18 OPINION
When to prescribe LAGEVRIO as the preferred * COVID-19 oral antiviral on the PBS ? 1 , 2
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18 OPINION
6 DECEMBER 2024 ausdoc . com . au
Insight
Why the AMA is wrong
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Dr Corinne Glenn GP in Melbourne , Victoria .
Cognitive screening of older doctors must be made mandatory .
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The AMA position also places a heavy psychological pressure on the treating GP .
The medical board should decide which cognitive tests should be used and ensure they form part of the standard assessments it wants GPs to carry out .
It would provide GPs with a clear standard , reducing the prospect of them facing undue
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pressure from older colleagues to not perform the test .
We all know the complicated power dynamics that can be played out — the pressure to sign off colleagues as fit to practise by not looking too hard .
If we put our emotions aside and approach it from a patient safety perspective , the checks make sense . As doctors , we like to think we
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will know when it is time to hang up the stethoscope ; however , we know we are generally not great at looking after our own health .
It is only in the past 5-10 years that , as a profession , we have placed importance on having our own GP — and still too few of us follow that commonsense advice .
Too many of us have been guilty of ordering our own investigations
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or writing scripts for colleagues in the corridor .
If we lack the insight to have our own GP and regular checkups , will we also lack the insight to know when it is time to quit ?
Pilots , commercial drivers and other professional groups are subject to regular medical assessments for the safety of the public . Why should we be exempt ?
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I
AM a middle-aged GP . As such , I have a while before I am likely to have to undergo the mandatory health check for older doctors being pushed by the Medical Board of Australia .
But I will be the one doing the health check if the task is assigned , as the medical board is suggesting , to the GPs of late-career doctors .
I believe these checks should be in the realm of occupational physicians , but the board says it is too expensive .
Its principal reason for this new regulatory requirement is patient safety . The medical board has made a big thing of its statistic that practitioners aged 70 or over are 81 % more likely to be subject to a notification than their younger peers .
So if the health check is implemented as a condition of registration , it insults everyone if it is a meaningless tick-box exercise .
The AMA has argued that cognitive testing should be excluded as a mandatory element and best left to the treating GP to decide .
On one level , that sounds fine : clinical autonomy is fundamental .
Part of the AMA argument is that
The AMA position places a heavy psychological pressure on the treating GP .
the MMSE is not sensitive enough and the other tests — such as the Addenbrooke ’ s Cognitive Examination or the Montreal Cognitive Assessment ( MoCA ) — are too time-consuming or require costly subscriptions .
However , for me , cognitive testing is the most important test to be done on doctors .
Impaired cognition that is not being managed threatens the most harm and is easily missed in short consults , particularly with a highly educated population .
When I did driving medicals for senior drivers , I would routinely use the MoCA , and I was often surprised at how many patients , many of whom I had known for some time , scored lower than I expected .
Further investigations often revealed moderate cognitive impairment , which allowed the appropriate supports to be put in place .
Because it is time-consuming is not a reason not to do the test if it is important .
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When to prescribe LAGEVRIO as the preferred * COVID-19 oral antiviral on the PBS ? 1 , 2
* LAGEVRIO must be for use when nirmatrelvir-ritonavir is contraindicated . 1 , 2
For your at-risk adult patients who test positive for COVID-19 , LAGEVRIO may be prescribed when : 2-4
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The patient has a history of clinically significant hypersensitivity reactions to nirmatrelvir-ritonavir
The patient has severe renal impairment or severe hepatic impairment
There is a risk of potential drug-drug interactions with nirmatrelvir-ritonavir that cannot be safely managed
Considerations include : 5
• Can the medicine be withheld safely ?
• Can a dose adjustment be done easily ?
• Can the patient be advised on adverse events to monitor for ?
Why is the choice of oral antivirals relevant in patients aged ≥70 years ?
50 % of Australians aged ≥65 years live with 2 or more chronic conditions 7
ABS data from the National Health Survey 2022
Scan QR code to access the Liverpool COVID-19 Drug interaction checker 6
Chronic conditions often require multiple medications , which may increase the risk of potential drug-drug interactions . 8
PBS information : Authority required ( STREAMLINED ): LAGEVRIO must be for use when nirmatrelvir (&) ritonavir is contraindicated . 1 The contraindications to nirmatrelvir (&) ritonavir can be found using the Liverpool COVID-19 Drug interaction checker or the TGA-approved Product Information for nirmatrelvir (&) ritonavir . 1 , 4 , 6 Visit www . pbs . gov . au for more information .
References : 1 . Pharmaceutical Benefits Scheme . www . pbs . gov . au ( accessed March 2024 ). 2 . Pharmaceutical Benefits Scheme . Lagevrio ® ( molnupiravir ) Pharmaceutical Benefits Scheme Factsheet – Updated June 2024 . https :// www . pbs . gov . au / publication / factsheets / covid-19-treatments / PBS-Factsheet-lagevrio-molnupiravir-June-2024 . pdf ( accessed September 2024 ). 3 . LAGEVRIO Product Information , October 2023 . 4 . Paxlovid ( nirmatrelvir-ritonavir ) Product Information . September 2024 . 5 . University of Liverpool . COVID-19 Drug Interaction Prescribing Resources – Assessing a patient for treatment with Paxlovid . Available at www . covid19-druginteractions . org / prescribing _ resources / paxlovid-patient-assessment ( accessed October 2024 ). 6 . University of Liverpool . COVID-19 Drug Interaction Checker . Available at https :// covid19-druginteractions . org / checker ( accessed March 2024 ). 7 . Australian Bureau of Statistics . Health conditions prevalence ( 2022 ). Available at https :// www . abs . gov . au / statistics / health / health-conditions-andrisks / health-conditions-prevalence / latest-release ( accessed August 2024 ). 8 . Shini Rubina SK et al . Diabetes Metab Syndr 2022 ; 16 ( 3 ): 102451 . 9 . Bernal AJ et al . N Engl J Med 2022 ; 509 – 520 . 10 . Van Heer C et al . Lancet Reg Health West Pac 2023 ; 41:100917 . 11 . Gentry CA et al . J Infect 2023 ; 86 ( 3 ): 248 – 255 . 12 . Lin DY et al . JAMA Netw Open 2023 ; 6 ( 9 ): e2335077 . 13 . Park HR et al Infect Chemother 2023 ; 55 ( 4 ): 490 – 499 . 14 . Ahmad WA et al . Clin Microbiol Infect 2024 ; 30 ( 10 ): 1305 – 1311 .