OPINION 13
Insight
How GPs are different
There ’ s a stark contrast between a GP ’ s daily work and that of other doctors — and that ’ s because the personal and social problems our patients face are often ingrained into our consults and projected onto us .
We must manage these issues alongside the array of medical conditions they have . It is this closeness to our patients and the strife they face that makes our role different to those of other specialists .
It is also likely the very reason we bulk-bill at higher rates than other doctors .
However , it runs contrary to the belief held by many of our patients and medical colleagues that the GP role is prosaic , which makes it even more interesting that this part of our job is growing .
I ’ m not sure about anyone else , but my consult room has become something of a confessional box .
Whether this is due to the decline in religious affiliations in the Australian population , I don ’ t know . 1 , 2
One such area I see a lot of is patients grappling with marriage and relationship breakdown . Whole consults can be spent discussing the emotional and practical implications of these issues .
With one in three marriages now ending in divorce , this is hardly surprising . 3
For many patients , disclosing such personal details to their trusted GP is far more comfortable than doing so to a relationship counsellor or psychologist they ’ ve never met before .
Their GP may even know their partner , children and other family members .
But herein lies the problem . In this situation you need to be highly vigilant about patient privacy .
A recent medicolegal case described how GPs can go seriously wrong in this area . 4
The GP failed to fathom the meaning of patient privacy by disclosing a patient ’ s infidelity to their unknowing spouse — who was also a patient .
In her defence , the GP told a Medical Board of Australia hearing she was “ not even thinking about confidentiality ” during the wife ’ s consultation when she told her about her husband ’ s extramarital affair .
The case also highlights a second glaring issue with GPs taking on relationship counselling : we are not trained in it .
Dr Paul Muthiah Medical editor at Australian Doctor and GP on the Central Coast , NSW .
It is not taught in medical school , and I personally have not done any postgraduate training in it .
My own parents ’ marriage
Diagnosed T2D ended in divorce . This childhood experience has proved invaluable in that it makes these consults much easier , as I have at least my own experience to go on . But is it enough to effectively advise a couple who ’ ve been married for more than 50 years ?
This becomes more important when you look at the health impacts of marriage breakdown , which can be severe with generational reach . Children who are subjected to acrimonious parental separations are in turn more likely to have poor longterm health outcomes . 5
It is clearly important for GPs to support patients and their families through these challenging periods in their lives . But I fear many of us are currently ill-equipped to do so . I am starting to think that managing relationship breakdown and caring for those individuals and families affected by it should be properly recognised as part of the GP role , and our training adapted to include it .
Doing so would also help highlight and strengthen the unique role GPs play within medicine . One that includes helping patients manage personal and social issues alongside their health , which often requires vast amounts of empathy , superb interpersonal skills and the willingness to draw on one ’ s own personal experiences .
References on request from jo . hartley @ adg . com . au
GALVUMET ® ( vildagliptin / metformin hydrochloride ) Indication : For patients with Type 2 diabetes mellitus : ( a ) as an adjunct to diet and exercise to improve glycaemic control in patients whose diabetes is not adequately controlled on metformin hydrochloride alone or who are already treated with the combination of vildagliptin and metformin hydrochloride , as separate tablets ; treatment of type 2 diabetes should not be initiated with this fixed-dose combination ; or ( b ) in combination with a sulfonylurea as an adjunct to diet and exercise in patients inadequately controlled with metformin and a sulfonylurea ; or ( c ) as add-on to insulin as adjunct to diet and exercise to improve glycaemic control in patients when a stable dose of insulin and metformin alone do not provide adequate glycaemic control . Dosage and administration : Starting dose should be on the patient ’ s current regimen of vildagliptin and / or metformin hydrochloride : 50 / 500 , 50 / 850 or 50 / 1000 twice daily . Do not exceed the maximum recommended daily dose of vildagliptin ( 100 mg ). Should be given with meals . To minimise the risk of lactic acidosis , only one strength of Galvumet should be prescribed and used at any one time . Patients should also be advised to discard their previous metformin medication when initiated on Galvumet . When used in combination with a sulfonylurea or insulin , the selected dose should provide 50mg vildagliptin twice daily and metformin similar to the dose already being taken . Dosage adjustment may be required in patients with GFR between 30 and 90 ml / min . Contraindications : Hypersensitivity to vildagliptin or metformin hydrochloride or to any of the excipients . Severe renal impairment ( GFR < 30ml / min ). Congestive heart failure . Acute or chronic metabolic acidosis including lactic acidosis or diabetic ketoacidosis . Temporarily discontinuation recommended in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials . Precautions : Not for type 1 diabetes or diabetic ketoacidosis . Risk of lactic acidosis . Monitoring of renal function before treatment initiation and regularly thereafter . Caution with concomitant use of medications that may affect renal function * or inhibit renal transport and increase metformin systemic exposure . Not recommended in patients with hepatic impairment including patients with a pre-treatment ALT or AST > 2.5x the upper limit of normal ; liver function tests ( LFT ) to be performed prior to treatment initiation , at three-month intervals during the first year and periodically thereafter ; withdrawal of therapy is recommended if an increase in AST or ALT of 3x upper limit normal or greater persist ; following withdrawal of treatment and LFT normalisation , treatment should not be reinitiated . Not recommended in patients with rare hereditary problems of galactose intolerance , the Lapp lactase deficiency or glucose-galactose malabsorption . Not recommended in paediatric patients . Discontinue treatment in case of hypoxemia . Temporary discontinuation in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials or surgical procedure . Excessive alcohol intake to be avoided . Risk of decreased vitamin B12 serum levels . Risk of hypoglycaemia . May be temporarily withhold in case of loss of glycaemic control . Elderly patients ’ renal function should be assessed more frequently . Discontinue in patients who present with or experience an exacerbation of joint symptoms during treatment . Discontinue if bullous pemphigoid is suspected and consider referral to a dermatologist . Pregnancy ( Category C ): Should not be used unless the potential benefit justifies the potential risk to the foetus . Breast-feeding : Should not be used . Interactions : Vildagliptin has a low potential for drug interactions . No clinically relevant interactions with other oral antidiabetics ( glibenclamide , pioglitazone , metformin ), amlodipine , digoxin , ramipril , simvastatin , valsartan or warfarin were observed after co-administration with vildagliptin . • Interactions with metformin hydrochloride : furosemide , nifedipine , glyburide , * drugs that reduce metformin clearance , drugs tending to produce hyperglycaemia , alcohol . Side effects : • Vildagliptin : Common : dizziness ; Uncommon : headache , constipation , oedema peripheral ; Rare : angioedema , hepatic dysfunction ( including hepatitis ); • Metformin : Very common : flatulence , nausea , vomiting , diarrhoea , abdominal pain , loss of appetite ; Common : metallic taste ; Very rare : decrease of vitamin B12 absorption , lactic acidosis , liver function test abnormalities , hepatitis , skin reactions such as erythema , pruritus and urticaria . • Common effects of vildagliptin and metformin combination : headache , tremor , dizziness . • Triple combination with a sulfonylurea : Common : dizziness , tremor , asthenia , hypoglycaemia , hyperhidrosis . Add-on to insulin : Common : headache , chills , nausea , gastrooesophageal reflux disease , decreased blood glucose . Post-marketing experience : Rare : hepatitis ( reversible upon drug discontinuation ); Unknown : pancreatitis , urticaria , bullous and exfoliative skin lesions , including bullous pemphigoid , arthralgia , sometimes severe . *( gam140521m based on PI gam140521i ).
* Please note changes in Product Information .
When HbA 1c is uncontrolled on metformin after 3 months 1
Choose a DPP-4i for established safety and tolerability profile 1-3
– Switch to
Galvumet 3
Please review Approved Product Information before prescribing . Approved Product Information can be accessed at https :// www . novartis . com . au / products / healthcare-professionals / products
PBS Information ( Galvumet ): Authority required ( STREAMLINED ) for dual therapy , triple therapy or add-on to insulin therapy for Type 2 Diabetes . Refer to PBS Schedule for full Authority information . This product is not PBS listed for use as initial therapy or in combination with a thiazolidinedione ( glitazone ), a glucagon-like peptide-1 or an SGLT2 inhibitor .
WARNING ( Galvumet ): Life-threatening lactic acidosis can occur due to accumulation of metformin . The main risk factor is renal impairment , other risk factors include old age associated with reduced renal function and high doses of metformin above 2000 mg per day .
References : 1 . Australian Diabetes Society . Australian Type 2 Diabetes Glycaemic Management Algorithm . Available at : http :// t2d . diabetessociety . com . au / documents / BD92rkh5 . pdf ( accessed May 2021 ). 2 . Galvus ® Approved Product Information , 8 November 2018 . 3 . Galvumet ® Approved Product Information , 14 May 2021 . 4 . Bosi E et al . Diabetes Care 2007 ; 30:890 – 95 .
Abbreviations : BD , twice daily ; DPP-4i , dipeptidyl peptidase-4 inhibitor ; HbA 1c , glycated haemoglobin concentration ; T2D , type 2 diabetes .
Proven 1.1 % HbA 1c
reduction 4 *
* In type 2 diabetes patients uncontrolled on metformin monotherapy ( vildagliptin 50 mg BD + metformin vs . placebo + metformin p < 0.001 ) 4
Get HbA 1c moving in the right direction 4
Galvus and Galvumet are registered trademarks of Novartis Pharmaceuticals Australia Pty Limited ABN 18 004 244 160 . 54 Waterloo Road , Macquarie Park NSW 2113 . Ph ( 02 ) 9805 3555 . Copyright © 2021 Viatris Inc . All rights reserved . Mylan Health Pty Ltd , Level 1 , 30 The Bond , 30-34 Hickson Road , Millers Point NSW , 2000 . ABN 29 601 608 771 . Tel : 1800 274 276 . SHOW3787b GGT-2021-0007 AU-16822 . Date of preparation : May 2021 .
MYL3787 GALVUMET A4 SP AD 210x273 FA . indd 2 8 / 6 / 21 10:40 pm