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Pharmacology

Substance‐related disorders Letters 21 November 2022 Free

What doctors should consider before prescribing e‐liquids for e‐cigarettes

To the Editor: As nicotine prescribers, we welcome much needed advice for doctors on prescribing nicotine. However, we disagree with several recommendations and concerns raised in the article by Ween and colleagues.1 First, in our experience, the recommended starting nicotine concentration of 18mg/mL is inappropriate for most new users. The most popular devices for transitioning to vaping (pod vapes) have small batteries and require higher nicotine salt concentrations to effectively relieve cravings and withdrawal symptoms, typically 20–50mg/mL.2 On the other hand, 18mg/mL would be too strong for a smoker with low nicotine dependence using a more powerful vape pen or mod device. The concentration of nicotine required should be personalised for each user based on the level of nicotine dependence, device type and puffing topography.3 Second, the authors’ concerns about the toxicity of nicotine are overstated in our view. Nicotine is a toxic poison in its highly concentrated form, but the low concentrations used for vaping carry minimal risk of serious harm, although the long term impact of inhaled nicotine on lung tissue is not yet known.4 Third, Ween and colleagues raise concerns about the addictiveness of nicotine. However, most smokers who switch to vaping are already nicotine‐dependent. Dependence on vaping is generally less than for smoking5 because, in many cases, peak nicotine levels from vaping are lower and nicotine delivery is slower. In vitro and animal studies suggest other chemicals in smoke may also increase dependence, but human studies are lacking.6,7 Fourth, a blanket “3‐month prescription maximum” and an “agreed abstinence plan” do not recognise the diversity of the needs of smokers. Switching to vaping and then ceasing smoking can take many months or years for some smokers. Many continue to vape long term to avoid relapse to smoking or for perceived benefits. Therefore, a more flexible and personalised approach is needed. Last, Ween and colleagues are correct that unknown harms from flavours may appear over time and these need to be carefully monitored. However, flavours are an integral part of the appeal of vaping. Flavours encourage the uptake of vaping by smokers and are associated with higher quit rates.8,9 A recommendation to avoid flavours risks inadvertently increasing smoking.

Colin P Mendelsohn · Carolyn Beaumont

Mja2 51764
Musculoskeletal diseases Letters 5 September 2022 Free

Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk

To the Editor: Khatri’s and Stuckey’s1 article, Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk, sums up the authors’ knowledge and experience of medication‐related osteonecrosis of the jaws (MRONJ) in the latter part of the title. They quote the risk of MRONJ as being very low and equal for denosumab and oral bisphosphonates. This is incorrect. The risk of MRONJ is 0.3%.2 In our study we found the risk following extractions at 1.8%.3 The recent 2022 update of the position paper on MRONJ4 found that the risk with denosumab is an order of magnitude higher than for bisphosphonates. There is no discussion in Khatri’s and Stuckey’s article1 of the effect of MRONJ on patients. A patient with stage 3 or end‐stage MRONJ has months of severe pain and requires jaw resection with or without microvascular reconstruction similar to that required for advanced jaw cancer.4,5 The impact of this is similar to vertebral collapse, both largely avoidable disasters. The current Australian recommendations for dental extractions for patients taking denosumab for osteoporosis are to delay extractions to 6 months after the last injection of denosumab and then to allow 4weeks for initial socket healing before the next injection.6 The risk is greater if the patient has been taking antiresorptives for more than 4years and if they are immunocompromised.4,7 We would agree that education and communication between prescribers, patients and dentists are key. This can only be achieved by close, mutually respectful communication and understanding between medical, dental, oral and maxillofacial surgeons and patients. However, this is easier to say than put into meaningful practice. Most definitive articles on MRONJ are in oral and maxillofacial surgery journals, which are not commonly read by physicians who prescribe antiresorptives. The most likely reason that the patient was taken off denosumab for 5 months was that the dental plan was not only to extract the teeth but to replace them with dental implants. Implants require time for osseointegration.8 Hopefully, this letter helps correct the distorted precepts expressed by Khatri and Stuckey for prescribers of this, otherwise, useful drug.

Alastair Goss

Mja2 51681
Infectious diseases Narrative review 18 July 2022 Open Access

Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient‐centred multidisciplinary care

Using a multidisciplinary, pragmatic, patient-centred, non-judgemental approach may allow people who inject drugs to achieve improved outcomes for invasive infections and reduce their risk of subsequent admissions

Lucy O Attwood · Megan McKechnie · Olga Vujovic · Peter Higgs · Martyn Lloyd‐Jones · Joseph S Doyle · Andrew J Stewardson

Mja2 51623
Digestive system diseases Consensus statement summary 7 March 2022 Free

Australian consensus recommendations for the management of hepatitis B

This statement provides guidance to managing hepatitis B, recognising groups at increased risk of HBV infection and appropriate, timely screening strategies

John S Lubel · Simone I Strasser · Alexander J Thompson · Benjamin C Cowie · Jennifer MacLachlan · Nicole L Allard · Jacinta Holmes · William W Kemp · Avik Majumdar · David Iser · Jess Howell · Gail V Matthews

Mja2 51430
Pharmacology Systematic review/meta‐analysis 14 February 2022 Free

Efficacy, safety, and dose‐dependence of the analgesic effects of opioid therapy for people with osteoarthritis: systematic review and meta‐analysis

Opioid medications may provide very small benefits for people with osteoarthritis, but also increase the risk of adverse events

Christina Abdel Shaheed · Wasim Awal · Geoffrey Zhang · Stephen E Gilbert · Daniel Gallacher · Andrew McLachlan · Richard O Day · Giovanni E Ferreira · Caitlin MP Jones · Harbeer Ahedi · Mamata Tamrakar · Fiona M Blyth · Fiona Stanaway · Christopher G Maher

Mja2 51392

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