Published: 15th November, 2024
Contents
In case you missed it - Recovery at work: Reframing the conversation
You wouldn’t prescribe opioids without ensuring the dose, frequency and duration are appropriate – so shouldn’t the same principles apply to prescribing time off work? Current evidence suggests that many injured patients are spending more time away from the workplace and taking longer before they return to normal work hours or tasks. Prescribing too much time off work can detrimentally affect health, vocational and social outcomes, without providing any added benefit to recovery, in the same way that inappropriate prescribing of medicines can.
bpacnz has recently published a comprehensive guide for supporting primary care clinicians to help patients navigate the ACC Recovery at Work process, including considerations when conducting an initial medical certification consultation, medical certificate definitions, as well as the ACC-mediated supports available if further assistance is required.
Read the full article here. A B-QuiCK summary is also available.
Have your say: In the previous bulletin we asked for your feedback on aspects of the ACC Recovery at Work framework to incorporate into upcoming CPD activities and a panel discussion. There is still time to contribute: send us your feedback (your details will not be shared). Email: editor@bpac.org.nz
New from bpacnz: medicine misuse peer group discussion + COPD tool minor update
We recently published an article covering the prevention, identification and management of medicine misuse in primary care, including tapering summaries for opioids, benzodiazepines/zopiclone and gabapentinoids. Withdrawing patients from these medicines, that in many cases have been taken for months or years, can be very challenging.
As a continuation of this theme, we have now released a series of questions that can be used as discussion points for peer groups or self-reflection of practice. You can also comment on these questions online using the comment feature or by sending your feedback to us, and we will post this anonymously online: editor@bpac.org.nz
View the peer group discussion here.
Also new from bpacnz: COPD prescribing tool updated to include triple medicine inhaler
Fluticasone furoate with umeclidinium and vilanterol (ICS/LAMA/LABA; Trelegy Ellipta), a triple medicine inhaler, has been funded with Special Authority approval for people who meet eligibility criteria, since May, 2024 (as reported in Bulletins 93 and 97). The triple medicine inhaler has now been added to the appropriate steps in the bpacnz interactive COPD prescribing tool. The triple medicine inhaler is emphasised in international guidelines; however, we will await any revision of New Zealand guidelines in accordance with the GOLD 2023 report before revising the bpacnz COPD prescribing tool in full. Special Authority approval criteria for the triple medicine inhaler currently requires patients to be stabilised on ICS/LABA or LAMA/LABA therapy first.
Calling all primary care education enthusiasts
Are you passionate about evidence-based medicine? Do you quote studies to your colleagues and wow them with your clinical facts? Do you care deeply about high quality, independent guidance and knowledge, firmly rooted in the New Zealand primary care context?
If you answered “Yes!” to all those questions, we want you! An exciting opportunity is available to become a member of B-PAP – the bpacnz Primary care Advisory Panel. We are looking for a diverse range of primary care clinicians to provide expert review and commentary on our clinical education resources and be part of the development process. This is a virtual position (no need to start browsing the Dunedin real estate market) and will involve between 0 – 6 hours per month of your time. Panel members will be sent draft resources to review, and can opt in or out, depending on availability and interest in the topic. You will receive remuneration for your time.
We are looking for approximately five B-PAP members and seek applications from general practitioners, nurse practitioners, practice nurses, pharmacist prescribers, community pharmacists, Māori and Pacific health providers and any other primary care clinicians. We encourage experienced voices along with those who are new to primary care.
If you are interested, send us an email with the following information:
- A brief bio of who you are: where you work, how long you have been in your position, what other roles you have done
- Your qualifications and any relevant academic and professional affiliations and memberships
- A sentence or two about why you would love to be a member of B-PAP
Applications close on Friday, 6th December. We look forward to selecting our panel!
Rebecca Harris, Editor, bpacnz Publications: editor@bpac.org.nz
Decision to widen access to empagliflozin for some patients with heart failure
A decision has been made following consultation on the proposal by Pharmac to widen access to the SGLT-2 inhibitor empagliflozin for people with chronic heart failure with a reduced ejection fraction (HFrEF; as reported in Bulletin 106). Previously, empagliflozin was only funded for people with type 2 diabetes who meet eligibility criteria.
From 1st December, 2024, funded access to empagliflozin will be widened to include people with heart failure who have NYHA class II – IV symptoms who are receiving concomitant optimal standard chronic heart failure treatments. The criteria 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. Evidence shows that SGLT-2 inhibitor treatment reduces the risk of hospitalisation for heart failure or cardiovascular death, irrespective of the patient’s diabetes status.
Special Authority applications can be made by any relevant practitioner and further application renewal will not be required at this stage. Concurrent funded treatment with empagliflozin (with or without metformin) and a GLP-1 receptor agonist* is possible for patients who meet the eligibility criteria for both heart failure and type 2 diabetes, respectively.
* Due to increased demand, worldwide supplies of GLP-1 receptor agonists are limited and as of May, 2024, no new patients can be initiated on funded dulaglutide or liraglutide in New Zealand.
Read more
There have been significant shifts in the approach to pharmacological management of HFrEF in recent years, with international guidelines now strongly advocating for the prompt initiation and optimisation of “guideline-directed medical therapy” (GDMT). GDMT includes treatment with:
- An angiotensin receptor-neprilysin inhibitor (ARNI; preferred) or an ACE inhibitor/ARB if this is not possible; and
- A beta blocker (either carvedilol, bisoprolol or metoprolol succinate); and
- A mineralocorticoid receptor antagonist; and
- A SGLT-2 inhibitor
These Special Authority changes now facilitate funded delivery of the final component of GDMT for patients with HFrEF in New Zealand.
The management of patients with heart failure with a preserved ejection fraction (HFpEF; includes patients with a LVEF ≥ 50%, and evidence of relevant structural heart disease and/or diastolic dysfunction with a high filling pressure) is more complex and typically directed by cardiologist advice. However, international guidelines strongly advocate for the use of a SGLT-2 inhibitor in all patients with HFpEF without contraindications. The current Special Authority criteria do not include patients with echocardiogram-confirmed HFpEF.
Watch this space: We will be updating our existing resources regarding the diagnosis and management of heart failure in the coming months.
Decision to fund lisdexamfetamine and remove Special Authority renewal requirements for stimulant medicines
A decision has been made by Pharmac, following consultation on proposals to fund lisdexamfetamine for ADHD and to remove Special Authority renewal requirements for stimulant medicines (as reported in Bulletin 108).
From 1st December, 2024:
- Lisdexamfetamine (Vyvanse) will be funded with Special Authority approval for patients with ADHD (approvals valid without further renewal). It is a prodrug of dexamfetamine and has a controlled, gradual release of the active medicine.
- The availability of lisdexamfetamine will provide patients who have ADHD with another funded option if they have not experienced adequate symptom improvement with other funded medicines, if supply issues are restricting access to another funded medicine (or they are not suitable), or if there is concern about the patient diverting or misusing other funded medicines.
- Special Authority renewal requirements for stimulant medicines will be removed. Patients prescribed methylphenidate, dexamfetamine and modafinil will no longer require specialist review every two years to renew their Special Authority to continue funded access to treatment. These changes apply to patients with an existing or recently expired (within two years) Special Authority approval. N.B. Lisdexamfetamine is to be listed without renewal criteria. Ongoing prescribing of stimulant medicines would be managed in primary care, with clinicians seeking specialist advice if required.
- Initiation criteria for dexamfetamine will be also aligned with methylphenidate as part of this change. This will allow nurse practitioners (in addition to medical practitioners) to submit a Special Authority application for dexamfetamine for patients with ADHD aged five years and over on the recommendation of a paediatrician or psychiatrist.
Education to support primary care clinicians in the management of patients with ADHD and other indications for ongoing prescription of stimulant medicines is planned.
New COVID-19 vaccine available early 2025
Medsafe has approved an updated COVID-19 vaccine by Pfizer, which targets the JN.1 strain, for use in people aged 12 years and older in New Zealand. The updated vaccine, Comirnaty JN.1, is expected to be available from early 2025. There are currently no changes to COVID-19 vaccine eligibility. In the meantime, the Pfizer Omicron XBB.1.5 vaccine remains available; continue to encourage those who are eligible and at risk of severe illness from COVID-19 to get vaccinated.
Further information about the JN.1 vaccine is expected to be available on the Pharmac website soon.
Medicine news: Insulin, HIV PrEP/PEP
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.
Isophane insulin discontinuation update
Novo Nordisk brands of biphasic insulin have been discontinued (as reported in Bulletin 103). Stock of PenMix 50 and Mixtard 30 is now exhausted; PenMix 30 is expected to be supplied until April, 2025. Prescribers are advised to switch any patients who are currently prescribed PenMix 30 to an alternative premixed insulin preparation.
The New Zealand Society for the Study of Diabetes (NZSSD) has published guidance for switching patients to an alternative insulin preparation; see Bulletin 105 for details.
Tenofovir disoproxil with emtricitabine (HIV PrEP/PEP) supply issue
There is an ongoing supply issue affecting stock of tenofovir disoproxil with emtricitabine (Viatris), prescribed for HIV pre-exposure prophylaxis and post-exposure prophylaxis (unapproved indication) and for the treatment of HIV infection in combination with other antiretroviral medicines. An alternative brand (Teva) has been listed on the Pharmaceutical Schedule since October, 2024. It contains a different salt form of tenofovir disoproxil, however, patients can be reassured that both brands are considered clinically equivalent and are interchangeable. Some patients may already be familiar with the Teva brand as it has previously been funded. Re-supply of the Viatris brand is currently expected in January, 2025.
- Viatris: tenofovir disoproxil maleate 300 mg + emtricitabine 200 mg
- Teva: tenofovir disoproxil 245 mg + emtricitabine 200 mg
A HIV pre- and post-exposure prophylaxis guide for primary care is available from: https://bpac.org.nz/2024/hiv.aspx
New guide: Continence management for people with dementia mate wareware
Researchers from the University of Auckland have published a guide about promoting and managing continence for people living with dementia mate wareware. The two-part guide provides practical information and advice for people with dementia mate wareware and their carers about how to navigate through the system, e.g. how to access disability support services, allied health professionals or specialist community support groups, and possible solutions to commonly encountered continence problems, e.g. locating, accessing and using public toilets, personal continence products.
Read the full guide here. A narrated video guide is also available here (15 minutes).
For general information on diagnosing dementia, including special considerations for Māori, see: https://bpac.org.nz/2020/dementia.aspx
World Antimicrobial Awareness Week (WAAW): 18th – 24th November
World Antimicrobial Awareness Week (WAAW) is almost upon us, and the theme for this year is “Educate. Advocate. Act now.” Further information and resources for the global campaign from the World Health Organization are available here.
WAAW is a chance for healthcare professionals to reflect, and act, on the multidisciplinary responsibility for antimicrobial stewardship (AMS). The overarching goal of AMS is to improve the appropriate use of antimicrobials and minimise antimicrobial-related harms, including resistance and adverse effects.
The bpacnz Primary Care Antibiotic Guide is a widely used resource among primary care prescribers to assist in making treatment choices for infections commonly managed in the community. The guide is a living document; keep checking regularly to ensure you are up to date with the latest recommendations.
November is Diabetes Action Month
This month is Diabetes Action Month, and the theme for 2024 is “Don't Sugar Coat Diabetes”, which aims to raise awareness and understanding of diabetes through addressing common misconceptions, e.g. that eating too much sugar causes diabetes or only overweight people get diabetes. Read more here.
bpacnz has published a suite of diabetes resources, including:
Resources for healthcare professionals about continuous glucose monitors and insulin pumps for people with type 1 diabetes are available here.
Medicines Adverse Reactions Committee (MARC) vacancy
Medsafe is currently seeking a community pharmacist 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 10th January, 2025.
Podcast of the Week: Croup in children
A recent episode of GPnotebook, a clinical education platform in the United Kingdom for primary care clinicians, discusses the identification and management of croup in children. Croup, also known as laryngotracheobronchitis, is inflammation of the upper airways, commonly caused by parainfluenza viruses. Although croup is more associated with the “winter ills” season, it can be associated with a variety of illnesses including COVID-19 and rarely, measles. Typical symptoms include a seal-like barking cough and stridor, often preceded by a mild upper respiratory tract infection. Symptoms are usually worse at night and tend to peak within 48 hours of onset. It can be extremely worrying for parents and caregivers, and sometimes challenging for primary care clinicians to decide whether a child with croup can be safely managed at home or if they require hospital referral.
In most cases, a child with croup can be managed with supportive care including adequate hydration, antipyretics or oral corticosteroids (e.g. prednisolone, dexamethasone). More severe symptoms or signs indicate the need for hospital referral, e.g. cyanosis, respiratory distress, stridor at rest, pallor.
Listen to the podcast here (13 minutes)
Some aspects of management may differ from current New Zealand guidance. For further information on croup, see: https://starship.org.nz/guidelines/croup/ (New Zealand-based) or
https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/ (Australian-based)
Paper of the Week: Different inhalers for different folks
Inhalers are a significant technological advancement in medicine delivery allowing patients to self-manage their respiratory conditions. However, these devices are far more complicated than conventional medicines, i.e. taking a tablet or applying an ointment, and poor inhaler technique is associated with worse health outcomes. This is highlighted by stories of patients who do not take the mouthpiece cap off beforehand or use their inhaler like a perfume bottle. While patient education is paramount to ensuring inhalers are used effectively, how else can clinicians help? The answer lies in prescribing the appropriate device. Inhaler technology continues to advance, introducing new devices with different delivery systems and dosing mechanisms, but it is up to the prescriber to ensure the patient is using the device that is most appropriate for their needs. Pharmacists (and asthma nurse specialists and educators where available) can assist prescribers and patients to select an appropriate inhaler, as well as provide education and training to patients on correct inhaler technique.
An article published in Australian Prescriber provides an overview of the different inhaler devices and considerations when choosing the most appropriate medicine delivery system for a patient. Patient-specific factors that influence the choice of device include their inspiratory flow rate and volume and their functional ability (e.g. cognitive impairment, hand-breath coordination, finger strength). Other factors to consider include the aerosol velocity and delivered particle size of the device, inhaler regimen complexity, funding status and the environmental impact of the device, e.g. propellants, and poor symptom control leading to medicine overuse. Patient preference is a key aspect when selecting a device and shared decision-making should be used to ensure the patient is prescribed a medicine they can confidently use.
When reviewing inhaler use, how often do patients admit they are struggling to use their prescribed device? Are there specific devices that patients tend to have more problems with than others? Do you regularly use demonstration devices when discussing inhaler technique? What resources do you direct patients to if they require more information on inhaler technique than you can provide in a single appointment? Do you ever consider the environmental impact of your prescribing?
Read more
Pressurised metered-dose inhalers (pMDIs) – e.g. aerosol inhalers
- Cost effective, widely available and suitable in emergencies
- Must be shaken before each dose and may need to be primed if it has not been used for a number of days
- Most patients do not use a spacer device but should be advised to. Spacers optimise particle size and velocity and reduce reliance on co-ordinating dose delivery and inhalation to receive the appropriate dose in the desired location, i.e. the lungs.
- Patients who do not use a spacer must be able to inhale and operate the device at the same time to receive the appropriate dose
Soft mist inhalers (SMIs) – e.g. Respimat
- Slower aerosol velocity compared with pMDIs improves particle lung deposition and may be beneficial for people who find it difficult to co-ordinate breathing with inhaler actuation, however, sufficient coordination and inspiratory function to inhale while delivering the dose is still required
- The device must be loaded correctly to deliver the appropriate dose (the device will click when the new dose has been loaded)
- Device requires priming before first use and if it has not been used for a number of days
Dry powder inhalers (DPIs) – e.g. Accuhaler, Breezhaler, Ellipta, Spiromax, Turbuhaler
- Sufficient respiratory function is required to ensure correct dose delivery and limits DPI use, i.e. not suitable for young children, people with severely compromised respiratory function or in emergencies
- Common mistakes with DPIs include incorrect dose preparation, not exhaling to empty lungs before dose delivery (must not breathe into the device so the powder stays dry) or not positioning the inhaler correctly in the mouth and insufficient inspiratory flow
- Single dose DPIs require manual loading prior to use, introducing further complications, e.g. risk of patients taking the dose orally, sufficient finger dexterity required to load dose, inter-dose variability and build-up of dose residue potentially affecting dose delivery
- Do not contain propellent which reduces their carbon footprint (compared to other devices)
Patient considerations
- The location of medicine deposition in the respiratory tract is affected by the patient’s inspiratory flow rate and volume. Effective dosing using DPIs requires the patient to be able to produce sufficient airflow.
- pMDIs or SMI may be preferred for patients who cannot perform a full exhalation or sharp inhalation
- The assess, choose and train (ACT) algorithm is a useful tool for selecting the appropriate inhaler device for an individual patient based on their respiratory function (see Figure 1 in the full article)
Environmental considerations
- Short-acting beta2 agonist (SABAs) pMDIs are a significant contributor to greenhouse gas emissions. Limit the need for a SABA inhaler by controlling symptoms with appropriate prescribing of long-acting beta2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs).
- Prescribe dry powder inhalers where appropriate as the lack of propellant reduces their carbon footprint
- Advise patients to return used inhalers to the pharmacy for disposal. This limits the ongoing release of pMDI propellent into the atmosphere from inhalers disposed in standard waste collection.
Ridby D. Inhaler device selection for people with asthma or chronic obstructive pulmonary disease. Aust Prescr 2024;47:140–7. doi:10.18773/austprescr.2024.046
For further information on managing respiratory conditions in primary care, see:
This Bulletin is supported by the South Link Education Trust
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