Published: 4th October, 2024
Contents
In case you missed it: 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. 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, including tapering summaries for opioids, benzodiazepines/zopiclone and gabapentinoids. Read the full article here. A B-QuiCK summary is also available here.
Has this resource increased your knowledge about managing patients who have been taking escalating doses of opioids or other medicines? Would you feel confident initiating a slow tapering protocol in primary care? Email us with any feedback or specific scenarios you would like to share: editor@bpac.org.nz
Medicine funding decisions: oestradiol gel, fosfomycin
A decision has been made following consultation on proposals by Pharmac to fund oestradiol transdermal gel and widen access to fosfomycin in the community (as reported in Bulletin 104).
From 1st November, 2024:
- Oestradiol gel (Estrogel, 0.6 mg/g, 0.75 mg/actuation) will be funded without restriction. Oestradiol is indicated for use in menopausal hormone therapy and post-menopausal osteoporosis prophylaxis. It may also be used for oestradiol-based gender affirming hormone therapy and for premature ovarian insufficiency (unapproved indications). Oestradiol is also available in patches and tablets. See the NZF for dosing information.
- Given the ongoing supply issues affecting oestradiol patches, the availability of oestradiol gel will provide people who take oestradiol with another funded option
- For further information on menopausal hormone therapy, see: https://bpac.org.nz/2019/mht.aspx
- Fosfomycin (UroFos, 3 g sachet of powder, dissolved in half a glass of water; single dose) will be funded with Special Authority approval for patients with an acute, symptomatic, bacteriologically-proven uncomplicated urinary tract infection/cystitis with Escherichia coli if the bacteria is resistant to, or the patient has a contraindication or intolerance to, all of the following antibiotics: trimethoprim, nitrofurantoin, amoxicillin, cefalexin, cefaclor, amoxicillin with clavulanic acid and norfloxacin. Fosfomycin powder was previously only funded for use in a hospital setting. See the NZF for dosing information.
Medicine supply news: atorvastatin, omeprazole, oestradiol patches, latanoprost with timolol
The following news relating to medicine supply, of particular interest to primary care, has recently been announced. These items are selected based on their relevance to primary care and where issues for patients are anticipated, e.g. 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.
Atorvastatin temporarily moved to monthly dispensing
Dispensing of atorvastatin (Lorstat) 10 mg, 20 mg and 40 mg tablets was temporarily switched to monthly (from 1st October) to avert a possible supply issue affecting 20 mg tablets. However, the supply issue has now been resolved, and stat dispensing is expected to resume from 1st November, 2024.
Omeprazole: new look
The supplier (Teva) has advised of a change in capsule colour and packaging of omeprazole. These changes will occur once existing stock has been exhausted; it is currently expected that the new look omeprazole 20 mg and 40 mg capsules will be supplied in October, 2024, and the 10 mg capsules in March, 2025.
Advise patients taking these tablets that the packaging and capsules will look slightly different but reassure them that there has been no change to the formulation, manufacturer or manufacturing method. A patient information sheet is available here.
Lyllana oestradiol patches now Medsafe approved
Lyllana oestradiol patches have been funded since July, 2024 (as reported in Bulletin 103). Originally, these patches needed to be prescribed for supply under Section 29 of the Medicines Act 1981 as they were not approved by Medsafe. Lyllana patches have now been approved by Medsafe, and can be prescribed by any relevant prescriber.
Latanoprost with timolol (Arrow-Lattim) eye drops out of stock
Pharmac has advised that latanoprost with timolol (Arrow-Lattim) eye drops, used in the treatment of glaucoma, are out of stock due to manufacturing delays. It is not currently known when supply will resume. Alternative products are available, but patients will require two prescriptions, one for latanoprost eye drops and one for timolol eye drops.
NZF updates for October + tips about glucose monitors
Significant changes to the NZF in the October, 2024, release include:
- Severe cardiac failure removed as a contraindication for aspirin. Cardiac failure and other conditions that predispose to fluid retention (doses > 300 mg/day) have been added as a caution.
- Dosing regimen for ADHD updated in the lisdexamfetamine monograph (Pharmac is currently seeking feedback on a proposal to fund lisdexamfetamine from 1st December, 2024; read more here)
- Updates to the therapeutic notes of removal of ear wax, including wax softeners
- Updates to the contraindications for tranexamic acid
You can read about all the changes in the October release here. Also read about significant changes to the NZF for Children (NZFC), here.
NZF practice highlight – glucose monitors
The NZF team discuss tips for prescribing and dispensing subcutaneous insulin pumps and continuous glucose monitoring (CGM) systems now that access to these products has been widened since 1st October (as reported in Bulletin 107):
- Any prescriber involved in the care of patients with diabetes can apply for a Special Authority and prescribe for all CGMs. They can also continue to prescribe for insulin pump consumables once pump therapy is commenced.
- Prescribe using brand names to ensure patients are dispensed the correct product
- Subcutaneous insulin pumps are recommended by the NZSSD to be started within a secondary care multidisciplinary diabetes service
Further guidance is available from the NZF on CGMs and subcutaneous insulin pumps. A podcast is also available from the Goodfellow Unit: https://www.goodfellowunit.org/podcast/diabetes-technology.
Breast Cancer Awareness Month
October is Breast Cancer Awareness Month. Breast cancer is the most common cancer diagnosis among females in New Zealand and accounts for more than 600 cancer deaths per year. Males can also be diagnosed with breast cancer in rare cases. Take this opportunity to encourage patients to perform regular self-checks, and to book a consultation if there are any concerns.
The overall ten-year survival rate for females diagnosed with breast cancer if a lump is the first sign is 85%, and this rises to 95% if breast cancer is detected via mammogram screening. Check that your practice has a system in place to invite eligible patients to participate in the national breast screening programme (BreastScreen Aotearoa). Remind female patients aged between 45 and 69 years that they are eligible for free mammogram screening every two years, tell them how to enrol in the programme and record their breast screening status in their clinical notes. Patients can phone BreastScreen Aotearoa (0800 270 200) to book a mammogram or self-enrol here.
For further information on BreastScreen Aotearoa, see: https://www.tewhatuora.govt.nz/health-services-and-programmes/breastscreen-aotearoa
Legionnaires’ disease: not to be forgotten
Health New Zealand, Te Whatu Ora, is reminding people to be aware of the risk of Legionnaires’ disease associated with the inhalation of Legionella bacteria from bags of compost and potting mix. There have been 108 confirmed cases of Legionnaires’ disease this year; case numbers have been trending upwards in recent years.
Ask about recent history of potting mix or compost exposure in patients presenting with symptoms and signs of pneumonia. Gastrointestinal effects may be more prominent in patients with Legionella pneumonia than with other causes of pneumonia. Legionnaires’ disease (i.e. Legionellosis) is notifiable on suspicion.
Read more
Legionella species are often associated with more severe, sometimes fatal, cases of pneumonia. Legionella pneumonia is most common in warmer months (although it can occur at any time) and is particularly associated with recent use of potting mix or compost (usually L. longbeachae) or exposure to a contaminated water source (usually L. pneumophila), e.g. spa pools, rainwater tanks, air conditioning systems. Risk factors for Legionella pneumonia include older age (aged > 50 years), smoking, chronic respiratory disease and immunosuppression.
Preventing Legionnaires’ disease when handling compost
To prevent Legionella infection when handling compost or potting mix, patients can be advised to:
- Work in a well-ventilated outdoor area
- Wear a face mask and gloves
- Open bags away from their face using scissors
- Dampen down the product before using it to reduce dust
- Wash their hands after use, before touching their face or removing their face mask
Patient information on Legionnaires’ disease is available from: https://info.health.nz/conditions-treatments/lungs/legionnaires-disease-legionellosis
Legionnaires’ disease was first identified after an outbreak of illness and deaths among attendees (Legionnaires) of the American Legion conference in Philadelphia in 1976. An investigation found that the source of illness was bacteria in the hotel’s air conditioning system. The bacterial genus was subsequently named Legionella.
For further information on community-acquired pneumonia, including Legionella pneumonia, see: https://bpac.org.nz/2024/pneumonia.aspx
ACC “Fit for selected work” new patient resource
ACC has published a new resource for healthcare professionals to provide to patients who have received a “Fit for selected work” medical certification. This resource is intended to support patients to understand this category of medical certification, including the benefits, why they are not “Fully unit” and how to access support, e.g. weekly compensation. Click here to view the resource.
Keep an eye out for our upcoming resource: Recovery at Work – Reframing the conversation, developed 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.
Long-term outcomes in people with myocarditis/pericarditis following COVID-19 vaccination
Health New Zealand, Te Whatu Ora, has released the findings from a study into the long-term outcomes of people with myocarditis and pericarditis following COVID-19 vaccination with the Comirnaty vaccine. Myocarditis and pericarditis are rare adverse effects reported after COVID-19 vaccination; these cardiac effects can also be caused by COVID-19 and other viral infections.
In 2022, Medsafe commissioned Health New Zealand, Te Whatu Ora, to undertake a survey of people diagnosed with myocarditis and/or pericarditis in New Zealand following Comirnaty vaccination to determine long-term outcomes, e.g. physical and mental health, social impact. Participants could also nominate their healthcare provider to be surveyed, e.g. about diagnosis, recovery, cardiac testing and prescribed medicines. The study was not designed to determine whether vaccination was the cause of, or related to, myocarditis/pericarditis.
Myocarditis and pericarditis had a significant impact on respondents, including their physical and mental health, and aspects of daily life. An ECG and serum troponin were the most commonly requested investigations, and colchicine and ibuprofen the most frequently prescribed medicines.
Read more
- People aged 12 years and over, who had received at least one dose of the Comirnaty vaccine, had been diagnosed with myocarditis or pericarditis at least 90 days following vaccination, and had reported their clinical diagnosis to CARM were eligible for this study. The survey was conducted from March to October, 2022.
- A total of 289 people participated (62% male; median age 36.5 years), of which 198 were diagnosed with pericarditis and 100 with myocarditis. The survey also included 161 healthcare providers.
- Chest pain was the most common physical symptom experienced by participants (96%); fainting was the least common (7%). Other physical symptoms surveyed were fatigue (86%), shortness of breath (84%), palpitations (79%) and dizziness (63%).
- Feeling nervous, anxious or on edge was the most common psychological symptom experienced by participants (70%); not being able to stop or control worrying was the least common (43%). Other psychological symptoms surveyed were feeling down, depressed or hopeless (56%) and having little interest or pleasure in doing things (49%).
- An ECG was the most commonly requested investigation by healthcare providers at the time of diagnosis, followed by serum troponin, an echocardiogram and cMRI
- Results were normal for the majority of participants who had their serum troponin measured or who had an echocardiogram
- Results were abnormal for over half of participants who had an ECG (55%) or a cMRI (79%)
- In order of frequency, the types of prescribed medicines to participants were: colchicine, ibuprofen, other medicines, other NSAID, beta blocker, corticosteroid, ACE inhibitor, ARB and diuretic
- More than half of healthcare providers (56%) considered that their patient had recovered from myocarditis/pericarditis
- Chest pain was the most frequent ongoing symptom (reported by 59% of participants), closely followed by fatigue (54%)
View the full report here. A summary of the findings is also available here.
Upcoming webinars: mastitis, adolescent vaccination
Adolescents and vaccination. IMAC is hosting a webinar on approaching the conversation of vaccination with adolescents, including how to engage and connect, with a particular focus on meningococcal vaccination and HPV. The webinar will be held on Tuesday, 8th October, from 12.15 – 1.15 pm. Register here.
Mastitis. HealthPathways is hosting a webinar on mastitis: “Rethinking Mastitis: Guideline changes and treatment options”. This free webinar is aimed at providers of primary and urgent care and will cover updated assessment techniques, management strategies, and breastfeeding and pumping advice and support. The webinar will be held on Wednesday, 6th November from 7 – 8 pm. Register here (a certificate of attendance and CPD points are available).
Medicines Adverse Reactions Committee (MARC) vacancy
Medsafe is currently seeking an epidemiologist/biostatistician to join the Medicines Adverse Reactions Committee (MARC). MARC is an independent expert advisory group that provides recommendations to the Minister of Health regarding adverse effects of medicines to promote their safe use in New Zealand. MARC meets four times per year and the committee appointment is for a three-year term (with the option of a second three-year term).
Further information on required applicant experience and qualifications, as well as how to submit an application can be found here. Applications close 30th October, 2024.
For further information on the role of MARC, see: www.medsafe.govt.nz/committees/marc.asp
Paper of the Week: Are you having a laugh? The best medicine for dry eyes
Dry eye syndrome, or keratoconjunctivitis sicca, is a common ocular condition that occurs when the tear film that maintains optimal ocular moisture and lubrication is disrupted. Deficiency or dysfunction of tear production can result in a feeling of dryness and irritation, which can worsen throughout the day. This condition can be extremely frustrating for people who experience it.
Standard treatment involves regular use of artificial tears and managing lifestyle factors that may exacerbate symptoms, e.g. screen time. However, a potential link between symptoms of dry eye syndrome and mental health, especially anxiety and depression has also been identified, therefore other treatment modalities warrant investigation. Laughter is, as they say, the best medicine, and it has been shown to have a beneficial effect in patients with higher levels of anxiety, depression, chronic pain and stress. Given the possible correlation between negative emotions and dry eye syndrome, could laughter improve ocular symptoms? Laughter itself may also stimulate lubrication of the eyes.
A study published in the British Medical Journal evaluated the efficacy of laughter exercise in patients with symptomatic dry eye syndrome. It was found that compared to conventional treatment with artificial tears, regular laughter resulted in similar improvements in the symptoms of dry eye disease. After eight weeks, the mean reduction in ocular surface disease index, a measure of ocular discomfort where higher scores imply more severe symptoms, was -10.5 points for laughter exercises compared to -8.8 points for the control. The investigators highlighted that the safety profile and low-cost of this intervention make laughter exercises an appealing first-line treatment option for managing symptoms of dry eye syndrome. In practice, prescribing structured laughter exercises may not be feasible, however, making patients aware of the potential link between laughter and dry eye disease may help them to improve their symptoms though self-directed laughter interventions – funny cat videos may be a good place to start!
Have you ever suggested laughter to a patient as an adjunct treatment for any condition?
Read more
- This randomised controlled trial was conducted at a large ophthalmic centre in southern China and involved almost 300 participants aged between 18 and 45 years, of which three-quarters were female
- Medical history and symptom assessment (using the ocular surface disease index, a measure of symptom severity with scores from 0 – 100, with 100 being most severe) occurred in screening prior to the study. Participants were included if they had an ocular surface index score between 18 and 80 points and a fluorescein tear film breakup time of no more than 8 seconds.
- Participants were randomised to receive either 0.1% sodium hyaluronic acid eye drops or laughter exercises. Both interventions were administered four times daily, for eight weeks.
- The laughter exercise intervention involved a five-minute session where an instructional video was viewed and participants recited phrases, e.g. "Hee hee hee, hah hah hah, cheese cheese cheese, cheek cheek cheek, hah hah hah hah hah hah" up to 30 times
- Adherence for both groups was supported by a mobile app that sent reminders, allowed participants to log their treatments and prompted catch up of missed treatments
- Mean change from baseline in ocular surface disease index score after eight weeks was the primary outcome
- Non-inferiority was defined as ≤ 6 points difference in ocular surface disease index between intervention and control groups after eight weeks
- Participants underwent assessment after seven days of treatment, then 14 days, then fortnightly until 12 weeks. Both intervention and control treatments were stopped after eight weeks.
- Ocular surface disease index scores reduced by 10.5 points (95% confidence interval [CI]: −13.1 to −7.8) in the laughter exercise group and by 8.8 points (95% CI: −11.7 to −6.0) in the control group, after eight weeks of treatment
- Over this period, the laughter exercise group also experienced a more significant improvement in the non-invasive tear breakup time compared to the control group (mean between-group difference, 2.30 seconds; 95% CI: −1.3 to −3.3; P < 0.001)
- Notably, no participants reported adverse events in either of the study groups over the study period
- The physiology underlying how laughter results in improved dry eye symptoms is not well understood but may involve autonomic nervous system stimulation, increased contraction of the orbicularis muscle or promotion of oxytocin secretion
Li J, Liao Y, Zhang S-Y, et al. Effect of laughter exercise versus 0.1% sodium hyaluronic acid on ocular surface discomfort in dry eye disease: non-inferiority randomised controlled trial. BMJ 2024;:e080474. https://doi.org/10.1136/bmj-2024-080474.
For further information on the management of dry eye syndrome and other ocular conditions associated with "red eye", see: https://bpac.org.nz/BPJ/2013/August/redeye.aspx
This Bulletin is supported by the South Link Education Trust
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