General Medical issues thread

[bosox76]

I had better guard my travel bag as it has Xarelto and Anginine on board. Now tell me Vytorin costs a bunch too.

Anginine pfffft. That stuff gets handed out like lolly water. Vytorin however...

 

[Pushka]

Sorry I may have missed part of the history but have you had recurrent DVT's or just the one? Xarelto is only PBS listed for initial treatment of a DVT or for recurrent clots or non-valvular AF. Thus if you're beyond 6 months from your DVT or haven't had further clots technically you don't qualify for PBS subsidisation. Now as stated I may well have missed a lot of vital info and if that's the case I apologise. However if it's the above case and PBS finds out then your rheumatologist technically becomes liable to pay the difference for the scripts that they've written :0

Btw it's great that you have such a great relationship with your doctor. That's extremely important.

https://m.pbs.gov.au/industry/listing/elements/pbac-meetings/psd/2013-03/rivaroxaban-pe.html
"Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) for the prevention of recurrent DVT and PE."
I fall into the latter category. I have antiphospholipid syndrome which has very high risk of recurrent DVT esp in the next 6 months if anticoagulation is discontinued. The lack of successful pregnancy is also evidence of clotting events. So I take Xarelto for the prevention of recurrent DVT. Warfarin is usually prescribed but the new NOACs are taking over.

http://www.racgp.org.au/afp/2014/may/anticoagulation/
"Although rivaroxaban is available and subsidised by the PBS for extended secondary VTE prevention......"

https://m.pbs.gov.au/medicine/item/2268J.html
"Authority Required (STREAMLINED)
4132
Prevention of recurrent venous thromboembolism
Treatment Phase: Continuing treatment
Clinical criteria:
Patient must have a history of venous thromboembolism."

I reckon it's all good.

 

[bosox76]

https://m.pbs.gov.au/industry/listing/elements/pbac-meetings/psd/2013-03/rivaroxaban-pe.html
"Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) for the prevention of recurrent DVT and PE."
I fall into the latter category. I have antiphospholipid syndrome which has very high risk of recurrent DVT esp in the next 6 months if anticoagulation is discontinued. The lack of successful pregnancy is also evidence of clotting events. So I take Xarelto for the prevention of recurrent DVT. Warfarin is usually prescribed but the new NOACs are taking over.

http://www.racgp.org.au/afp/2014/may/anticoagulation/
"Although rivaroxaban is available and subsidised by the PBS for extended secondary VTE prevention......"

https://m.pbs.gov.au/medicine/item/2268J.html
"Authority Required (STREAMLINED)
4132
Prevention of recurrent venous thromboembolism
Treatment Phase: Continuing treatment
Clinical criteria:
Patient must have a history of venous thromboembolism."

I reckon it's all good.

I totally agree that you're high risk and should be anticoagulated. and that it's great that you don't have to have the hassle of warfarin. I am not a rheumatologist so have no personal experience prescribing a NOAC for APS. I am just playing devils advocate as I do know that many of my colleagues often fudge the rules or blur the lines when it comes to streamline authorities for many different meds and probably don't realise that it's the prescriber who becomes responsible for any cost differences if they get busted. There are probably only a handful of medications that I prescribe more often than NOACs.
As stated though it's great you don't need the hassle of INR's

 

[Flying mermaid]

FM - when my niece was put on methotrexate there was a clear plan of attack and blood markers in place. There must be something in her blood work that is leading to the treatment? Maybe a skin biopsy?

Pretty sure it must be the elevated CK, but this is one of the questions she is going to ask... The skin biopsy was discussed today but the dermatologist said while it could definitely say whether it was scleraderma or not, it couldn't say whether it was active and as they were totally sure it was scleraderma there din't seem any point....

 

[wandering_fred]

Unless the chemists over east are "different", the script label should provide the "full cost" of the medications therein.

The only expensive one for me at the moment is ezetrol. But if it keeps the GP happy I am just as happy to avoid the statins. COVERSYL ARGININE (perindopril) seems to be a favorite and I have never found the same dosage levels overseas when I have enquired.

PS: I got the shingles vaccine today. Querying about a lot of the other immunizations, the GP offered blood serology exams for a number to see if I need boosters. Blood work is "free" (to me) and the vaccines are not.

Happy wandering

Fred

PS (Again) You should now know how old I am (at a minimum)

 

[bosox76]

COVERSYL ARGININE (perindopril) seems to be a favorite and I have never found the same dosage levels overseas when I have enquired.

PS (Again) You should now know how old I am (at a minimum)

That's because most pharmacies and countries supply Perindopril erbumine which has a slightly different molecular weight. This was also the original "Coversyl" before Servier changed it to Arginine a year before it came off patent so they could "extend" their patent on "Coversyl". If you want Perindopril arginine you'll need the script to say Coversyl and the "no brand substitution" box ticked.
And yes I have a reasonable idea at a minimum

 

[Pushka]

FM - an update on Methotrexate.
I just met with my niece who has Lupus and has been on plaquenil for years and now 6 weeks of methotrexate. She has noticed significant improvement since starting and is really happy on methotrexate. She tolerates it very well. It's taken once a week and by the end of day 6 she can feel symptoms coming back. Specialist upped her dose yesterday. So maybe its worth a try? Sometimes you don't know how poorly you feel until you start to feel better as it's such an insidious thing these auto immune things.

 

[love_the_life]

FM, Canberra may be a big country town but it is streets ahead of anything down the coast. A good friend is at end of life bowel cancer and has had a dickens of a time down there where they live. Earlier this week they brought him to Canberra by ambulance and things are much more stable.

Moral of this story for me is at my time of life, do not even consider living somewhere that is not a major city with all the supports and services. Each time the friend had chemo it was a full day to drive to the hospital, have treatment and drive back. GP is a shorter drive but still a couple of hours used up for any visit. The country hospital where he was taken late last week when he deteriorated seemed not to have a clue, so poor hydration and no real sustenance as he cannot eat. Had a heart attack as they seem to have overdosed the potassium and then the kidneys started to shut down. Yes, he is dying but there are better palliative care regimes than what he was getting there. There has been minimal support for both he and his wife and she has basically had to most things herself. At least here we have services to assist her (and there is also family which is not the case down the coast). I know where I would rather be.

 

[Flying mermaid]

FM - an update on Methotrexate.
I just met with my niece who has Lupus and has been on plaquenil for years and now 6 weeks of methotrexate. She has noticed significant improvement since starting and is really happy on methotrexate. She tolerates it very well. It's taken once a week and by the end of day 6 she can feel symptoms coming back. Specialist upped her dose yesterday. So maybe its worth a try? Sometimes you don't know how poorly you feel until you start to feel better as it's such an insidious thing these auto immune things.

Yes I am trying to talk her into it..... She claims she has no symptoms, but thinking about it she has been getting tired very easily for years. I can't see the downside in trying - if it doesn't make her feel better and there is no reduction in CK then she can go off again. Anyway she is waiting for her Rheumatologist to get back with answers to her questions and then she will decide. Thanks for the feedback

 

[Flying mermaid]

FM, Canberra may be a big country town but it is streets ahead of anything down the coast. A good friend is at end of life bowel cancer and has had a dickens of a time down there where they live. Earlier this week they brought him to Canberra by ambulance and things are much more stable.

Moral of this story for me is at my time of life, do not even consider living somewhere that is not a major city with all the supports and services. Each time the friend had chemo it was a full day to drive to the hospital, have treatment and drive back. GP is a shorter drive but still a couple of hours used up for any visit. The country hospital where he was taken late last week when he deteriorated seemed not to have a clue, so poor hydration and no real sustenance as he cannot eat. Had a heart attack as they seem to have overdosed the potassium and then the kidneys started to shut down. Yes, he is dying but there are better palliative care regimes than what he was getting there. There has been minimal support for both he and his wife and she has basically had to most things herself. At least here we have services to assist her (and there is also family which is not the case down the coast). I know where I would rather be.

Yes I agree - from what I have heard many of the rural centres are very poorly resourced. I am not knocking Canberra, but what she has is very rare, they don't know much about it and a second opinion from a major population centre won't go astray. My plan is for her to start on Methotrexate straight away, but see someone else in Sydney (Dr FM has given me some names), just to talk through options a bit more. Having trouble convincing Miss FM of this at the moment, might have to get more pushy..... It is not as though once you start you can't stop, so she can take it and see how she feels on it.

 

[Quickstatus]

Canberra has some excellent doctors and some useless ones. I would put her Rheumatologist in the good basket, but at the end of the day we are a country town......

There is a saying: In Canberra when you get sick go to the airport.... Not sure how true it is...

 

[love_the_life]

Probably true in the past but we are improving.

 

[love_the_life]

Yes I agree - from what I have heard many of the rural centres are very poorly resourced. I am not knocking Canberra, but what she has is very rare, they don't know much about it and a second opinion from a major population centre won't go astray. My plan is for her to start on Methotrexate straight away, but see someone else in Sydney (Dr FM has given me some names), just to talk through options a bit more. Having trouble convincing Miss FM of this at the moment, might have to get more pushy..... It is not as though once you start you can't stop, so she can take it and see how she feels on it.

I agree that anything really rare or high end can be a problem here. A friend's son had his kidney transplants in Sydney at RPA. CBR is just not up to it. We have considered Melbourne for another surgeon to look at DrL_t_L's hip but it is improving slowly so she (we) are holding off.

Unfortunately for our friend with the bowel cancer I think he had a rambo surgeon who rushed in and removed all the bowel and bladder. PET scans some weeks after the surgery showed that it had metastasised to the liver at least and was also still present in the original site. I just don't think that they had the full information to allow them to make a proper decision. This was done in a private hospital in Sydney. I would be wanting one of the big teaching hospitals for anything major.

 

[Flying mermaid]

There is a saying: In Canberra when you get sick go to the airport.... Not sure how true it is...

Don't think it is true - we have some excellent doctors and specialists. However for more unusual things you still need to go to Sydney. E.g. A friend developed some strange intolerances - ended up having to go to RPA in Sydney for years while they tested and worked out what was wrong with him. Just didn't have that kind of expertise in Canberra. Another friend has a baby with heart problems and she travels constantly to Westmead in Sydney for treatment and operations. For run of the mill stuff we are fine though. I am just in a parental panic at the moment and localised Scleraderma only affects .003% of the population, so I want to make sure it is treated correctly.

 

[Flying mermaid]

I agree that anything really rare or high end can be a problem here. A friend's son had his kidney transplants in Sydney at RPA. CBR is just not up to it. We have considered Melbourne for another surgeon to look at DrL_t_L's hip but it is improving slowly so she (we) are holding off.

Unfortunately for our friend with the bowel cancer I think he had a rambo surgeon who rushed in and removed all the bowel and bladder. PET scans some weeks after the surgery showed that it had metastasised to the liver at least and was also still present in the original site. I just don't think that they had the full information to allow them to make a proper decision. This was done in a private hospital in Sydney. I would be wanting one of the big teaching hospitals for anything major.

That's terrible . When Mr FM had his brain abscess and the doctor at Calvary was convinced he had cancer he was talking of sending him over to a private hospital for surgery after he had been home for awhile (having R&R). The more junior doctor talked to me afterwards and told me he really wouldn't advise going to a private hospital for that kind of surgery - he felt they were fine for plain jane elective stuff, but you needed a public hospital for anything more serious.

 

[love_the_life]

That's terrible . When Mr FM had his brain abscess and the doctor at Calvary was convinced he had cancer he was talking of sending him over to a private hospital for surgery after he had been home for awhile (having R&R). The more junior doctor talked to me afterwards and told me he really wouldn't advise going to a private hospital for that kind of surgery - he felt they were fine for plain jane elective stuff, but you needed a public hospital for anything more serious.

Agree wholeheartedly with that.
The survival rate for our friend's cancer was so low (even without the full scans only about 5% for 5 years) it just seems that I would like to have all the options laid out. As it is, he has had 3 months of s**t, never able to do anything really. I wonder what a well constructed palliative care package could have offered him. Until it is you affected, you can't really make any judgements though.

 

[mrs.dr.ron]

Agree wholeheartedly with that............................................................................................
Until it is you affected, you can't really make any judgements though.

Yes, I agree with that. I have seen many different approaches to treatment/outcomes and thought what would I do - but until it IS you in the hot seat it is all just speculation.

 

[drron]

It is not as easy as saying private hospitals are good for some things and public for others.
You need to know the doctors involved and their strengths,things like infection rates,the quality of nursing and allied health staff etc,etc.
With all due respect to junior doctors most have never been associated with a private hospital and develop their opinions because they see transfers when things have gone wrong.Just as I see transfers from major hospitals that are supposedly routine but where they have missed the bleeding obvious.

Just as something that seems counter intuitive it is sometimes much better having a local doctor who doesn't have a great breadth of knowledge but knows his/her limitations than one who knows a great deal but is supremely confident in his judgement.The first has usually developed a group of trusted doctors that you will be referred to.

 

[whatmeworry]

I remember reading somewhere Footscray/Sunshine Hospital usually gets the lower performing students from Melbourne Uni.

 

[bosox76]

There is a saying: In Canberra when you get sick go to the airport.... Not sure how true it is...

I know of a few doctors who work at The Canberra hospital. They are excellent. Like all professions in life though, there are some good and some bad (unfortunately)