Published: 9th August, 2024
Contents
Spotlight on: Contraception - which option for which patient?
The “Contraception: which option for which patient?” series is consistently one of the most popular resources on our website. This collection of five articles provides guidance for primary care prescribers when selecting the right contraceptive option for a patient. It includes comprehensive information on each method of contraception, along with a CME quiz* and peer group discussion:
Previously, oral contraceptive pills were the most frequently used form of contraception, but there has been an increasing shift towards longer term options such as implants and intrauterine devices. There has also been a change in the way that oral contraceptive pills are dosed, with continuous use now being recommended in many cases. These resources are particularly useful when deciding on the best option for a patient with specific co-morbidities or clinical considerations, and in cases when a patient’s regular contraceptive option is not available, e.g. funding changes, medicines supply issues (see below).
*Users must be logged in to their mybpac account to access CME quizzes
Norethisterone-containing oral contraceptives temporarily move to monthly dispensing
A supply issue is affecting oral contraceptive medicines containing norethisterone due to difficulties obtaining the active ingredient (i.e. norethisterone). It is anticipated that this issue may be ongoing for the rest of 2024.
In response, Pharmac has moved Brevinor-1 28 (ethinylestradiol 35 micrograms + norethisterone 1 mg), Norimin (ethinylestradiol 35 micrograms + norethisterone 500 micrograms) and Noriday 28 (norethisterone 350 micrograms) oral contraceptives to monthly dispensing. Alternative products for Brevinor-1 28 and Noriday 28 have been sourced, however, they will not be available until later in the year (see below). The move to monthly dispensing is designed to ensure there is enough stock until resupply or alternative products arrive. The alternative products will need to be prescribed for supply under Section 29 of the Medicines Act 1981. These include:
- Alyacen 1/35 (ethinylestradiol 35 micrograms + norethindrone* 1 mg) has the same active ingredients in the same amounts as Brevinor-1 28 and will be funded from 1st October, 2024
- Norethindrone Tablets USP (norethindrone* 350 micrograms) has the same active ingredient and in the same amount as Noriday 28 and will be funded from 1st September, 2024
- Restock of Norimin is being prioritised. There is no alternative product at this stage.
*Norethisterone is known as norethindrone in the USA
Discuss with patients the importance of avoiding dosing interruptions while taking these medicines, especially if taking progesterone-only oral contraceptives; patients will need to plan when they will pick up their prescriptions to avoid missed doses. Once alternatives are available, pharmacists should ensure patients are familiarised with the product as the appearance may differ from their usual medicine, e.g. Brevinor-1 28 hormone-free tablets and Alyacen 1/35 active tablets are similar colours.
For further information on selecting a contraceptive, including long-acting options, see: www.bpac.org.nz/2019/contraception/options.aspx
NZSSD guidance ahead of discontinuation of Novo Nordisk insulin preparations
Novo Nordisk is discontinuing Mixtard 30, PenMix30 and PenMix 50 insulin preparations from 30th September, 2024, as reported in Bulletin 103. Prescribers are advised to begin switching affected patients to an alternative premixed insulin preparation to avoid supply issues later in the year. The New Zealand Society for the Study of Diabetes (NZSSD) has published guidance for switching patients to an alternative insulin preparation (see below). The guidance can also be found here.
Read more
The NZSSD guidance is summarised in Table 1.
Table 1. NZSSD recommendations when switching a patient from Mixtard 30, PenMix30 and PenMix 50 insulin preparations to a new premixed insulin.
| Current insulin preparation |
New insulin preparation |
Dosing changes |
| Penmix 30 or Mixtard 30 |
Humulin 30/70 |
Keep units of insulin the same |
| Novomix 30/70 |
Keep units of insulin the same or consider a 10% dose reduction for patients at elevated risk of postprandial hypoglycaemia |
Humalog Mix 25
(this is a change from 30% short acting insulin to 25% rapid acting insulin) |
Consider a 10% dose reduction |
| Penmix 50 |
Humalog Mix 50 |
Keep units of insulin the same or consider a 10% dose reduction for patients at elevated risk of postprandial hypoglycaemia |
|
All patients switching to a new premixed insulin preparation should be closely monitored and have their dosing titrated depending on their clinical response
|
Alternatively, consider a basal bolus insulin regimen (particularly for people with type 1 diabetes) or non-insulin medicines for those with type 2 diabetes.
For further information on prescribing insulin, see:
Medicines supply news: oxycodone, levothyroxine, olanzapine, famotidine, capsaicin
The following issues relating to medicine supply, of particular interest to primary care, have recently been announced. These items are selected based on their relevance to primary care and where issues for patients are anticipated, e.g. there is no alternative medicine available or changing to the alternative presents issues. Information about medicine supply is available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
New brand of oxycodone immediate-release tablets and liquid
Pharmac has announced that Oxycodone Amneal is the new brand of oxycodone immediate-release tablets (all strengths) due to the supplier of OxyNorm withdrawing from New Zealand. Oxycodone Amneal is approved by Medsafe and has been funded since July, 2024. Pharmacists should advise patients that the new brand of oxycodone contains the same active ingredient, but in tablet form instead of a capsule. Stock of OxyNorm 5 mg and 10 mg oxycodone capsules is now exhausted while remaining stock of OxyNorm 20 mg oxycodone capsules is expected to run out in October, 2024.
An information sheet is available to give to patients here.
The funded brand of oxycodone liquid has also changed from OxyNorm (5 mg/5 mL) to Oxycodone Lucis (1 mg/mL). The new brand is unapproved and will need to be prescribed for supply under Section 29 of the Medicines Act 1981.
Prescribers could use this brand switch as an opportunity to review their opioid prescribing, especially whether ongoing prescriptions for oxycodone are appropriate. An overview of opioid prescribing in New Zealand is available here. N.B. Personalised data is available for primary care prescribers; you must be logged in to your mybpac account and recorded as a prescriber in your personal information to view your prescribing history.
Reminder: Eltroxin (levothyroxine) has a new look and formulation
New olanzapine tablet packaging
The Zypine brand of olanzapine tablets is switching from foil packaging to bottle packs. This change affects the 2.5 mg, 5 mg and 10 mg strengths of olanzapine tablets (Zypine). Medsafe is aware that some of the new bottle packs arrived without child-resistant caps. Future batches will have child-resistant caps, however, limited quantities of the tablets with incorrect packaging are being released to maintain sufficient stock in circulation. Pharmacists should remind patients about safe storage of medicines when dispensing olanzapine with new packaging.
Famotidine supply issue
There is a supply issue affecting famotidine 20 mg tablets (Hovid, Section 29); currently the only funded histamine H2-receptor antagonist, indicated for reducing gastric acid secretion. Famotidine 20 mg tablets are currently out of stock with the supplier, however, new stock is expected to arrive in mid to late August, 2024. This stock may take one to two weeks to reach pharmacies. Famotidine 40 mg tablets and famotidine 40 mg/4 mL injections are unaffected.
If 20 mg tablets are not available in pharmacies (and using 40 mg tablets is not appropriate), some patients may have to temporarily change to an alternative medicine, e.g. a proton pump inhibitor.
New brand of capsaicin cream
Zo-Rub is replacing the Zostrix brand of capsaicin cream. Zo-Rub capsaicin cream is available in two strengths, 0.025% (Zo-Rub Osteo) and 0.075% (Zo-Rub HP), and was listed in the Schedule from 1st August, 2024. The new brand is unapproved and will need to be prescribed for supply under Section 29 of the Medicines Act 1981.
There have been ongoing supply issues affecting capsaicin preparations and an alternative brand (Rugby Capsaicin Topical Cream, Section 29) was listed on the Pharmaceutical Schedule in 2022. The Zo-Rub brand of capsaicin cream will be supplied once current stocks (Rugby brand) are exhausted.
Proposal to fund cetuximab for colorectal cancer
Pharmac has released a proposal to widen access to cetuximab for colorectal cancer from 1st November, 2024. Cetuximab is a chimeric monoclonal antibody that binds and inhibits epidermal growth factor receptors (EGFR) preventing cancer cell growth and metastasis. Cetuximab is Medsafe approved and currently funded for the treatment of locally advanced head and neck cancers. It is given weekly via intravenous infusion over 60 or 120 minutes; in the proposal, “off-label” dosing every two weeks is also being considered. Cetuximab would be funded for people with left-sided colorectal cancer who meet eligibility criteria; it is expected that 180 people would benefit from this decision in the first year. People who are currently privately funding cetuximab treatment would be able to change to funded treatment if they meet eligibility criteria. Additional considerations include resource implications for the provision of infusions and specialised laboratory testing to confirm eligibility for treatment.
Submissions are due 4 pm on Friday 23rd August, 2024.
A summary of the proposal can be found here
Monitoring Communication: direct acting oral anticoagulants and potential mood changes
Medsafe has issued a Monitoring Communication to seek more information from clinicians on the risk of mood changes in people taking direct acting oral anticoagulants, e.g. dabigatran, rivaroxaban, apixaban. This safety communication comes in response to a report to the Centre for Adverse Reactions Monitoring (CARM) and Medsafe regarding the development of personality changes, anxiety and irritability in an older male soon after being initiated on rivaroxaban. Responses can be submitted until February, 2025.
Be alert to potential mood changes in patients taking direct acting oral anticoagulants and report any suspected cases to CARM.
For further information on selecting an appropriate oral anticoagulant, see: https://bpac.org.nz/2023/anticoagulants.aspx
NZF updates for August
Significant changes to the NZF in the August, 2024, release include:
- New indications (unapproved) added to the carvedilol monograph (prevention of bleeding from medium or large oesophageal varices in individuals with liver cirrhosis and portal hypertension [under specialist supervision], primary prevention of decompensated liver cirrhosis in individuals with clinically significant portal hypertension [under specialist supervision]). Advice in hepatic impairment section has also been updated.
- Sections updated in the therapeutic notes for acne, photodamage, topical treatment for psoriasis, nutritional supplements in pregnancy and breast feeding (vitamin D section updated), analgesics (pharmacological treatment for acute pain, non-opioid analgesics, opioid analgesics, opioid choice [new guidance section], other analgesics and adjuvants, and pain management of common specific conditions [new guidance section on complex regional pain section] sections updated)
- Content updated in the guidance section in the following immunisation chapters: coronavirus disease (COVID-19) vaccines, human papillomavirus vaccines, measles vaccines, mumps vaccines, pertussis (whooping cough) vaccines, pneumococcal disease vaccines, respiratory syncytial virus vaccine, rubella vaccines
- Contraindications, cautions, monitoring, adverse effects and patient advice updated in the phentermine monograph
You can read about all the changes in the August release here. Also read about any significant changes to the NZF for Children (NZFC), here.
South GP CME conference 2024 is almost here
The South GP CME conference 2024 is once again upon us. It is being held at the Te Pae Christchurch Convention Centre, 15th – 18th August, 2024. The variety of sessions and workshops on offer this year reflects the ever-widening spectrum of primary care; for the full agenda click here.
If you haven’t registered yet, it’s not too late.* Register now to secure your place.
South Link Education Trust returns as the Diamond Sponsor of the GP CME conferences. It is home to some of primary care’s most familiar names, including South Link Health Services, InPractice, BPAC Clinical Solutions, bpacnz Publications and the New Zealand Medicines Formulary (NZF and NZFC). The conference team will be presenting the range of products and services available across the organisation, along with showcasing the new Smartcare GP range, including Inbox Manager.
*The “Emergency Resuscitation for GPs” CORE Skills course and some pre-conference workshops are now fully booked
Upcoming Goodfellow Unit webinars
The Goodfellow Unit, University of Auckland, is hosting several free access webinars in the coming months. These webinars are intended to provide topical and relevant health information for primary care clinicians. Continuing professional development (CPD) points are also available. Webinars are often recorded and available to watch at a later date. Upcoming webinars include:
- Improving outcomes for diabetes and thyroid disorders in pregnancy. This webinar is part of the Te Tiri Whakāro: Sharing Knowledge series and is supported by Health New Zealand, Te Whatu Ora. Dr Heena Lakhdhir will cover gestational diabetes mellitus, and Dr May Soh will discuss thyroid disorders in pregnancy. The webinar will be held on Tuesday 27th August from 7.30 pm. Click here to register.
- Modern pathways in prostate cancer investigation and management, presented by Dr Andrew Williams, Mr Andrew Lienert and Dr Remy Lim. The webinar will be held on Tuesday 10th September from 7.30 pm. Click here to register.
Reminder: ACC Pain Management Service
An interdisciplinary pain management service is available for the assessment and treatment of patients with ongoing pain lasting longer than expected recovery time frames. In some cases, this may include assessment by a specialist pain medicine physician. People who have pain for at least three months following an injury covered by ACC can be referred directly to the pain management service. Those with diagnosed complex regional pain syndrome (CRPS) may be referred earlier than three months after an injury. A referral triage template for clinicians is available here.
Click here for a list of pain management service providers in your region.
Review of the End of Life Choice Act 2019: public consultation opens
The Ministry of Health, Manatū Hauora, has announced that public consultation on review of the End of Life Choice Act 2019 opened on 1st August, 2024. The End of Life Choice Act 2019 took effect in November 2021, and as part of the legislation, must be reviewed within the first three years, and then every five years thereafter. A review of how well the Act is currently operating and whether it is achieving its purpose is already underway. The consultation is designed to gather public feedback on potential future changes to the Act. This consultation is open to anyone, however, there are options for healthcare professionals, including clinicians directly involved in providing assisted dying services, to identify their role when making submissions. Submissions close at 5 pm on Thursday 26th September.
Submissions can be made here.
Further information on the End of Life Choice Act 2019 review can be found here.
The Ministry of Health, Manatū Hauora, has also released the Publication of the Registrar (assisted dying) Annual Report 2024. This document provides information on applications for assisted dying between 1st April, 2023 and 31st March, 2024. The full report can be found here.
Rare disorders health strategy released
The Ministry of Health, Manatū Hauora, has published the Aotearoa New Zealand Rare Disorders Strategy. Rare disorder is an umbrella term for medical conditions characterised by a specific set of symptoms and signs identified in fewer than 1 in 2,000 people in New Zealand. This document was written in conjunction with people who experience rare disorders and their family/whānau and outlines a framework and long-term goals to improve how healthcare systems approach, manage and support them. It is intended for people living with rare disorders, their family/whānau and people who provide support to them, as well as healthcare professionals.
Read more
The strategy details five priorities:
- Gearing the system for quality care - Kia tika ngā whakaritenga, kia pai ngā mahi tautiaki – establishing leadership and processes to connect current support services, develop new capabilities and to promote and prioritise rare disorders during decision-making
- Learning and sustaining progress – Te ako me te whakaūnga o ngā ahunga whakamua – improving the quality of health data collection that can inform decision-making and support research
- Equipping the health workforce to provide quality care for rare disorders – E hāpai ana i ngā kaimahi hauora ki te whakarato i ngā mahi tautiaki tōtika mō ngā mate mokorea - increasing awareness and understanding of rare disorders among healthcare professionals through education, the development of national guidelines and pathways, and access to specialists
- Giving voice to people and their whānau living with rare disorders - Kia rangona ngā reo o ngā tāngata rātou ko ō rātou whānau e pāngia ana e ngā mate mokorea – ensuring those living with rare disorders are heard through inclusion in working groups, committees and advisory boards
- Joining up to achieve more - E tūhono atu ana ki whenua kē kia piki ake tonu ngā hua – initiating international partnerships to promote collaboration, allow for information sharing and increase access to international clinical trials and emerging technologies
Click here to read the strategy document. Supporting documents providing context and evidence used in the development of the strategy and a summary of thoughts and perspectives from those who contributed are also available here.
*New* The Medical Factorium
Every now and then, patients ask “why?” and the answer eludes us. In this new bulletin segment, we will attempt to answer some of those curious questions.
This week, like you, our eyes have been glued to the Olympics, but we keep wondering, why are so many of the athletes yawning before their events? Are the cardboard beds really that bad? Or is there something else going on?
Read more
As expected, the answer isn’t exactly clear. Yawning is likely controlled by centres in the brainstem. It most commonly occurs during transition between wake and sleep but may also be induced by exogenous triggers, e.g. contagious yawning after witnessing or hearing someone else yawn, or endogenous triggers, e.g. stress – such as prior to an Olympic event, or for the less athletically inclined, just because you are hungry or tired. There are several proposed functions of yawning including brain thermoregulation, blood gas balance, nervous system arousal and communication, none of which are universally agreed upon.1 In an athlete’s case, yawning may increase blood oxygen levels and cool the brain establishing a relaxed but alert state of mind before competition. While this is only a theory, maybe a quick yawn before seeing the next patient could get you “in the zone” too?
- Krestel H, Bassetti CL, Walusinski O. Yawning—Its anatomy, chemistry, role, and pathological considerations. Progress in Neurobiology 2018;161:61–78. doi:10.1016/j.pneurobio.2017.11.003
Do you have a clinical oddity that you would like us to investigate, or better yet, can you share a fascinating medical fact with our readers? Email: editor@bpac.org.nz
Paper of the Week: "Call me if there are any problems..."
Uncertainty is a constant presence in primary care. Given the nature of community medicine and resource limitations, safety-netting is a proven strategy for reducing patient harm (and helping clinicians sleep at night). Ideally, clear instructions are provided explaining when and how to seek further medical attention, increasing patient confidence and enabling self-care. In contrast, generic or insufficient information and impractical suggestions can lead to patients re-presenting when their condition could be managed at home, or worse, delaying presentation.
An article published in the British Journal of General Practice examines the use of safety-netting advice in after-hours primary care. The authors found safety-netting advice was provided in more than three-quarters of consultations, however, patients were given generic advice in approximately half of those consultations and only one-fifth were advised of a specific timeframe after which to seek medical attention (if their symptoms did not improve or deteriorated). Clinicians were also more likely to provide safety-netting advice in-person, when prescribing or if an infection was suspected. Surprisingly, situations where safety-netting advice was less commonly given included mental health and telephone consultations. As primary care continues to evolve in the face of current challenges, safety-netting advice remains a critical tool in preventing serious patient harms, but clinicians must keep their tools sharp.
bpacnz Clinical Sharpeners: Safety-netting advice
- Provide specific rather than generic advice where possible (enabling patients to take more responsibility for their health)
- Give timeframes for when to seek further medical attention
- Use written advice (if available), especially with more complex information, e.g. multiple symptoms
- Document any advice given in the patient’s notes, e.g. symptoms, timeframes
What factors increase the likelihood that you would provide safety-netting advice during a consultation, e.g. patient age, specific symptoms or conditions, distance from hospital? Do you always provide a timeframe when advising patients to re-present if they experience clinical deterioration (or lack of improvement)? If you do, how do you determine what timeframe is appropriate?
Read more
- This retrospective cohort study analysed adult medical consultations between July, 2013 and February, 2020 in Birmingham, United Kingdom
- Information was extracted from the general practice research database of a single after-hours primary care provider, used by approximately 1.4 million people
- A monthly sample of 30 consultations was reviewed, comprising of even numbers of in-clinic, telephone and home-based consultations (total = 2400 consultations)
- Consultations were excluded if they primarily involved dentistry, requests for prescription repeats, or when a patient required hospital referral, was not assessed by a clinician or was already deceased
- Final analysis was carried out on 1,886 consultations involving 1,862 unique patients (63% female, mean age ~ 58 years) and 353 unique clinicians (who undertook between 1 and 44 consultations).
- Safety-netting advice was provided in 78% of consultations with the highest rate for consultations involving a respiratory issue (86%), whereas only 52% of consultations involving mental health issues contained safety-netting advice
- This is particularly alarming given the risks for patient harm in some situations
- Generic advice, e.g. "call back if worsens" was provided slightly more often (53%) than specific advice (47%), e.g. "if no better in 2 days see GP"
- The average number of symptoms to be alert for included in safety-netting advice was 2.6, however, this ranged from 1 – 12
- Only 20% of consultations involving safety-netting advice where the patient was advised to seek further medical attention if symptoms persisted, included a timeframe for this
- Between 2014 and 2019, the use of safety-netting advice increased from 76% to 82%. This change was accompanied by an increase in the average number of symptoms to monitor for and the specificity of advice.
- Safety-netting advice was more likely to occur in face-to-face consultations in a medical clinic compared to telephone consultations (odds ratio [OR] = 2.58, confidence interval [CI] = 1.94 – 3.43, p < 0.001), which is surprising given the accepted limitations of telehealth. Other factors associated with an increase in safety-netting advice included prescribing (OR = 1.97, CI = 1.57 – 2.47, p < 0.001) and if an infection was suspected (OR = 1.96, CI = 1.56 – 2.46, p < 0.001).
- Future education and training around safety-netting should focus on providing more specific advice, e.g. timeframes, and increasing the use of safety-netting advice during telephone consultations and mental health consultations
- Limitations of this study include:
- The potential for under-reporting as available evidence suggests safety-netting advice is commonly left off medical notes
- The use of data from a single health provider as in-house procedures and training may differ from standard practice elsewhere
- The study was conducted pre-COVID-19 pandemic, and practice is likely to have changed as a result, particularly regarding telephone consultations
Edwards PJ, Finnikin SJ, Wilson F, et al. Safety-netting advice documentation out-of-hours: a retrospective cohort from 2013 to 2020. Br J Gen Pract 2024;:BJGP.2024.0057. https://doi.org/10.3399/BJGP.2024.0057
This Bulletin is supported by the South Link Education Trust
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