Published: 23rd August, 2024
Contents
bpacnz Reminder: Are you aware of B-QuiCK?
“When you’re in the middle of a consult and need the main points fast – think B-QuiCK!”
B-QuiCK, which stands for bpacnz Quick Clinical Knowledge, provides short clinical summaries from some of the full articles available on our website. Relevant sections from these resources have been condensed into “notepad pages” or algorithms designed to offer rapid access to practical clinical information, such as what to ask, examine, investigate, prescribe and monitor when managing a condition.
Recently published B-QuiCK resources include:
All topics are initially displayed by default when you open the B-QuiCK page (click on the tile on our homepage) and arranged by order of publishing. Topics can be filtered by category by clicking on the menu bar at the top. We regularly add new topics and are gradually developing a comprehensive quick reference library for primary care clinicians.
N.B. A link to the full article is included at the end of each summary; it is strongly recommended to review the original resource at your convenience for full details of recommendations and evidence.
Proposal to fund empagliflozin for heart failure
Pharmac is seeking feedback on a proposal to widen access to empagliflozin for patients with chronic heart failure with reduced ejection fraction. Empagliflozin has been funded with Special Authority approval for patients with type 2 diabetes since February, 2021. International guidelines now recommend the use of sodium-glucose co-transporter 2 (SGLT-2) inhibitors, including empagliflozin, for improving prognostic outcomes in people with heart failure, with or without diabetes.
It is proposed that Special Authority criteria for empagliflozin will be widened from 1st December, 2024, to include patients with heart failure who have NYHA class II – IV symptoms and who are receiving concomitant optimal standard chronic heart failure treatments. The criteria also state that patients should have confirmed left ventricular ejection fraction (LVEF) < 40%, however, empagliflozin can be initiated if the clinician believes “the patient would benefit from treatment” and echocardiography is not practically possible. Special Authority applications could be made by any relevant practitioner and further application renewal will not be required at this stage.
Submissions are due by 4 pm, Friday, 13th September. Read more about the proposal here.
For further information on the management of heart failure in primary care, including the role of SGLT-2 inhibitors, see: https://bpac.org.nz/2022/heart-failure.aspx
Medicine supply news: methylphenidate, intra-uterine devices, norethisterone-containing oral contraceptives
The following news 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.
Ongoing supply issue to affect both brands of extended-release methylphenidate
Pharmac has announced that stock of both Concerta and Teva brands of extended-release methylphenidate are expected to be impacted by ongoing supply issues that may continue through until mid-2025. At this stage, both Concerta and Teva 27 mg and 54 mg extended-release methylphenidate tablets are expected to be out of stock from late-August to the middle or end of September, 2024, while the 18 mg and 36 mg strength tablets will be out of stock for one to two weeks in October, 2024. It is likely that there will be some instances where patients will be unable to access either brand. An information sheet for pharmacists to provide to patients is available. Clinical advice for prescribers, including dose equivalence of methylphenidate presentations, is available here.
New patients
Do not start new patients on extended-release methylphenidate (unless other options are not appropriate). Pharmac advises that immediate-release tablets or eight-hour Ritalin LA or Rubifen SR brands of sustained-release methylphenidate may be considered as a funded alternative.
Current patients
For patients currently taking extended-release methylphenidate (12-hour duration of action), a change in regimen may be required, e.g. switch to a sustained-release formulation twice daily, or immediate-release formulation taken more often.* Pharmac also suggest prescribers consider whether the patient could go on a treatment break. Patients (or their parent/caregiver) can be recommended to contact their usual pharmacy to see which formulations are available, or when supplies are expected, before getting their prescription dispensed.
* A new Special Authority application may be required depending on what brand and formulation the patient is moved to
Intra-uterine device brand change
A new brand of copper intra-uterine device (IUD) will be listed on the Pharmaceutical Schedule from 1st September, 2024: TCu 380 Plus Normal IUD. This will replace the Choice TT380 Standard IUD which is being discontinued on 1st October, 2024. A key difference is that the new brand is only licensed to remain in situ for up to five years, compared to ten years with the previous brand. The Choice TT380 Short IUD has been impacted by supply issues since 2022 (as reported in Bulletin 57); 380 7 Med NSHA IUD remains available as a replacement device. Choice Load 375 has been out of stock since May, 2024; there is currently no alternative device available.
For information on intra-uterine devices and other long-acting contraceptives, see: https://bpac.org.nz/2021/contraception/long-acting.aspx
Change in advice regarding norethisterone-containing oral contraceptives
In our last bulletin we reported that Pharmac had moved several norethisterone-containing oral contraceptives to monthly dispensing in response to a shortage of the active ingredient, norethisterone.
Today, Pharmac has announced that this information on their website was incorrect and that the affected oral contraceptive products, i.e. Brevinor-1 28, Norimin and Noriday 28, should be dispensed three-monthly.
For further information, see: https://bpac.org.nz/Bulletin/bestpractice/105.aspx#2
Invasive group A streptococcal infection to become a notifiable disease
The Ministry of Health, Manatū Hauora, has announced that invasive group A streptococcal infection (iGAS) is to become a notifiable disease. iGAS is associated with the development of severe disease such as necrotising fasciitis, cellulitis, bacteraemia, pneumonia, sepsis and toxic shock syndrome. From 1st October, 2024, health practitioners and laboratories must notify the local Medical Officer of Health if iGAS is suspected or confirmed. Do not wait for laboratory confirmation before notifying. The rate of infection is reportedly increasing in New Zealand and this change is expected to improve disease surveillance and allow timely and effective responses from health authorities when required.
For further information on iGAS, see: https://www.esr.cri.nz/digital-library/invasive-group-a-streptococcal-infection-in-new-zealand-2023/
Mpox declared a public health emergency by WHO
The World Health Organization has declared mpox (previously known as monkeypox) a Public Health Emergency of International Concern (PHEIC) for the second time since 2022, following outbreaks in parts of Africa and the spread of a new strain (mainly via sexual transmission). A vaccine for mpox is available in New Zealand for eligible people at dedicated clinics (as reported in Bulletin 66); further information is available from the Burnett Foundation Aotearoa.
Guidance for clinicians
Be alert for symptoms and signs consistent with mpox, particularly in people who have recently travelled overseas and those with higher risk sexual practices, e.g. men who have sex with men, people with multiple sexual partners or anonymous sexual partners. Mpox may be suspected with the presence of acute, unexplained skin and/or mucosal lesions or proctitis (e.g. anorectal pain, bleeding). N.B. More common causes of acute skin rashes with similar appearances should be considered and excluded where possible, e.g. varicella zoster, herpes simplex, syphilis, molluscum contagiosum.
If a patient is suspected to have mpox, consider telemedicine where possible or ensure adequate PPE, and obtain relevant travel, sexual history and smallpox immunisation history. Contact the local Medical Officer of Health on suspicion of any mpox case prior to the collection of any test samples. Patients should isolate and avoid close contact with others while awaiting test results.
For further information on mpox, see: https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/diseases-and-conditions/monkeypox (currently under revision) and https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/communicable-disease-control-manual/mpox/
Latest annual STI surveillance report shows distinct rise in syphilis cases
The Institute of Environmental Science and Research (ESR) has released the 2023 sexually transmitted infection (STI) surveillance report. Syphilis infections in 2023 rose markedly, increasing 45% from the previous year to 736 cases, and exceeded rates seen pre-COVID. The highest number of cases were among men who have sex with men (MSM), and people aged > 30 years. Chlamydia infections increased in 2023 by approximately 12%, and it remains the most prevalent STI in New Zealand, with 28,166 laboratory-confirmed cases (approximately 62% females). The number of reported gonorrhoea infections also increased from the previous year by around 12% with a total of 7,794 cases, with the highest rates among MSM.
Prioritise opportunistic sexual health discussions and STI screening among at-risk patient groups. A sexual health audit may be an effective strategy to increase awareness in your practice about STI screening. The bpacnz Sexual health checks in younger males audit provides a structured plan and can also be customised for different demographic groups.
Read the full report here. An online dashboard is also available here.
Aotearoa Immunisation Register (AIR): patients can now restrict access to their records
The ability to access and share immunisation records in the Aotearoa Immunisation Register (AIR) can now be controlled by patients. If a patient chooses to restrict access to their immunisation history, healthcare providers will only be able to view records of immunisations that were administered at their facilities. Vaccinations will still be added to the patient’s record in the AIR, however, their enrolled healthcare provider will not be notified of immunisations administered to that patient by different providers, e.g. a pharmacy, workplace or school. More information for healthcare professionals is available here.
Discuss the potential implications of restricting access with any patients who are considering this. As part of informed consent, ensure patients understand that clinicians and vaccinators may not be able to confirm whether a vaccine has previously been administered. This could result in them missing out on targeted health information (e.g. immunisation eligibility), vaccine doses being deferred as a precaution or extra doses administered by mistake. Advise patients who choose to restrict access to their data to keep an up to date copy of their immunisation record with them to refer to if needed.
Information for patients about AIR privacy is available here
Consultation on Medical aspects of fitness to drive
The NZ Transport Agency Waka Kotahi (NZTA) is seeking feedback on proposed changes to the Medical aspects of fitness to drive: a guide for health practitioners (published in 2014). Key changes include updates to medical guidelines and standards, clarity around roles and the responsibility of healthcare professionals, improved access to hold a driver’s license for people with some medical conditions and consideration of certain recommendations from coroner reports where medical conditions were associated with fatalities. The draft document is available here. A summary of the changes is also available.
Submissions close Friday, 27th September; you can submit feedback directly to NZTA here, or to the Royal New Zealand College of General Practitioners (RNZCGP) to inform a College submission: rnzcgp@rnzcgp.org.nz (submissions to the College are due by Friday, 13th September).
Upcoming webinar. A webinar about the proposed changes, with NZTA panellists and RNZCGP Medical Director, Dr Luke Bradford, is being held on Tuesday 10th September from 6 – 6:45 pm. To be sent the link to the webinar, email: medaspectsreview@nzta.govt.nz with your name, role and organisation.
Daffodil Day next Friday
Next Friday (30th August, 2024) is the annual Cancer Society Daffodil Day fundraiser. Money raised in the appeal will contribute towards cancer care for patients and their whānau through the Cancer Society education and awareness programmes and cancer research efforts.
The bpacnz website has a dedicated section for supporting cancer care in New Zealand. Click here to view guidance on bowel, lung and prostate and gynaecological cancers, melanoma and cancer cachexia.
bpacnz focus: Picky eater or avoidant restrictive food intake disorder?
Distinguishing “picky eating” from “disordered eating” in children can be challenging, particularly as eating patterns vary with age and development, and many children (and adults) have preferences and aversions to certain foods. Given the potential for significant long-term consequences of disordered eating patterns (e.g. delayed growth and development, functional impairment, poor mental health), early identification of at-risk children is needed to improve food relationships and lead to positive outcomes.
Avoidant restrictive food intake disorder (ARFID) is characterised by the avoidance of or restricted intake of certain foods which results in one of the following: significant weight loss (or not achieving expected weight gain or faltering growth in children), significant nutritional deficiency, marked interference with social functioning or dependence on enteral feeds or oral supplements. Notably, food restriction or avoidance is not driven by body image concerns; possible reasons include sensory aversion, difficulty digesting certain foods, fear of choking, gagging or vomiting or a lack of interest in food/no appetite.
Initial assessment in primary care
If ARFID is suspected, guidance from the United Kingdon recommends clinicians undertake an initial assessment, including:
- A brief history of the presenting difficulties, including whether there were any early feeding difficulties, current diet, impact
- Consideration of whether there is a medical condition or physical cause that may contribute to food aversion or impact appetite and requires further investigation, e.g. anorexia nervosa, paediatric feeding difficulty, gastrointestinal disturbance. Also consider the possibility of co-existing autism spectrum disorder.
- Physical assessment that is checked against MEED guidelines (Guidance on Recognising and Managing Medical Emergencies in Eating Disorders), e.g. measure weight and height
Following the initial assessment, referral to a paediatrician, eating disorder service or mental health clinician may be indicated. A dietitian is also likely to be helpful for nutritional assessment and management.
A two-page summary is available from the British Journal of General Practice. A blog post from the United Kingdom is also available here.
An overview of ARFID for healthcare professionals is available from the Royal Australian and New Zealand College of Psychiatrists: https://www.ranzcp.org/clinical-guidelines-publications/clinical-guidelines-publications-library/eating-disorders-cpg-and-associated-resources; some regional HealthPathways also have information
Parent/patient information is available from Healthify or KidsHealth. Support for carers is available from the Eating Disorders Association of New Zealand.
Podcast of the Week: Symptoms after antidepressant discontinuation
GPnotebook is a clinical education platform in the United Kingdom that hosts a range of articles, podcasts and short video episodes for primary care clinicians. The latest episode of GPnotebook TV discusses findings from a recently published systematic review and meta-analysis on discontinuation symptoms following antidepressant withdrawal.
The study found that one in six or seven patients experienced pharmacological withdrawal symptoms following antidepressant discontinuation; more common than previous evidence has shown. Patients should be reassured that most withdrawal symptoms are transient, but up to one in 30 may experience severe withdrawal symptoms. Imipramine was most likely to be associated with discontinuation symptoms (including most severe symptoms), followed by venlafaxine and escitalopram. Sertraline and fluoxetine were the least likely. N.B. The study did not include data on patients discontinuing from mirtazapine, amitriptyline or bupropion.
Watch the video here (nine minutes)
Paper of the Week: Managing dermatological solar damage in primary care
People in New Zealand are at high risk of ultraviolet (UV) radiation skin damage due to a propensity for outdoor activities and a reduced stratospheric ozone layer. Actinic keratoses (AK), or solar keratoses, are a common manifestation of chronic UV exposure and are a regular finding among patients in primary care. While usually benign, people with multiple AKs are at increased risk of developing squamous cell carcinomas and basal cell carcinomas. The presence of multiple AKs also suggests the person is at higher risk of developing other skin cancers, including melanomas, due to their sun exposure. An article published in the Australian Journal of General Practice provides an overview of solar damage management in primary care, including the assessment and treatment of individual AKs and the wider affected area, i.e. field treatment.
How confident do you feel distinguishing between benign and malignant skin lesions? Given the low risk of malignancy, do most patients choose to proceed with treatment or wait and monitor the lesion for progression? Which treatment methods are most effective for AKs, in your experience? What advice do you offer patients on how to manage or limit adverse effects of field treatments (e.g. topical fluorouracil, imiquimod) to prolong treatment duration?
Read more
Assessment
- Undertake opportunistic assessment for solar damage regularly and ask if the patient has noticed any lesions of concern. A preliminary assessment of visible skin is a good place to start, i.e. face and hands.
- A focused clinical history to assess skin cancer risk includes personal or family history of skin cancers and treatments, and the patient’s level of UV exposure, e.g. occupation and recreational activities
- Ask about severe sunburn resulting in blistering, especially during childhood
- Examine lesions using inspection, palpation and a dermatoscope, and use the SCAN acronym when assessing a specific lesion (patients can also use this acronym as part of self-skin checks):
- Sore or Symptomatic – unresolving, painful, bleeding or itchy lesions
- Changing and/or Concern – change in appearance over time, e.g. colour, size, shape. In most cases, ‘patient-identified’ lesions of concern require focused examination, biopsy and follow-up, unless malignancy can be easily ruled out.
- Abnormal – lesions that can be differentiated from others around them, i.e. an “ugly duckling”
- New – newly identified lesions that have not healed within four to six weeks, or a new “mole” that has developed in a patient aged over 40 years
- Consider individual lesions in isolation and as part of the entire field region during initial observation
- Dermatoscopic evaluation significantly increases diagnostic specificity and sensitivity
- Exclude squamous cell carcinoma. Distinguishing between benign and malignant lesions can be challenging; Table 3 in the article summarises examination features of common hyperkeratotic skin lesions.
Treatment
- If there is suspicion of non-melanoma skin cancer, a punch biopsy is preferred over a shave biopsy to allow assessment of the lesion base for diagnosis
- Cryotherapy is first-line treatment for isolated AK, however, most patients with a significant history of UV exposure will present with extensive AK over a large area or ‘field region’
- Field treatments, e.g. topical fluorouracil, imiquimod, methyl aminolevulinate (not funded), are likely to result in increased patient satisfaction (regarding appearance) compared to treating individual lesions with cryotherapy
- Detailed information on prescribing fluorouracil and imiquimod is available from bpacnz here
- Appropriate choice of field treatment is determined by the size of the area requiring treatment, clinician experience and patient factors, e.g. occupation, treatment expectations, personal preference
- Adverse effects of field treatments include inflammation, pain and erosion; patient tolerance limits treatment duration
- Pre-treating affected areas with topical salicylic acid 2% (for two weeks) or using cryotherapy on specific lesions before field treatments can improve overall treatment efficacy
- Arrange a follow up review at six to eight weeks after field treatment has ended to ensure inflammation has reduced
- Discuss good sun protection behaviours (including correct sunscreen application) at every opportunity
- Advise patients that lesions still visible at follow-up are unlikely to disappear and require further investigation to rule out malignancy, e.g. dermatoscopy, biopsy. Definitive treatment may be indicated.
- Regular follow-up should be arranged, e.g. skin examinations every 6 – 12 months
Ayesa C. A pragmatic primary care approach to the patient with significant solar damage. Aust J Gen Pract 2024;53:547–53. doi:10.31128/AJGP-02-24-7159.
For further information on the management of non-melanoma skin cancer, see: https://bpac.org.nz/BPJ/2013/December/skincancer.aspx
For further information on the use of fluorouracil and imiquimod in primary care, see: https://bpac.org.nz/2017/skin-cancer.aspx
For further information on the detection and prevention of melanoma, see: https://bpac.org.nz/2021/melanoma-detection.aspx and https://bpac.org.nz/2020/melanoma.aspx
This Bulletin is supported by the South Link Education Trust
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