethoprim+sulfamethoxazole for extended treatment of Listeria meningoencephalitis has been changed to a 12-hourly dosing schedule to improve patient adherence and avoid tablet splitting.
• All trimethoprim+sulfamethoxazole 5+25 mg/kg doses for adults have been capped at 96 kg to avoid overdosing in obese patients. This equates to a maximum unit dose of 480+2400 mg.
• Isavuconazole is now registered for use in Australia, so the footnote about availability through the Special Access Scheme has been deleted from the Aspergillosis section.

Dermatology guidelines

• The time needed to store clothes, towels and bedding in a sealed plastic bag to prevent transmission of scabies has been increased to 8 days in line with new evidence.

Gastrointestinal guidelines

• Table 6.22 (Oral 5-aminosalicylate preparations and dosages for ulcerative colitis) has been updated to reflect the change in criteria for accessing oral mesalazine on the Pharmaceutical Benefits Scheme (PBS)—for the treatment of ulcerative colitis, oral mesalazine is no longer reserved for patients with a documented history of a hypersensitivity reaction to a sulfonamide, or those intolerant to sulfasalazine.

Psychotropic guidelines

• Contact details for the Psychotropic Drug Advisory Service have been updated.

Guidelines reviewed

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Practice-changing updates to other guidelines

As well as including a comprehensive update to the Oral and Dental guidelines, the December 2019 release of eTG complete also includes the following practice-changing updates to other guidelines.

Antibiotic guidelines

• A PDF guide for assessing patients with reported penicillin allergy has been added.
• The advice on dosage adjustment of vancomycin in neonates and children has been updated to recommend seeking expert advice if a total daily dose of more than 70 mg/kg is required to achieve the target plasma concentration.
• The maximum unit dose of benzylpenicillin for children with erysipelas or cellulitis with systemic features has been changed from 2 g to 1.2 g to align with the maximum unit dose recommended for adults.
• A footnote has been added to explain the basis for the recommendations for dosage adjustment of oseltamivir for adults with impaired renal function.

Cardiovascular guidelines

• A footnote has been added to acknowledge the recommendation to use the sexless CHA₂DS₂-VASc score to stratify stroke risk in patients with ‘nonvalvular’ atrial fibrillation in the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand clinical guidelines for the diagnosis and management of atrial fibrillation 2018. <www.heartlungcirc.org/article/S1443-9506(18)31778-5/fulltex>
• The dosing of danaparoid for treatment of heparin-induced thrombocytopenia has been updated to align with the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) consensus statement on diagnosis and management of heparin-induced thrombocytopenia. <www.thanz.org.au/resources/thanz-guidelines>

Dermatology guidelines

• The management of primary oral mucocutaneous herpes has been updated to include currently available topical analgesics and anaesthetics. Episodic antiviral therapy for a minor recurrence in immunocompetent adults now includes a single dose of oral famciclovir.

Neurology guidelines

• The rate of infusion of intravenous sodium valproate for the acute management of seizures has been updated in line with evidence.

Psychotropic guidelines

• A footnote to alert users to the discontinuation of trifluoperazine and fluphenazine has been added.
• Sources of information for psychotropic drug use during pregnancy and while breastfeeding have been updated.