Oral furosemide a welcome addition to Prescriber Bag

The positive recommendation by the Pharmaceutical Benefits Advisory Committee states the addition of the medication is ‘appropriate to facilitate the urgent pre-hospital management of heart failure’.
 
The RACGP called for the changes in a submission after identifying an ‘immediate need for medicines to be added to manage acute and urgent pre-hospital treatment for heart failure, urinary tract infections and cellulitis’.
 
‘These issues are common and account for a large proportion of potentially preventable hospitalisations in Australia,’ the submission states.
 
The Pharmaceutical Benefits Scheme (PBS) Prescriber Bag – a list of medications doctors can dispense direct to patients free of charge – does not currently include medications for urgent management of heart failure.
 
Dr Edwin Kruys last year led the development of the RACGP’s Medication management and supply: A guide to best practice, which includes the Prescriber’s Bag.
 
He told newsGP the recommendation is excellent news and represents a ‘precedent for subsidised oral medication to be available for dispensing by GPs – the outcome we were hoping for’.
 
‘The bag mostly contains injectable medications. I am pleased that the PBAC has now acknowledged that in the community oral medications can play a key role in the immediate management of unwell people who are at risk of acute deterioration,’ he said.
 
‘[This] will support the immediate management of people with heart failure in the community and may assist to keep people out of ambulances, emergency departments and hospitals. GPs and practice nurses already regularly supply or administer medications in specific circumstances.
 
‘PBS-subsidised Prescriber Bag supplies are an essential part of the general practice toolkit for emergency and urgent use. The medications are used to stabilise patients and prevent clinical deterioration, in the practice, during home or nursing home visits and outside pharmacy business hours.’
 
However, the PBAC rejected the RACGP’s requested addition of three antibiotics – cephalexin, nitrofurantoin and trimethoprim – for treatment of urinary tract infections (UTIs) and cellulitis, citing concerns over antimicrobial stewardship.

The RACGP submission notes that UTIs and cellulitis caused almost 77,000 and 69,000 potentially preventable hospitalisations, respectively in 2017–18.
 
‘The addition of cefalexin, trimethoprim and nitrofurantoin … will not increase antibiotic use in the community, as patients who present to a general practice with an acute infection will be treated with antibiotics,’ the submission states. ‘The benefit of adding these antibiotics to the PBS Prescriber Bag is timely treatment and the avoidance of second line antibiotics.
 
‘Failure to treat acute infections at an early stage in the community setting may result in hospital presentations, longer duration of treatment and/or the use of second line antibiotics, combinations of antibiotics and IV antibiotics.’
 
The PBAC, however, ‘considered that adding cephalexin and nitrofurantoin to the Prescriber Bag was not consistent with antimicrobial stewardship and the quality use of medicines for antibiotics’.
 
‘The PBAC further considered that in the case of trimethoprim, the policy intent of the Prescriber Bag was to provide true emergency items to reduce preventable hospitalisations, which is unlikely in urinary tract infections,’ the committee stated.
 
The three antibiotics were recently approved by the Queensland Government for its controversial pharmacy prescribing trial for treatment of UTIs, which the RACGP and other medical bodies have strongly opposed on antimicrobial stewardship grounds.  
 
The PBAC recommendation opens the door to having pharmacists able to both prescribe and dispense these antibiotics for UTIs ­in Queensland, while Queensland GPs cannot.
 
‘A common reason people travel to hospital emergency departments is because of UTIs and cellulitis. For that reason, I hope that a limited range of oral antibiotics will become part of the Prescriber Bag in the near future,’ Dr Kruys said.
 
‘Pharmacies are prescribing and dispensing antibiotics in Queensland. It would make sense that the same medications are also available to patients via the PBS-subsidised Prescriber Bag supply at the local GP clinic, under certain conditions and in line with good antimicrobial stewardship.’
 
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antimicrobial resistance medication PBS Prescriber Bag