Vol 8 - Apr 2025 Evidence for Primary Care
Evidence for Primary Care: the latest evidence from the Trip Database
A summary of some of the most important new documents for primary care that have recently been added to the Trip Database
COPD, Chronic UTIs, and RSV: The Primary Care Plot Twist We Didn’t See Coming
In the ever-evolving world of primary care, some months feel like a steady jog through guidelines and updates… and others? Well, others feel like sprinting through a plot twist in a medical drama. April 2025 is one of those months.
First up: single-inhaler triple therapy for COPD. It sounds slick—one inhaler to rule them all! But don’t throw away those dual therapies just yet. Despite a few promising trial results, it turns out the triple threat might be more of a dramatic actor than a proven hero. Exacerbations were down, sure—but the plot thickens when you realize many participants were yanked off steroids abruptly, skewing results. Add a side order of increased pneumonia risk, and suddenly, that triple inhaler looks more like a Netflix villain than a knight in bronchodilating armor.
Then, we’re faced with the curious case of chronic urinary tract infections. Not quite fully defined, definitely not fully understood, but boy, do they cause problems. The Urological Society of Australia and New Zealand stepped in with a position statement that essentially says, “Yes, it’s real. No, we can’t define it. Yes, it’s still your problem.” With pyuria and persistent symptoms even when cultures say “all clear,” it’s time for clinicians to play detective—using a magnifying glass, a strong coffee, and probably a multidisciplinary team.
And just when you’re wiping your brow from that, along comes RSV to remind us it really doesn’t care about your schedule. But there’s good news: vaccines and monoclonal antibodies are swooping in like caped crusaders—especially for infants and older adults. Effectiveness is strong, especially in the first few months after use, and the data is finally stacking up like a well-stocked GP waiting room.
While those three took the lead roles this month, there’s no shortage of drama in the supporting cast—like the study that asked if GPs are prescribing too much simply because their paycheck depends on it (awkward). Or the one that boldly tried to compare treatments for ulcerative colitis–related diarrhoea and ended up with just one patient (even Netflix would cancel that trial).
So, what’s the takeaway from this month’s evidence binge? Be curious. Be skeptical. And maybe—just maybe—don’t believe every treatment with “triple” in the name is automatically better.
Until next time, keep your guidelines current and your sarcasm sharp.
In This Edition
- Does single-inhaler triple therapy improve outcomes in adults with moderate-to-severe COPD compared to dual therapy?
- How should clinicians diagnose and manage chronic urinary tract infections (chronic UTI)?
- How Effective Are RSV Vaccines and Monoclonal Antibodies in Preventing Serious Illness in Older Adults and Infants?
- Do Manual Joint Mobilization Techniques Effectively Reduce Pain and Disability in Adults With Nonspecific Neck Pain?
- How Should Pain Be Safely Treated During Pregnancy?
- Does Tailored Primary Care Improve Outcomes for Veterans Experiencing Homelessness?
- Which Non-Pharmacological Therapies Are Most Effective and Safe for Primary Dysmenorrhea?
- How Should Cavity Wounds Be Assessed and Managed in Clinical Practice?
- How can we evaluate interdisciplinary team-based primary care models?
- Do SGLT2 inhibitors increase the risk of urogenital infections compared to GLP-1 receptor agonists in people with type 2 diabetes?
- How should major depressive disorder be managed in primary care to achieve and sustain remission?
- Which treatments are effective for managing diarrhoea in patients with stable ulcerative colitis: low FODMAP diet, amitriptyline, ondansetron, or loperamide?
- Does real-time continuous glucose monitoring improve glycaemic control in adults with insulin-requiring type 2 diabetes?
- Is mirtazapine effective and safe for treating chronic insomnia in older adults?
- Do financial incentives for GPs undermine their role as effective gatekeepers?
Therapeutics Initiative
Does single-inhaler triple therapy improve outcomes in adults with moderate-to-severe COPD compared to dual therapy?
Clinical Bottom Line: There is insufficient high-quality evidence to support single-inhaler triple therapy as first-line treatment in treatment-naïve patients with moderate-to-severe COPD, even if deemed “high risk.” While trials suggest triple therapy may reduce exacerbation rates and potentially mortality compared to dual therapy, these findings are likely confounded by abrupt corticosteroid withdrawal in the comparator groups. Additionally, triple therapy increases the risk of pneumonia. Clinical decisions should emphasize shared decision-making, consider blood eosinophil count, and prioritize stepwise treatment based on symptom burden and exacerbation history.
Summary: This review assessed whether single-inhaler triple therapy improves outcomes in adults with moderate-to-severe COPD compared to dual therapy. Based on two large trials—IMPACT 2018 and ETHOS 2020—triple therapy appeared to reduce exacerbation rates and may lower mortality. However, these benefits are likely confounded by the abrupt withdrawal of inhaled corticosteroids in comparator groups. There is also an increased risk of pneumonia with triple therapy. No trials assessed triple therapy as first-line treatment in newly diagnosed or treatment-naïve patients. Overall, the evidence is of low quality, and clinical decisions should be cautious and individualized.
View ArticleUrological Society of Australia and New Zealand’s (USANZ)
How should clinicians diagnose and manage chronic urinary tract infections (chronic UTI)?
Clinical Bottom Line: Chronic urinary tract infection (chronic UTI) is an emerging but not yet formally defined condition, characterized by persistent urinary symptoms potentially due to bacterial persistence in the bladder wall. Despite limitations in current diagnostic tools, clinicians should consider chronic UTI when symptoms persist in the presence of pyuria—even with negative standard cultures. Management should be individualized, involve a multidisciplinary team, and include both antimicrobial and non-antibiotic adjunctive therapies.
Summary: This position statement from the Urological Society of Australia and New Zealand outlines a patient-centred, evidence-informed approach to diagnosing and treating chronic UTI, a condition that may contribute to persistent urinary symptoms and significantly impact quality of life. Although formal diagnostic criteria are lacking, the guidance emphasizes careful evaluation, individualized treatment strategies, patient education, and collaboration across specialties to improve outcomes.
View ArticleMcMaster Health Forum
How Effective Are RSV Vaccines and Monoclonal Antibodies in Preventing Serious Illness in Older Adults and Infants?
Clinical Bottom Line: RSV vaccines (AREXVY, ABRYSVO, mRESVIA) and the monoclonal antibody nirsevimab (BEYFORTUS) offer strong protection against RSV-related lower respiratory tract disease (LRTD) in high-risk groups. Vaccination of adults aged ≥60 years significantly reduces RSV-related hospitalizations and severe illness. Nirsevimab provides high efficacy and effectiveness in preventing RSV-related hospitalizations and ICU admissions in infants, especially within the first 6 months of life.
Summary: This evidence synthesis reviews data from 35 studies evaluating RSV vaccine and monoclonal antibody performance. RSV vaccines show 67–94% efficacy in adults ≥60 years, with effectiveness slightly declining after 60 days. In infants, the monoclonal antibody nirsevimab consistently shows 70–90% effectiveness in preventing RSV-related hospitalizations and severe outcomes. Maternal RSVpreF vaccination also provides meaningful early-life protection for infants. Data for adults under 60 and for newer products like mRESVIA and maternal RSVPreF3 remain limited. Ongoing surveillance is essential to monitor real-world effectiveness and guide policy.
View ArticleJ Orthop Sports Phys Ther.
Do Manual Joint Mobilization Techniques Effectively Reduce Pain and Disability in Adults With Nonspecific Neck Pain?
Clinical Bottom Line: Manual joint mobilization techniques provide small improvements in pain and disability for adults with nonspecific neck pain, but the evidence is of very low certainty. These benefits may not be clinically meaningful, and treatment decisions should be individualized.
Summary: This systematic review and meta-analysis of 16 randomized controlled trials (1,157 participants) assessed the effectiveness of cervical joint mobilization techniques compared to routine physiotherapy, minimal interventions, or no treatment. Modest improvements were found for pain and disability, but high heterogeneity and very low certainty of evidence limit confidence in the results. No major harms were reported, though minor adverse events such as temporary neck pain and headaches occurred. Further high-quality research is needed to clarify the value of these interventions.
View ArticleSpecialist Pharmacy Service
How Should Pain Be Safely Treated During Pregnancy?
Clinical Bottom Line: Paracetamol is the first-line analgesic for pain during pregnancy. NSAIDs may be used cautiously in early pregnancy but should be avoided after 20 weeks due to risks to the fetus. Opioids can be considered when necessary, with weak opioids (e.g., codeine) preferred initially. Strong opioids may be used for severe pain, but all opioid use requires careful risk-benefit assessment due to potential neonatal and fetal risks, especially with prolonged use or late in pregnancy.
Summary: Pain management in pregnancy should begin with non-drug measures and proceed cautiously to pharmacological options when needed. Paracetamol is the safest and most recommended option. NSAIDs like ibuprofen may be used in the first trimester but are discouraged from week 20 and contraindicated from week 28 due to fetal renal and cardiac risks. Opioids, including codeine, dihydrocodeine, morphine, and others, may be used for moderate to severe pain, with individualized assessment of maternal and fetal risks. Long-term or late-pregnancy opioid use may lead to neonatal withdrawal or respiratory depression. Risk assessments and minimal effective dosing are essential throughout.
View ArticleVA Health Systems Research
Does Tailored Primary Care Improve Outcomes for Veterans Experiencing Homelessness?
Clinical Bottom Line: Engaging Veterans experiencing homelessness in any form of primary care appears to reduce hospitalizations and emergency department use. Homeless-tailored primary care, which integrates specialized support services, may offer additional benefits such as improved satisfaction, reduced emergency visits, and cost savings. However, evidence is limited by methodological inconsistencies and observational designs.
Summary: This systematic review assessed the impact of primary care, particularly VA’s Homeless Patient-Aligned Care Teams (HPACT), on Veterans facing housing insecurity. While general primary care reduced acute care use, homeless-tailored primary care offered added advantages—such as better care experiences and more appropriate emergency care use. Tailored care may also reduce mental health and substance use visits while being cost-effective. Yet, studies were observational, varied in scope, and often lacked clarity on outcomes like disease-specific effects or housing stability. More rigorous research is needed to isolate which components of tailored care drive these benefits.
View ArticleJ Pain Res.
Which Non-Pharmacological Therapies Are Most Effective and Safe for Primary Dysmenorrhea?
Clinical Bottom Line: Acupuncture, moxibustion, and auricular point therapy appear to be the most effective non-pharmacological treatments for reducing pain and symptoms in individuals with primary dysmenorrhea. These therapies ranked highest across various outcome measures, although more high-quality studies are needed to confirm optimal treatment protocols.
Summary: This network meta-analysis reviewed 16 randomized controlled trials comparing eight non-pharmacological treatments for primary dysmenorrhea. Moxibustion, acupuncture, and auricular point therapy consistently showed significant improvements in pain (VAS) and symptom scores compared to controls, including placebo and blank control. Ranking analyses reinforced their superiority, while other options like yoga and acupressure showed more modest benefits. The findings support these three therapies as effective alternatives or complements to pharmacological treatment, though additional rigorous studies are needed to refine recommendations.
View ArticleWounds UK
How Should Cavity Wounds Be Assessed and Managed in Clinical Practice?
Clinical Bottom Line: Cavity wounds, due to their complexity and risk of complications, require structured assessment, thorough wound bed preparation, appropriate dressing selection, and holistic patient-centered care. Clinicians must be confident in identifying underlying structures, managing high exudate levels, preventing infection, and engaging patients in shared decision-making. Accurate documentation and consistent terminology are essential for optimal outcomes.
Summary: This Best Practice Statement outlines the clinical management of cavity wounds, which are complex, deep wounds with a high risk of complications. It emphasizes the need for structured assessment, thorough wound bed preparation, and careful dressing selection to manage exudate and reduce infection risk. Effective management also involves clear documentation, clinician confidence in dealing with underlying structures, and a holistic, patient-centered approach that considers pain, lifestyle, and shared decision-making to improve outcomes.
View ArticleMcMaster Health Forum
How can we evaluate interdisciplinary team-based primary care models?
Clinical Bottom Line: Interdisciplinary primary care teams improve patient access and care quality, but consistent, system-wide evaluation is lacking. Evaluating these models requires a range of approaches, including patient and provider feedback and administrative data. However, many evaluations overlook non-physician contributions and equity considerations, suggesting a need for more inclusive and standardized measures.
Summary: This rapid evidence profile reviewed 19 evidence syntheses and international practices to understand how to evaluate interdisciplinary primary care teams. It found that while numerous evaluation methods exist—like patient and provider surveys or administrative data—most studies focus on assessing overall effectiveness rather than developing or comparing specific evaluation tools. Commonly measured outcomes include access, patient satisfaction, provider experience, and health service use, with limited attention to costs or equity. There’s a need to standardize evaluation frameworks to ensure a more complete picture of team-based care’s value and performance.
View ArticleDiabetes Care.
Do SGLT2 inhibitors increase the risk of urogenital infections compared to GLP-1 receptor agonists in people with type 2 diabetes?
Clinical Bottom Line: SGLT2 inhibitors do not increase the risk of urinary tract infections compared to GLP-1 receptor agonists in people with type 2 diabetes. However, they are associated with a higher early risk of genital tract infections, particularly in the first year of use.
Summary: This large Danish cohort study of over 79,000 metformin users with type 2 diabetes compared the risk of urinary and genital tract infections between new users of SGLT2 inhibitors and GLP-1 receptor agonists. Over a median follow-up of 3–4 years, the risk of urinary tract infections was similar between groups. However, genital tract infections were significantly more common in SGLT2i users, especially during the first year. The findings support the continued use of SGLT2is, with awareness of early genital infection risks.
View ArticleACE Clinical Guidance (Singapore)
How should major depressive disorder be managed in primary care to achieve and sustain remission?
Clinical Bottom Line: For adults with major depressive disorder (MDD), psychological treatments are preferred first-line options, especially for mild to moderate cases. Antidepressants may be used when psychotherapy is not feasible or for more severe presentations, often in combination with psychotherapy. Continuing treatment after remission for at least six months helps prevent relapse. Management should be individualized based on symptom severity, functional impairment, risk of harm, and patient preferences.
Summary: This 2025 Singapore ACE Clinical Guidance provides a national framework for the management of MDD in adults, emphasizing the goal of achieving and sustaining remission. It recommends a stepped-care approach based on severity, starting with psychological therapies for mild to moderate depression and combining them with second-generation antidepressants for more severe cases. Treatment should continue after remission for at least six months to reduce relapse risk, and shared decision-making is essential throughout. The guidance also includes specific recommendations for managing MDD in perinatal populations, older adults, and adolescents, as well as strategies for addressing treatment resistance.
View ArticleNIHR HTA
Which treatments are effective for managing diarrhoea in patients with stable ulcerative colitis: low FODMAP diet, amitriptyline, ondansetron, or loperamide?
Clinical Bottom Line: The MODULATE RCT aimed to compare four treatments for managing diarrhoea in patients with stable ulcerative colitis but was unable to recruit sufficient participants due to pandemic-related challenges. As a result, no conclusions can be drawn about the relative effectiveness of these interventions. However, the trial offers valuable insights into remote and decentralised trial design.
Summary: The MODULATE trial sought to assess whether low-dose amitriptyline, ondansetron, loperamide, or a low FODMAP diet could improve diarrhoea symptoms in people with stable ulcerative colitis. Despite innovative adaptations for remote participation, the trial recruited only one participant due to COVID-19 disruptions and closed early. While efficacy data were not obtained, the experience highlights logistical considerations and potential models for future decentralised clinical trials.
View ArticleDiabet Med.
Does real-time continuous glucose monitoring improve glycaemic control in adults with insulin-requiring type 2 diabetes?
Clinical Bottom Line: In adults with insulin-requiring type 2 diabetes, 26 weeks of real-time continuous glucose monitoring (rtCGM) significantly increased time in range compared to self-monitoring of blood glucose (SMBG), without increasing adverse events. rtCGM appears to be a safe and effective tool to enhance glycaemic control.
Summary: The 2GO-CGM trial investigated rtCGM versus SMBG in adults with insulin-requiring type 2 diabetes. In this New Zealand-based study, rtCGM use led to a 15% greater time in the target glucose range, though HbA1c differences were not statistically significant. The intervention was well tolerated, with no severe adverse events. These results support rtCGM as a beneficial addition to diabetes management in this population.
View ArticleAge Ageing.
Is mirtazapine effective and safe for treating chronic insomnia in older adults?
Clinical Bottom Line: Mirtazapine 7.5 mg significantly improves sleep quality and reduces insomnia severity in older adults with chronic insomnia over 28 days. However, its use may be limited by mild but notable side effects, prompting higher discontinuation rates than placebo.
Summary: The MIRAGE trial is the first placebo-controlled RCT to assess mirtazapine for chronic insomnia in older adults. Compared to placebo, mirtazapine led to significantly greater improvements in the Insomnia Severity Index and other sleep measures. While no severe adverse events occurred, more patients discontinued due to side effects. These findings highlight mirtazapine’s potential benefits for sleep in this population, balanced against tolerability concerns.
View ArticleNorwegian Institute of Public Health
Do financial incentives for GPs undermine their role as effective gatekeepers?
Clinical Bottom Line: Financial incentives tied to fee-for-service models for self-employed general practitioners may weaken their gatekeeping role. Higher-earning GPs tend to have shorter consultations and more frequent prescriptions, referrals, and sick leave certifications. A shift to salaried positions may strengthen gatekeeping and offer potential societal cost savings.
Summary: This Norwegian report evaluated how GP remuneration affects their gatekeeping function. Self-employed GPs earning more per hour were more likely to prescribe antibiotics, addictive medications, and issue referrals and sick leaves—patterns suggesting weaker gatekeeping. Compared to salaried GPs, self-employed doctors showed higher activity in these areas, possibly influenced by fee-based incentives. The report also challenges assumptions about the cost of transitioning all GPs to salaried roles, suggesting it may be more economically and clinically advantageous for public health.
View Article
