Published: 27th June, 2024
Contents
Te Rā Aro ki a Matariki: Matariki observed tomorrow
Tēnā koutou katoa. Best Practice Bulletin is coming to you one day early this week as we celebrate Matariki on Friday 28th June: the start of the Māori new year.
Matariki is a time for remembering the deceased (Matariki Hunga Nui) – honouring those we have lost since the last rising of Matariki; celebrating the present (Matariki Ahunga Nui) – giving thanks for what we have; and planning for the future (Matariki Manako Nui) – looking forward to the promise of a new year. Matariki is about coming together and reconnecting with your home and whānau and is often celebrated by sharing kai (food).
Have a go to kōrero, e.g. greet patients into the medical centre with Kia ora or more formally, Tēnā koe (one person), Tēnā kōrua (two people) or Tēnā koutou (three or more people).
To find out more about Matariki, see: https://www.matariki.com/
Mānawa maiea te putanga o Matariki
Mānawa maiea te ariki o te rangi
Mānawa maiea te Mātahi o te Tau
Whano, whano
Haramai te toki ata huakirangi
Haumi e
Hui e
Tāiki e!
Celebrate the rising of Matariki
Celebrate the lord of the skies
Celebrate the new year
Unite, unite
And bring forth the dawn
Together
In union
We are one!
New report from bpacnz: Revisiting antibiotic use in New Zealand - how does your prescribing compare?
Excessive and inappropriate antibiotic prescribing accelerates the emergence of antimicrobial resistance, limiting the options available when they are required for managing bacterial infections. New Zealand has previously been identified as having higher rates of antibiotic consumption than many other developed countries, with a significant proportion likely representing inappropriate use.
To help prescribers reflect on antimicrobial stewardship, the Publications team at bpacnz has produced a report on New Zealand antibiotic use between 2019 – 2023. This encompasses the lead up and initial stages of the COVID-19 pandemic; a period of time already shown to be linked to disrupted patterns of medicine use, e.g. opioid prescribing.
Key findings from this new analysis demonstrate that:
- Following a significant decrease in overall antibiotic use between 2019 and 2020 (as reported previously), dispensing of oral antibiotics is now trending back upwards again. The overall five-year relative decrease in oral antibiotic dispensing between 2019 – 2023 matches what would have previously been expected for an annual decrease in the years preceding COVID-19.
- Amoxicillin is the most commonly dispensed oral antibiotic. Amoxicillin + clavulanic acid has few first-line indications, yet is the second most commonly used oral antibiotic; most amoxicillin + clavulanic acid use is occurring without prescribers first trialling another option.
- Nitrofurantoin is now much more commonly used than trimethoprim, suggesting prescribers have appropriately shifted their approach to antibiotic selection for uncomplicated UTIs (in line with changing recommendations)
- Almost half of all patients dispensed an oral antibiotic received a supply covering more than seven days; this is out of step with recommendations to prescribe shorter courses for many indications
- There remains significant variation in antibiotic dispensing across New Zealand. Pacific peoples, Māori and those living in socioeconomically deprived areas have higher rates of use than other groups.
These findings indicate a clear need to renew efforts to curb inappropriate antibiotic use in New Zealand, particularly as research shows that modest decreases in overall prescribing does not substantially compromise patient safety (at a population level).
Personalised prescribing data available: If you are a primary care prescriber, you can log in to see your personalised antibiotic prescribing snapshot, including how your prescribing weighs up against your peers and national trends. So...how do you compare?
To view the antibiotic report, click here
Patient information sheets
Antimicrobial stewardship is not only the role of prescribers – increasing patient knowledge and confidence is crucial in preserving the use of antibiotics. We have developed two information sheets that can be given to patients prescribed antibiotics or parents/caregivers of a child prescribed antibiotics.
Medicine news: prescription co-payments, testosterone patches, fluticasone, risperidone
The following news relating to medicine supply, of particular interest to primary care has recently been announced. Medicine supply information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Prescription co-payments to be reinstated from 1st July
From 1st July, 2024, a $5 prescription co-payment per item is being re-instated for prescriptions from approved providers. A co-payment will not be required for children aged under 14 years, people with a Community Services Card (and their dependents) or for people aged 65 years and over.
Testosterone patches to be discontinued
Pharmac has announced that testosterone patches (Androderm) are being discontinued by the supplier, Teva. Current supplies will expire in October, 2024, and Pharmac expect stock levels to be low from August; a delisting date is yet to be announced. Alternative formulations of testosterone are available and funded, including a topical gel and injections.
Flixonase out of stock again
Fluticasone propionate (Flixonase) nasal spray is out of stock again due to increased demand; resupply is expected next month (July). There was a supply issue affecting Flixonase back in April (as reported in Bulletin 96), which was resolved in May. Ipratropium bromide nasal spray is out of stock until October, which may further constrain supply of nasal sprays. Intranasal budesonide is a funded alternative, however, a new prescription will be required. N.B. Advise patients that intranasal budesonide 50 microgram/actuation is available from pharmacies without a prescription.
See the NZF or Pharmaceutical Schedule for further information on alternative products.
Risperidone 0.5 mg and 2 mg tablets out of stock
There is a supply issue affecting stock of risperidone (Teva) 0.5 mg and 2 mg tablets. An alternative brand (Risperdal) of both strengths will be listed on the Pharmaceutical Schedule from 1st July, 2024.* In the interim, patients prescribed the 2 mg strength can take two 1 mg tablets. Halving 1 mg tablets is not recommended for patients taking 0.5 mg tablets; a 1 mg/mL oral liquid is available.
*This listing will not appear in the online version of Pharmaceutical Schedule until 1st August, 2024
In brief: widened shingles vaccine eligibility criteria from 1st July
Funded access criteria to the shingles vaccine (Shingrix) will be widened from 1st July, 2024 (as reported in Bulletin 97) to include people aged 18 years and over who are immunocompromised due to any of the following:
- Pre- or post-haematopoietic stem cell transplant
- Pre- or post-solid organ transplant
- Haematological malignancy
- Poorly controlled HIV infection
- Planned or receiving disease modifying anti-rheumatic drugs (DMARDs) for polymyalgia rheumatica, systemic lupus erythematosus or rheumatoid arthritis
- End stage kidney disease (CKD 4 or 5)
- Primary immunodeficiency
Funded access will remain for people aged 65 years.
Interaction between warfarin and tramadol: report from the UK
In June, 2024, the United Kingdom Medicines and Healthcare products Regulatory Agency (MHRA) published a new Drug Safety Update alerting healthcare professionals to the potential interaction between warfarin and tramadol. Elevated International Normalised Ratio (INR) levels have been reported with concurrent use of warfarin and tramadol, which in some cases can cause significant bruising and bleeding.
Advice from the New Zealand Formulary Stockley’s Interaction checker is that, while this reaction is rare, close monitoring of INR levels is sensible when tramadol is prescribed with warfarin, and some patients may need a reduction in warfarin dose. Consider whether an alternative opioid, e.g. codeine, can be prescribed instead.
Read more
This MHRA update comes following a coroner’s recommendation to raise awareness among healthcare professionals of this interaction after a patient who was taking both warfarin and tramadol died from an intracranial haemorrhage. Healthcare professionals in the UK are advised to be aware of the risk of increased INR with concurrent use of warfarin and tramadol; to ask patients when prescribing warfarin about any other medicines they are taking; to consider whether additional INR monitoring or a reduction in warfarin dose is required when starting tramadol (or another medicine), and to ensure that patients are aware of the need to seek medical care if they experience any symptoms or signs of major bleeding, e.g. severe or unexplained bruising, unusual headaches, severe bleeding gums. Further information from the MHRA can be found here.
There have been no recent medicine communications from Medsafe regarding the interaction between warfarin and tramadol, however, in 2006, a Prescriber Update article was published highlighting evidence (locally and internationally) of the interaction. Medsafe advise that if tramadol is prescribed to a patient taking warfarin, close monitoring of INR is recommended due to an increased risk of bleeding, particularly during the first week of treatment. The patient’s INR may remain elevated for several days following tramadol withdrawal. Any adverse medicine reactions thought to be related to warfarin and tramadol use should be reported to the Centre for Adverse Reactions Monitoring (CARM).
For further information on prescribing tramadol appropriately, see: https://bpac.org.nz/2018/tramadol.aspx
For further information on prescribing warfarin, see: https://bpac.org.nz/2017/anticoagulants.aspx and https://bpac.org.nz/2023/anticoagulants.aspx
Sodium valproate use in males: evidence update
In 2023, Medsafe issued an Alert Communication on the use of sodium valproate (Epilim) in “people who can father a child” due to a potential increased risk of neurodevelopmental disorders in children after paternal use of sodium valproate at the time of conception (as reported in Bulletins 76 and 89). Healthcare professionals were advised to inform male patients who take sodium valproate to use contraception during and for at least three months after stopping this medicine.
This advice has not changed, however, a recently published Danish study undertaken in a similar population to the original study cohort was unable to find an association between paternal use of valproate at the time of conception and risk of major congenital malformations and neurodevelopmental disorders in children.
At this stage, males taking sodium valproate should continue to be informed about this potential risk, and those who are planning parenthood soon may consider switching to an alternative treatment. A letter for healthcare professionals from the manufacturer about this potential risk is available here.
Read more
In 2023, international medicines regulatory agencies, along with Medsafe, issued warnings that males who take sodium valproate should be advised to use contraception during and for at least three months after stopping this medicine. This was based on evidence from a retrospective observational study from population registry databases in Denmark, Norway and Sweden that showed a potential increased risk of neurodevelopmental disorders in children after paternal use of valproate at the time of conception. The results of this study have not been formally published at this stage but the final study report from European Medicines Agency is available here.
Results from the 2024 study published in JAMA Network Open differ from the original findings and are summarised here:
- Between January, 1997, and December, 2017, a total of 1,336 children born with fathers who were prescribed valproate in the months before conception were identified from a study cohort of more than 1,200,000 total births in Denmark
- The median follow-up period was 10.1 years for children born to fathers who were prescribed valproate and 10.3 years for children whose fathers were not prescribed valproate
- Approximately 44,000 children (3.6%) were diagnosed with a major congenital malformation in their first year of life, and approximately 52,000 children (4.2%) were diagnosed with a neurodevelopmental disorder during follow-up
- Of the children whose fathers were prescribed valproate, 48 (3.6%) were diagnosed with a major congenital malformation in their first year of life and 85 (6.4%) were diagnosed with a neurodevelopmental disorder during follow-up
- The authors found no association between paternal use of valproate at the time of conception and risk of major congenital malformations (adjusted relative risk = 0.9; 95% confidence interval [CI] = 0.7 – 1.2) and neurodevelopmental disorders in children (adjusted hazard ratio = 1.1; 95% CI = 0.9 – 1.4), after adjusting for confounders
- The results did not change when analysis was restricted to valproate monotherapy or when co-prescribed medicines with known teratogenic effects were removed
- Further studies are required to confirm the association between valproate use in males at the time of conception and neurodevelopmental disorders and congenital malformations in their offspring
Christensen J, Trabjerg BB, Dreier JW. Valproate use during spermatogenesis and risk to offspring. JAMA Netw Open 2024;7:e2414709. doi:10.1001/jamanetworkopen.2024.14709
The risk of adverse effects of antiepileptic medicines for females of reproductive age is already well documented, and precautions around effective contraception for females also apply. Read more here.
Medical Council seeking feedback on new registration pathway for overseas doctors
The Medical Council of New Zealand (MCNZ) is seeking feedback on a new pathway to expedite the registration process for overseas medical graduates. Currently, the MCNZ requests information from the applicant’s medical College before eligible overseas medical graduates with the appropriate specialist qualifications can be vocationally registered in New Zealand. This process may take up to six months.
Under the proposed pathway, the MCNZ would not need to seek information for overseas medical graduates who completed postgraduate medical training in certain specialties in the United Kingdom and Ireland. However, these graduates must have worked for at least two years (of the last five years) in a comparable health system. The relevant specialties currently include anaesthesia, emergency medicine, general practice and internal medicine.*
*The MCNZ requires further information regarding obstetrics and gynaecology, psychiatry and diagnostic and interventional radiology before these specialties will be included in the pathway
Click here for further information. Consultation closes Tuesday 30th July, 2024.
Initial findings on the pre-school oral health initiative published
The Health Promotion Agency has released a report of the first phase of the Oral Health Toothbrush and Toothpaste Initiative (TTI). The initiative which started in December, 2021, aims to improve the oral health of pre-school aged children who are most at risk of poor oral health outcomes by providing them and their family/whānau with free toothbrushes, toothpaste and educational material. Priority groups include pre-school aged children of Māori and Pacific ethnicity and those living in low socioeconomic areas.
Results from the implementation phase (December, 2021 – August, 2023) are positive and show that the TTI is reaching priority groups. Data from the New Zealand Health Survey show that the number of children who are brushing their teeth with fluoride toothpaste at least twice per day is increasing over time. A focus of the next phase of the TTI is to improve uptake of resources to support family/whānau in implementing good toothbrushing practices.
Read the full report here. An infographic summary is also available here.
Checking in on oral health in primary care
Use opportunities (e.g. B4 School Checks, during an immunisation consultation) to check in on, and support, the oral health of young children, particularly those of Māori and Pacific ethnicity or who live in areas of high deprivation; refer to community oral health services as needed. Promote good oral hygiene practices by reminding parents/caregivers that:
- Children should brush their teeth twice a day with fluoride toothpaste - half a pea-sized amount if aged < 5 years and a pea-sized amount if aged ≥ 5 years
- At least one of these times, the child’s teeth need to be brushed by an adult (up until age eight years)
- After brushing, spit but don’t rinse, to maximise the effect of the fluoride
Podcast of the Week: Sleep challenges in toddlers
A recent episode of The Good GP, an Australian podcast series, discusses insights into sleep challenges affecting toddlers for primary care clinicians and offers practical solutions to recommend to parents/caregivers. Sleep is variable for young children and is influenced by multiple factors including medical conditions (e.g. eczema), family dynamics, daytime sleep, screen time, diet and physical activity. Environmental and behavioural techniques are prioritised, e.g. setting up “monster traps” for children with nighttime fears.
Listen to the full podcast here (24 minutes)
Paper of the Week: Working together - Rongoā Māori and Western medicine
Indigenous populations around the world experience worse health outcomes and higher mortality rates compared to non-indigenous groups. A lack of cultural understanding and safety in Western health systems limits healthcare accessibility for indigenous populations and contributes to health inequities. Integrating traditional health practices into Western medicine is a potential strategy to improve healthcare accessibility. In New Zealand, Rongoā Māori, or traditional Māori healing, is considered separate to conventional Western medicine, restricting its integration into clinical practice. However, the inclusion of Māori cultural values in healthcare is viewed as beneficial and may increase Māori engagement in healthcare, adherence to treatment regimens and overall satisfaction with their healthcare experience.
A small study published in the New Zealand Medical Journal examined how Western medicine and Rongoā Māori could be used collaboratively as part of post-surgery follow-up and attempted to identify barriers to this treatment model. Seven themes were identified during the study suggesting that a collaboration between these two health approaches is not only possible in the New Zealand healthcare system, but beneficial for patients.
Is Rongoā Māori something you feel confident discussing with patients? Are there certain aspects of local Rongoā Māori approaches to patient health that can be incorporated into your primary care consultations?
Read more
- This small qualitative study involved three male and three female participants (aged 31 – 79 years) who had recently undergone treatment for upper gastrointestinal disease
- Participants (and their whānau) took part in three 45-minute follow-up sessions with their surgeon and a Rongoā Māori practitioner over six months.
- The patient’s management plan involved aspects of Western medicine (e.g. laboratory testing, radiological imaging) and Rongoā Māori
- Interviews with participants after the sessions revealed seven main themes:
- Participants felt empowered and valued, and comfortable discussing their health
- The approach acknowledged and addressed all aspects of health, not just immediate clinical symptoms, e.g. whatumanawa (heart/emotions) and wairua (spirit), and made participants feel seen and heard
- Participants appreciated and equally valued the different health perspectives and a combination of Western and Rongoā Māori treatments provided management that was tailored to their individual needs
- Practitioners found the overall experience beneficial and were able to empower both the participant and their whānau by using a manaakitanga (hospitality and generosity) approach to the consultation instead of a solely clinical approach. Concerns about situations where the collaboration would not work well did not eventuate.
- Practitioners found that including whānau in the consultation gave them a wider view of the patient’s health and facilitated a deeper connection
- All participants unanimously supported the collaborative process and felt many people would benefit from this approach
- Suggestions for future collaboration included longer consultation times, more often and widening the approach to include more cultures. A collaborative approach would work best when managing medium- to long-term care patients with complex health needs.
- Barriers to a Rongoā/medical collaborative approach include:
- Consultation time constraints in the current healthcare model – a 45-minute appointment with a healthcare professional is unusual and this level of access is likely unsustainable outside of the study
- The significant difference in belief systems between Western medicine and Rongoā Māori may lead to opposing clinical approaches. This barrier can be overcome when Western medicine practitioners have a solid understanding of Māori cultural values, as seen in this study.
- Limited training in this approach, lack of clearly defined roles, fears related to professional identity and communication between practitioners are other factors that need to be reconciled
Koea J, Mark G, Kerridge D, et al. Te Matahouroa: a feasibility trial combining Rongoā Māori and Western medicine in a surgical outpatient setting. NZMJ 2024;137:25–35. doi:10.26635/6965.6417
For further information on Rongoā Māori, see: https://bpac.org.nz/BPJ/2008/May/rongoa.aspx (published in 2008; some content may no longer be current)
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