best practice:- Issue 31 Contents

Issue 31 October 2010 - Contents

Welcome to BPJ 31

Which antihypertensive?

Once the decision has been made to initiate antihypertensive treatment, choice of medicine should be based on individual patient characteristics including age and co-morbidities. Combination treatment is ultimately needed to control blood pressure in the majority of patients so it is less important which antihypertensive is used initially. In non-frail, older people without co-morbidities a low dose thiazide diuretic is suitable as first-line treatment, unless contraindicated or if indications are present for one of the other treatment options (ACE inhibitor, calcium channel blocker or beta blocker).

The warfarin dilemma

Oral anticoagulation with warfarin in older people with atrial fibrillation

Evidence suggests that warfarin is under utilised in older people. The dilemma is that in older people with atrial fibrillation, the factors indicating a need for anticoagulation with warfarin are also the risk factors for intracranial haemorrhage. Providing bleeding risks can be managed, warfarin is still the most effective treatment in this group of people and should be considered for individual patients, based on an assessment of bleeding risk, stroke risk, co-morbidities, concurrent medicines and likely compliance with monitoring. Increasing age alone is not a contraindication for warfarin use.

Access to clopidogrel now widened

Clopidogrel, an antiplatelet medicine, is now able to be prescribed without Special Authority approval. Clopidogrel is not recommended for use in primary prevention of cardiovascular disease (CVD), but it can be considered for use in people with established CVD in place of aspirin, when aspirin is not tolerated or contraindicated. Clopidogrel may also be used in secondary stroke prevention as an alternative to aspirin/dipyridamole, in acute coronary syndrome without ST-segment elevation and in post-revascularisation procedures.

Screening and management of “the diabetic foot”

Foot ulceration and damage is one of the most common complications of diabetes and without regular screening and effective management, patients are at high risk of lower extremity amputation. Feet should be checked at least once per year in every person with diabetes and more often in those who are at higher risk of developing foot complications. Management focuses on prompt treatment and referral for any detected foot problems and providing patient education about foot care.