Published: 20th September, 2024
Contents
New from bpacnz: Unintentional misuse of prescription medicines
Patients prescribed sedative hypnotics, opioids, gabapentinoids and other pain medicines long term has become a significant issue for primary care. It can be challenging to withdraw medicines that have been taken for many months or years, and to recognise that use has become problematic in the first place.
In most cases, people do not set out to misuse medicines that are prescribed to them. It may begin with taking an occasional extra dose, taking two tablets instead of one or taking an “as needed” medicine regularly regardless of symptoms, but over time neurological changes occur, and control is lost over these decisions. The medicine is then perceived as a necessary means to function day to day and the person becomes trapped in a cycle of misuse.
Following a set of guiding principles for prescribing medicines that have a higher potential for misuse, and regularly assessing goals of treatment, can help to prevent this problem. However, even with careful prescribing practices, some patients still inevitably misuse their medicine.
This article covers the prevention, identification and management of medicine misuse in primary care. Click here to view the B-QuiCK summary. Tapering summaries are also available for opioids, benzodiazepines/zopiclone and gabapentinoids.
Coming soon: Recovery at Work – Reframing the conversation
Injury assessments are a routine aspect of practice for primary care clinicians. Depending on the nature of the injury and patient factors, there may be minimal disruption on a patient’s daily life, including their ability to engage in work. However, in some cases, injuries can have a more significant impact on functional capacity, and consideration must be given towards work capacity and associated decisions around medical certification.
Reintegrating into the workplace is considered an essential step in the recovery trajectory. However, recent evidence suggests many injured patients are being signed off for too long, potentially compromising long-term outcomes. In the same way that medicines must be prescribed at the right dose and for the right duration, so too must time off work.
With support from the Accident Compensation Corporation (ACC), we will soon be publishing a comprehensive resource relating to the “Recovery at Work” initiative. This aims to enhance primary care clinicians’ understanding of medical certification definitions, support decision-making and outline the important elements of Recovery at Work, including rehabilitation services.
How confident do you feel in navigating the recovery at work process with patients? Do you think you always strike the right balance when “prescribing” time off work, while still helping patients stay functionally engaged as they recover? What are some of the main challenges?
Pharmac medicine funding proposals for ADHD, RSV and COPD
Lisdexamfetamine for ADHD and removal of Special Authority renewal requirements for stimulant medicines
Pharmac has released a proposal to fund lisdexamfetamine (Vyvanse) from 1st December, 2024, for patients with ADHD who meet Special Authority criteria. Lisdexamfetamine is a prodrug of dexamfetamine, which means it has a controlled, gradual release of the active drug, therefore is taken once daily (as opposed to dexamfetamine which is taken several times daily). It is indicated for treatment of ADHD in adults and children aged six years and over. Lisdexamfetamine has a lower potential for misuse and diversion than dexamfetamine due its pharmacokinetic and prodrug properties, but a cautious approach to prescribing must still be taken.
Funding lisdexamfetamine is expected to help in easing supply constraints on ADHD medicines, and it provides patients with ADHD another option if other medicines are not suitable or appropriate. Read more about the proposal here. Consultation closes Thursday, 26th September.
In a separate consultation, Pharmac has also proposed that from 1st December, 2024, renewal requirements for stimulant medicines methylphenidate, dexamfetamine and modafinil, would be removed.* Currently, most patients taking these medicines require specialist review every two years to renew their Special Authority for funded access to continue. Annual review is required for children aged under five years. Removing this requirement is anticipated to reduce costs for patients and wait times to access secondary care; primary care prescribers would continue to manage ongoing prescribing and seek specialist advice as needed. Read more about the proposal here. Consultation closes Thursday, 3rd October.
* Patients with an existing or recently expired (within two years) Special Authority approval for these medicines would be issued a valid approval without needing further renewal
We encourage our readers to submit feedback, given the impact these changes will have on primary care. An associated news release for these two proposed changes is available here.
Palivizumab for RSV and budesonide with glycopyrronium and formoterol for COPD
Pharmac is seeking feedback on a proposal to fund medicines for the prevention of RSV and the management of COPD. This consultation also includes a proposal to fund osimertinib for non-small-cell lung cancer and trastuzumab deruxtecan for HER-2 positive metastatic breast cancer. Consultations close on Monday, 7th October.
It is proposed that from 1st January, 2025:
- Palivizumab (Synagis), a humanised monoclonal antibody (administered as an IM injection), would be funded for the prevention of severe illness from RSV in infants and young children at high risk of RSV who meet Special Authority criteria. It was previously funded during the RSV season in 2022 and 2023.
- Budesonide with glycopyrronium and formoterol (Breztri Aerosphere) triple medicine inhaler would be funded for patients with moderate to severe COPD who meet Special Authority criteria
- This would provide another triple medicine inhaler option in addition to the newly funded Trelegy Elipta (fluticasone furoate with umeclidinium and vilanterol); as reported in Bulletin 97. A single triple medicine inhaler means that patients only need to use one inhaler to achieve combination treatment (instead of two or three), which may improve treatment adherence.
- For further information on the management of COPD in primary care, see: https://bpac.org.nz/2020/copd.aspx. The bpacnz COPD prescribing tool is also available here.
An associated news release is available here.
*New* - fexofenadine to be funded, adding another antihistamine option
Pharmac have announced today, 20th September, that they have made a decision to fully fund two strengths of the Fexaclear brand of fexofenadine hydrochloride from 1st February, 2025. At present the 60 mg and 120 mg formulations (Telfast) are partly funded and the 180 mg strength (all brands) is not funded. From 1st February, 2025, both the 120 mg and 180 mg tablets of the Fexaclear brand will be fully funded. The 60 mg tablet (Telfast) will continue to be partly funded. The Telfast brand of 120 mg fexofenadine hydrochloride tablets will be delisted from 1st July, 2025. Read more here.
Decision to widen access to ferric carboxymaltose and aripiprazole injections
A decision has been made following consultation on the proposal by Pharmac to widen access to ferric carboxymaltose for patients with chronic inflammatory disease who have anaemia, and aripiprazole depot injection for schizophrenia and other psychotic disorders (as reported in Bulletin 103).
From 1st November, 2024, funded access to:
- Ferric carboxymaltose (administered via intravenous infusion or injection) will be widened to include people with chronic inflammatory disease and symptoms of anaemia who meet eligibility criteria; see bulletin 103 for further discussion
- Aripiprazole depot injection for schizophrenia will also be widened. The Special Authority criteria initially proposed have been updated to include people with other psychotic disorders as well as schizophrenia and the criterion relating to metabolic syndrome has been removed.
As part of this decision, access to methylnaltrexone bromide for opioid-induced constipation (hospital) and funded biologics, including adalimumab, etanercept, secukinumab and infliximab, for severe chronic localised genital or flexural plaque psoriasis will also be widened.
An associated news release is available here.
N.B. Widened access to immunotherapies for cancer: A decision has also been made following consultation on the proposal by Pharmac to widen access to pembrolizumab (Keytruda) from 1st October, 2024, and nivolumab (Opdivo) from 1st November, 2024, for six types of cancer (as reported in Bulletin 103).
Reminder: funding of rapid antigen test for COVID-19 ends this month
The funding of rapid antigen tests (RATs) for COVID-19 testing ends on 30th September, 2024. From October, RATs will only be available for purchase from the commercial market (for healthcare providers), pharmacies and some retail stores, e.g. supermarkets (for the public).
Reminder: COVID-19 continues to circulate in the community, and testing using a RAT is still recommended by Health New Zealand, Te Whatu Ora. A patient handout on managing at home with COVID-19 is available here. A handout on information for managing seasonal viral illness (“Cold & Flu”) is also available.
New mpox cases and vaccination update
The number of mpox cases in New Zealand is increasing, linked to the Winter Pride Festival in Queenstown (22nd Aug – 1st Sept); as of 12th September, five cases have been confirmed. Current cases have tested positive for clade II mpox virus (not associated with the clade I outbreak in Africa, that causes more severe disease). The National Public Health Service has released a new update on mpox, and is asking healthcare professionals to be alert for potential cases. Mpox may be suspected in patients presenting with flu-like symptoms and acute, unexplained skin and/or mucosal lesions or proctitis (e.g. anorectal pain, bleeding). Notify the local public health service on suspicion of mpox.
Mpox vaccination
The mpox vaccine, Jynneos, has been available since 2023 to prevent mpox in people at high risk. It is also recommended as post-exposure prophylaxis for people who have been in contact with a confirmed mpox case in the previous 14 days (but ideally within four days of exposure). Jynneos has now been granted provisional consent by Medsafe. Recommendations for key groups of people at risk of mpox and those who will likely benefit from vaccination is expected to be reviewed.
Principles for quality and safe prescribing
A joint set of prescribing principles have recently been developed by a range of authorities that regulate health practitioners who prescribe in New Zealand, including the Medical Council of New Zealand, Pharmacy Council, Nursing Council of New Zealand and the Dental Council.
The 12 principles aim to provide consistent prescribing guidance that applies to all prescribers, regardless of their profession or practice setting:
- Assess the person
- Consider the options
- Present options
- Prescribe
- Inform
- Monitor effectiveness and safety of treatment and review options
- Practise equitably
- Prescribe safely
- Ensure adequate record keeping
- Prescribe professionally
- Encourage quality improvement
- Collaborate
These principles are already included in the Medical Council’s statement on Good prescribing practice, therefore, the Principles for Quality and Safe Prescribing Practice have not been adopted as Council standards.
A media release is available here.
Mental Health Awareness Week (23rd – 29th September)
Next week (23rd – 29th September) is Mental Health Awareness Week. The theme for this year is “community is…what we create together”. As part of this, people are encouraged to carry out a community-based task for each day of the week:
- Monday: Do an act of kindness
- Tuesday: Support an independent merchant or community organisation
- Wednesday: Connect with an important person in your life
- Thursday: Get to know someone new in your community
- Friday: Express gratitude to someone in your community
The Ministry of Health, Manatū Hauora, is seeking feedback on the Suicide Prevention Action Plan for 2025 – 2029, which contains a range of strategies, initiatives and actions to contribute towards suicide prevention. The first action plan was released in 2019, and is due to expire this year. Consultation closes Friday 1st November, 2024.
In Brief: New NHI format from July, 2026
A new format for the National Health Index (NHI) will be introduced for people using the healthcare system for the first time from 1st July, 2026, i.e. newborn infants and new arrivals to New Zealand. This timing replaces the previously announced date of 1st October, 2025. People with an existing NHI number will not be changed to the new format.
The current NHI format is AAA111# (three letters and numbers, followed by a special single number, e.g. ABC1234). The new format will change to AAA11A# (three letters, two numbers, one letter and one special single letter, e.g. ABC12AB), allowing for greater capacity for unique identifiers and efficiency of patient identification. Click here for further information.
Medical aspects of fitness to drive webinar recording
As reported in Bulletin 106, RNZCGP Medical Director, Dr Luke Bradford, recently hosted a webinar with NZTA panellists to explain proposed changes to the NZTA Medical aspects of fitness to drive: a guide for health practitioners. If you missed it, you can view a recording of the webinar here.
Reminder: The consultation on proposed changes closes Friday, 27th September. You can submit feedback directly to NZTA, here.
The Medical Factorium: Why do joints or old injuries ache when it’s cold?
Every now and then, patients ask “why?” and the answer eludes us. In this occasional bulletin segment, we attempt to answer some of those curious questions.
Situation: You’ve woken up on a cold morning or the wind has changed outside and suddenly that old injury or a particular joint begins to ache. What causes this and why does it happen so many years after the injury supposedly healed?
Read more
As expected, there is no clear answer. The most common theory relates to low barometric pressure. The drop in air pressure associated with the change in weather can cause expansion of soft tissues and fluid around joints. This can lead to joint stiffness and nerve irritation and therefore, pain. See Arthritis NZ and Merivale Hand Clinic for further information.
Another theory is that scar tissue may become less “pliable” in the cold, which can lead to increased tension around the site of injury and pain. Local vasoconstriction in response to cold weather may also influence inflammation and discomfort. In addition, being sedentary in cold weather may result in inactive joints and contribute to stiffness and pain.
Some studies have shown no connection between weather changes and joint pain, while others have shown associations with both low and high barometric pressure.
Click here to view the previous Medical Factorium: why do athletes yawn before competing?
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
Podcast of the Week: Hidradenitis suppurativa
A recent episode of The Good GP, an Australian podcast series, discusses hidradenitis suppurativa (HS; also known as acne inversa), a chronic autoinflammatory skin condition that affects apocrine gland-bearing skin. HS is particularly distressing for patients and can negatively impact their mental health and body image. Primary care clinicians can recommend patients make certain lifestyle interventions, e.g. avoidance of triggers (e.g. friction), smoking cessation, maintain a healthy weight, diet (e.g. avoid high fat and high sugar diets). Patients with excessive sweating may benefit from Botox injections. Antiseptic washes, antibiotics (topical and oral) and anti-androgen therapy (e.g. spironolactone, cyproterone-containing oral contraceptive pill) are usual management options. In severe cases, intralesional steroid injections, deroofing surgery and biologic treatments (e.g. adalimumab) may be considered.
Listen to the full podcast here (23 minutes)
Correspondence: Paper of the week - TCAs for IBS?
In Bulletin 107, we reviewed a study investigating patient and clinician opinions about use of amitriptyline for irritable bowel syndrome (IBS). bpacnz received a comment from a reader that many people with IBS are lactose intolerant, and as lactose is an excipient in amitriptyline and nortriptyline tablets, these medicines could actually worsen IBS symptoms. The availability of a liquid formulation was also queried. This comment raises an interesting point about excipients in medicines and the role they play.
In general, the lactose content in medicines is not enough to cause symptoms in most people with lactose intolerance, unless their intolerance is very severe.
Read more
Guidance from the Christchurch Medicines Information Service states that generally most medicines do not contain sufficient lactose to produce symptoms in the majority of people (unless severely lactose intolerant).1 Several reviews have also highlighted that the minimal lactose content in medicines can usually be tolerated, but prescribing these medicines to patients who are lactose intolerant should be done with caution due to the variable amount of lactose and unpredictable individual response.2, 3 Data sheets for tricyclic antidepressants (TCAs) in New Zealand do not state the amount of lactose contained in the formulations. Other medicines, e.g. naproxen and the funded brands of loperamide tablets and capsules (sometimes prescribed for IBS), also contain lactose as an excipient.
A liquid formulation of amitriptyline or nortriptyline would be an appropriate option for patients with lactose intolerance and these are available overseas, however, there is no liquid formulation for any TCA currently approved or available in New Zealand.
It is likely that most patients with IBS will tolerate lactose in the available TCA tablets, but caution is recommended, especially in patients with more severe symptoms. Clinicians should discuss the benefits and risks with the patient before initiating treatment, start slowly and monitor closely for adverse effects.
References
- Christchurch Medicines Information Service. Gluten and lactose in medicines. 2021. Available from: https://www.medicinesinformation.co.nz/wp-content/uploads/2021/09/Gluten-and-Lactose-in-Medicines.pdf (Accessed Sep, 2024).
- Drug and Therapeutics Bulletin. Medicines, excipients, and dietary intolerances. BMJ 2017;:j3468. doi:10.1136/bmj.j3468.
- Figueiredo A, Auxtero MD, Santo M, et al. Risks of dairy derived excipients in medications for lactose intolerant and cow milk protein allergic patients. Sci Rep 2024;14:15631. doi:10.1038/s41598-024-66380-8.
Paper of the Week: Protein intake and chronic kidney disease?
The relationship between protein intake and mortality risk in older adults in the general population is unclear. A moderate daily intake of 1.0 – 1.2 grams of protein per kilogram of bodyweight per day (g/kg/day) in older adults may be beneficial for overall health, reducing skeletal muscle loss and aiding recovery from illness. For example, a 70 kg adult should consume between 70 – 84 g of protein per day to meet this recommendation (information on the protein content of common food items is available here). In contrast, increased protein consumption has been shown to negatively affect glomerular filtration and accelerate renal function decline in people with chronic kidney disease (CKD); recently published guidelines recommend people with CKD do not exceed a protein intake of 1.3 g/kg/day and those with severe disease (i.e. CKD stages G3–G5) should not exceed 0.8 g/kg/day. The evidence supporting low protein diets in older adults with mild-to-moderate CKD is, however, unclear, as is the understanding of how plant protein influences kidney function (in comparison to animal protein).
A study published in JAMA Network Open evaluated the impact of protein intake (including total protein, animal and plant protein), on mortality in older people with mild-to-moderate CKD. Participants who consumed 1.0 g/kg/day of protein had a 12% lower mortality risk after ten years compared to those consuming 0.8 g/kg/day. This risk reduction for mortality increased to 21% at a protein intake of 1.2 g/kg/day and 27% at 1.4 g/kg/day. This effect was comparable regardless of protein source or participant age. These results highlight the importance of discussing dietary protein with older patients and that decreasing protein intake may not be appropriate unless a diagnosis of severe CKD has been established (and should only be carried out under nephrologist/dietitian supervision).
Is protein intake something you discuss with patients who have CKD? Do patients with CKD ask about the possible benefits of reducing protein intake, or animal vs plant protein? What other lifestyle advice do think influences CKD progression?
Read more
- This observational study involved 8,543 participants aged 60 years and over with and without CKD stage 1 – 3. People with CKD stage 4 or 5 were excluded.
- Participants were observed at baseline and up to two to three follow-ups
- Annual dietary history and food composition tables were used to establish average total daily protein intake and protein source, i.e. animal or plant protein
- National death registries were used to assess ten-year all-cause mortality. There were 1,468 deaths over the follow-up period.
- Among participants with mild-to-moderate CKD, increased protein consumption was associated with lower mortality. The risk of mortality was 12% lower after ten years in participants who consumed 1.0 g/kg/day (total) of protein compared with those who consumed 0.8 g/kg/day (hazard ratio [HR] = 0.88, 95% confidence interval [CI] = 0.79 – 0.98). Compared to protein intake of 0.8 g/kg/day, this effect increased across all levels of daily protein intake that were evaluated:
- 21% risk reduction at 1.2 g/kg/day (HR = 0.79, 95% CI = 0.66 – 0.95)
- 27% risk reduction at 1.4 g/kg/day (HR = 0.73, 95% CI = 0.57 – 0.92)
- 33% risk reduction at 1.6 g/kg/day (HR = 0.67, 95% CI = 0.51 – 0.89)
- These associations were comparable between participants consuming animal or plant-based proteins (HR = 0.80, 95% CI = 0.65 – 0.98 vs HR = 0.88, 95% CI = 0.81 – 0.95) and participants aged under 75 years and those aged 75 years and over (HR = 0.9, 95% CI = 0.85 – 1.04 vs HR = 0.91, 95% CI = 0.85 – 0.98)
- The authors concluded that the benefits of increased protein consumption may outweigh the risks in older adults with mild-to-moderate CKD. This was based on the association with low mortality being more pronounced in participants without CKD.
- Limitations of this study include different tools being used to measure dietary intake/record diet history between the cohorts, eGFR measurements not being available for all participants and the possibility that some patients may have received medical direction to limit their protein intake outside of the study
- In practice, this study suggests older adults with mild-to-moderate CKD should not be limiting their protein intake and that advising patients to maintain the recommended daily protein consumption may reduce overall mortality in this patient group
Carballo-Casla A, Avesani CM, Beridze G, et al. Protein intake and mortality in older adults with chronic kidney disease. JAMA Netw Open 2024;7:e2426577. doi:10.1001/jamanetworkopen.2024.26577.
For further information on dietary protein including examples of the protein content of common food items, see: https://nutritionfoundation.org.nz/nutrition-facts/nutrients/protein/
For further information on the management of CKD, including a discussion on low protein diets, see: https://bpac.org.nz/2022/ckd.aspx
This Bulletin is supported by the South Link Education Trust
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