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UBC-based, independent, evidence-informed, practical #BetterPrescribing information for #Physicians, #NursePractitioners, #Pharmacists #MedEd #CME RT≠endorse
Shanil Keshwani Profile picture 1 subscribed
Nov 30, 2022 7 tweets 7 min read
🧵 How well do you know your dopamine antagonists? 💊💊

1/ Using these drugs safely requires that clinicians & patients appreciate their important #AdverseEffects, which are not always well understood


#MedEd #prescribing #deprescribing #medsafety 2/ #AdverseEffects may include:

⚠️ Drug-induced #Parkinsonism
-↘️ or slowed movements, rigidity/tremor/unsteadiness, facial expression loss

⚠️ #Akathisia
-intense internal restlessness or desire to move (which may be mistaken for anxiety)

👉🏽Pt videos:
Nov 3, 2022 7 tweets 7 min read
🧵 Reducing unnecessary use of proton pump inhibitors (PPIs)

1/ Many people take #PPIs but up to 50% don’t have a good reason to take them > 8 wks

Read on for tips on how you as a clinician can work together with pts to decide if/how to 🛑 or reduce PPIs

#MedEd #deprescribing Image 2/ Does this person need #PPIs long-term (> 8 wks)?
Find pts who might not need long-term PPI:
1⃣ Flag refill requests
2⃣ Use a poster or video in waiting room
3⃣ Run EMR report
This @bmj_latest article has more tips to help with #deprescribing PPIs:
Sep 15, 2022 10 tweets 13 min read
🧵 Reducing #PrescribingCascades ⬇️

1/ What are #Prescribing Cascades?

1⃣ A drug is prescribed 💊
2⃣ #AdverseEvent occurs but is misinterpreted as a new medical condition ⚠️
3⃣Another drug is prescribed for the drug-induced adverse event 💊💊 #MedEd Image 2/ Anticholinergics ➡️ cognitive dysfunction ➡️ drugs for #dementia

#Anticholinergic 💊 block acetylcholinergic neurotransmission in the brain, impairing cognition & memory

Can lead to new Rx or ↗️ acetylcholinesterase inhibitor doses #MedEd #FOAMed Image
May 26, 2022 9 tweets 8 min read
THREAD: #Prescribers, how do YOU respond to Conflicts of Interest (COI)? 👀

1/8 This thread looks at the issues highlighted in our TI Therapeutics Letter on COI

👉🏼Full Letter:

#ConflictofInterest #MedEd #MedicalEthics 2/8 Kirsten is a clinical pharmacist attending a primary care conference👩🏽‍⚕️

When a keynote speaker reports financial relationships💰with several drug companies, Kirsten takes note🤨

Find out why she prefers #MedEd free of commercial sponsorship:
May 16, 2022 8 tweets 10 min read
THREAD: Online Portraits for BC family physicians

1/7 UBC’s Therapeutics Initiative now has Online #PrescribingPortraits:

✅ Timely evidence
✅ Personalized, confidential prescribing data
✅ Recommendations to support

#BetterPrescribing & #BetterHealth Image 2/7 Why have a #PrescribingPortrait?

"How do I prescribe compared to others or to evidence standards?"

✅Portrait does NOT tell individual doctors how to practice
✅Portrait DOES promote optimal prescribing based on best available evidence

More here: Image
Mar 28, 2022 7 tweets 8 min read
THREAD: How best to treat Urinary Tract Infections?

1/6 Our new TI Therapeutics Letter 135 describes the best approach for treating symptomatic, uncomplicated lower urinary tract infections (UTIs)


#MedEd #FOAMed #UTIs #BetterPrescribing 2/6 Use symptoms, not tests to diagnose UTIs:

Uncomplicated lower UTI can be diagnosed with > 90% probability if pt has 2 or more of dysuria, urgency, and frequency, and no vaginal discharge.

This is less reliably predicted for older women.


Feb 28, 2022 7 tweets 9 min read
THREAD: Bring it down safely! ↘️💊

1/6 6⃣tweets about our new TI Therapeutics Letter 134: Finding the lowest effective dose for non-opioid #analgesics

👉🏾 Full Letter:

#MedEd #medsafety #prescribing #BetterPrescribing Image 2/6 Consistent evidence that minority of pts get clinically meaningful pain relief from any dose of:
#Cyclobenzaprine (at best 1/4)
#Duloxetine (at best 1/6)
#Gabapentin / #Pregabalin (at best 1/6)


#MedEd #ptsafety #BetterPrescribing #prescribing Image
Feb 2, 2022 9 tweets 9 min read
THREAD: Primary #hypertension therapy: after thiazides, an ACEI or an ARB?

1/8 Nearly 650,000 British Columbians took an ACEI or ARB in 2021

Our new TI Therapeutics Letter reiterates evidence for one of the most common primary care tx choices:

#MedEd 2/8 Lower #BloodPressure not the Main Goal

#Antihypertensives lower various measures of blood pressure (BP) 💊

But... not all BP lowering drugs are proven to reduce both morbidity & mortality


#MedEd #prescribing #hypertension
Jan 21, 2022 6 tweets 8 min read
THREAD: #ExercisePrescriptions

1/5 The TI’s Dr. Josh Levin asks:

Clinicians, can you help your patients be more active? 🏃🏾‍♀️🏊🏾‍♂️ 🚶🏾‍♂️

👉🏾Watch Dr. Levin’s recent presentation: 👨🏾‍💻

#Exercise #prescribing #twitterRx 2/5 #ExercisePrescriptions: How much activity should people get? It depends on their age.

👉🏾See the Canadian Society for Exercise Physiology activity guidelines for different age groups: 🏊🏾‍♂️🏃🏾‍♀️🚶🏾

#Exercise #prescribing #twitterRx #BetterHealth
Nov 27, 2021 6 tweets 12 min read
THREAD: SGLT2 inhibitors for #diabetes

1/5 Dr. Jamie Falk @jamisonfalk presented "A Deep Dive into #SGLT2i: What Comes to the Surface for Individuals with Diabetes"

👉🏽Watch the presentation here: 🧑🏾‍💻

#T2DM #medsafety #FOAMed #MedEd 2/5 #AdverseEffects for #SGLT2i to be aware of: genital infections, hypovolemia, DKA, amputations

✅Check out the image ⬇️ for the risk estimates
✅Watch @JamisonFalk's presentation here:🧑🏾‍💻

#T2DM #medsafety #FOAMed #MedEd #diabetes #ptsafety
Nov 10, 2021 7 tweets 9 min read
THREAD: Evidence for oseltamivir for #influenza prevention

1/6 Not much #flu last year, yet almost 14,000 BC residents were prescribed #oseltamivir (Tamiflu) for prevention

✅Flu guidelines

✅Systematic review of Tamiflu safety 2/6 #Oseltamivir for prevention reduces ↘️ symptomatic influenza by 3%, (NNT=33) with an uncertain effect on asymptomatic #influenza

It likely has a central symptom reducing effect but may not reduce viral transmission

#Tamiflu #prescribing
Sep 19, 2021 7 tweets 8 min read
THREAD: Medication adherence and shared decision-making

1/6 Our TI Letter 132 suggests a more democratic & ethical approach to shared decision-making:

Here are 5⃣ highlights…

#MedEd #FOAMed #MedicationAdherence #PatientPreferences 2/6 Patients always retain right to say “no, thank you”🛑

Some pts may not want to accept their doctor's recommendations for a prescribed 💊 & have their own reasons to feel that it's not worth it for them.

This "intentional non-adherence" is a choice that should be respected
Jul 12, 2021 9 tweets 10 min read
THREAD: Shedding light on the risks of anticholinergic drugs

1/8 NEW information on risk of dementia and harm in the frail elderly. Free #BestEvidence webinar w/ Dr. Aaron Tejani @amtejani on July 14th


#MedEd #deprescribing #medsafety 2/8 One of every 14 of the top 200 💊 prescribed in BC has anticholinergic properties

They include: amitriptyline, cyclobenzaprine, fluoxetine, quetiapine, sertraline, trazadone, venlafaxine, zopiclone, citalopram...

👉🏽More here…

#MedEd #deprescribing
Jun 30, 2021 6 tweets 7 min read
THREAD:5⃣things to know from 5 recent TI Therapeutics Letters👩🏽‍🔬

1/5: How to choose a good #mirtazapine dose? 🤔

Mirtazapine has a dose response 💊for harm but NOT for efficacy: harm ↗️ after 30mg/day but efficacy doesn't:

#MedEd #deprescribing #ptsafety 2/5: Want to learn about recent @GovCanHealth #medsafety or international warnings for medications?

Read our Therapeutics Letter on international drug safety advisories: ⚠️ 💊

#drugsafety #SegPac #ptsafety
May 11, 2021 7 tweets 7 min read
THREAD - What if we could track and record repeat Adverse Drug Events? 🤔 💊

1/6: Register for our May 12 #BestEvidence webinar, as @corinne_hohl talks about Assessing the Impact of Information Continuity on Health Outcomes: #MedEd 2/6: Why do Adverse Drug Events (ADEs) matter?

Each year in British Columbia, ADEs account for:
👉240,000 emergency dept (ED) visits
👉480,000 days in hospital
👉approx. 1 in 9 adult ED visits

More here:
#drugsafety #ptsafety #MedEd
Apr 24, 2021 8 tweets 8 min read
THREAD: Dr. John Mandrola: “The more you see, the harder the medicine gets”

1/7 Some new views on legacy prescriptions: Beta-blockers, ASA & #statins by Dr. John Mandrola

(based on @drjohnm presentation hosted by @drug_evidence Oct 17, 2020:

#MedED 2/7 Example 1: Beta blockers in heart failure 💊♥️

Observational studies suggest beta-blockers for heart failure tx beyond 3 years are NOT associated with beneficial outcomes 😯

These findings challenge current recommendations:

#MedEd #deprescribing
Jan 28, 2021 8 tweets 9 min read
THREAD: Trama-DO or Trama-DON'T?
What to know about #tramadol

1/7 Tramadol has multiple mechanisms of action:
- via serotonin & norepinephrine reuptake inhibition
- after metabolism to M1 metabolite, via opioid agonism #chronicpain #arthritis #MedEd 2/7 People metabolize #tramadol variably 🤔💊

- Some who are ‘ultra rapid’ produce more M1 (opioid);
- Some ‘poor’ metabolizers (~20% with inactive CYP2D6) may have more SSRI/SNRI-like effect

Thus, analgesic & adverse effects are unpredictable #MedEd
Dec 12, 2020 7 tweets 7 min read
THREAD: Tamiflu for #influenza prevention – the evidence

1/6 In 2019 21,000 BC citizens were prescribed Tamiflu (oseltamivir), many to prevent the flu. Flu prevention guidelines. AMMI Canada

Systematic review of Tamiflu safety: 2/6 Tamiflu for prevention ↘️ symptomatic flu (by 3%, NNT=33) with uncertain effect on asymptomatic flu.

One likely explanation is that Tamiflu has a central symptom lowering effect but may not ↘️ viral transmission.

#influenza #flu #tamiflu
Oct 7, 2020 7 tweets 6 min read
THREAD: Are we using ACEIs & ARBs properly? A TI Tweetorial

1/6: British Columbia doctors give 4.5m scripts/year for ACE inhibitors (ACEIs) & angiotensin receptor blockers (ARBs) to control bp. Goal is to ↘️ mortality & morbidity, not simply to ↘️ bp.

#MedEd #hypertension 2/6 BEST EVIDENCE on ARBs & ACEI for #hypertension

3⃣@CochraneHTN systematic reviews:

ACEs v ARBs for htn

BP lowering efficacy of ACEIs for htn

BP lowering efficacy of ACEIs for htn

#MedEd Image
Sep 25, 2020 7 tweets 6 min read
THREAD: 5 Things You Need to Know About PPIs

For many years, we've dissected the research on Proton Pump Inhibitors (PPIs) 🤔

This thread captures our publications on PPIs that can help you in clinical practice:

#MedEd #medsafety #DrugEvidence #GERD 2/6 PPI COSTS VARY CONSIDERABLY 💰

Even without differences in efficacy or safety between PPIs, costs can vary x 10. The cheapest in BC? Pantoprazole Mg 40mg or Rabeprazole 10mg. Most expensive: Dexlanzoprazole

More here:

#MedEd #DrugCosts #GERD
Jun 24, 2020 12 tweets 15 min read
THREAD: Ten Commandments for patient-centred treatment 🧾

1/11 A TI Tweetorial on the “Ten Commandments’ of the New Therapeutics

Revisiting timely words of medical wisdom from the BMJ…

#MedEd #prescribing 2/11 1st Commandment:

Thou shalt have no aim except to HELP patients, according to the GOALS they wish to achieve 👩‍⚕️…

Shared decision-making lessons from @LessIsMoreMed:

#MedEd #TreatmentGoals