Published: 13th December, 2024
Contents
Welcome to the final issue of Best Practice Bulletin for 2024
It feels like only yesterday that we were crafting this same message for 2023. I think we can all agree that time flies even faster when life is hectic. It has been another challenging year for primary care in New Zealand, dealing with funding shortfalls, lack of resources and financial stress for many practices. But we also must acknowledge the positives, such as new funded treatments becoming available for many patients, the resilience of people working in primary care and the sense of joy you still feel when you are able to make a difference in a patient’s life.
During these stressful times for the healthcare sector, we aim to continue to provide evidence to guide your decision-making and bring you the information you need at hand. Some of our key topics this year included prescription medicine misuse, anticholinergic burden, beta blockers, atrial fibrillation, HIV prophylaxis, pneumonia, smoking cessation and a revision of the ever-popular article on the role of melatonin. We have also recently begun our series on Recovery at Work, which will continue to be a focus in 2025. Other upcoming publications include heart failure, angina and COPD.
Our offices will be closed from 12.30 pm, Tuesday, 24th December and re-open Monday, 6th January. We hope that you find time for some relaxation and re-setting over the summer break, and we look forward to sharing new resources with you next year. As always, we are extremely grateful to all of you who support our work.
There really is only one thing left to say:
Last Christmas we gave you a chart (the opioid prescribing report)
But the very next May (well actually June, but close enough), you gave it away (to look at your antibiotic prescribing report instead)
Next year, to save us from tears (we get so many emails about it!) we’re giving you something special (Annual report is back!)
Sorry Whamageddon players, but we couldn’t resist a Christmas jingle!
Meri Kirihimete me ngā mihi o tau hou. Merry Christmas and a happy new year from Rebecca, Sharyn, Adrian, Tayla, Sam, Michael and all of the team at bpacnz.
New from bpacnz: Generalised anxiety disorder in adults
Anxiety is a normal human emotion that affects most people at some time. It becomes a disorder when it is of greater intensity and duration than expected and if it leads to impairment/avoidance behaviours or disability. Anxiety disorders are the most prevalent mental health condition in the community, yet many people do not seek treatment.
Generalised anxiety disorder (GAD) is a predominant form, characterised by excessive and uncontrollable worry about multiple aspects of everyday life, e.g. employment, education, relationships, and often co-occurs with depression and other anxiety disorders. Psychological, e.g. cognitive behavioural therapy (CBT), and pharmacological, e.g. selective serotonin reuptake inhibitors, treatments are equally effective in the management of GAD, but patients engaging with CBT may be less likely to relapse.
This is a revision of our previously published article, and includes a general update of evidence and the addition of new sections on the management of GAD during pregnancy, online CBT and follow-up and ongoing monitoring.
Read the full article here. A B-QuiCK summary is also available.
In case you missed it: Prescribing testosterone in ageing males
Rates of testosterone prescribing in older males in New Zealand continue to increase, however, the long-term risks and benefits of treatment are still uncertain for older males without clinically proven hypogonadism. Therefore, testosterone replacement treatment should be reserved for patients with clinical features of androgen deficiency and early morning serum total testosterone levels below the accepted threshold of normal.
Read the full article here. A B-QuiCK summary is also available.
Latest edition of Prescriber Update released
The December edition of Prescriber Update has been published. Particular items of interest for primary care include:
• Medicine-induced hyperhidrosis
Excessive and uncontrollable sweating caused by a medicine is referred to as medicine-induced hyperhidrosis. Acetylcholinesterase inhibitors (e.g. rivastigmine), opioids, antidepressants (SSRIs, SNRI, TCAs), corticosteroids and thyroid medicines are commonly implicated. Consider lowering the dose of the causative medicine or switching to an alternative (if possible) if a patient experiences hyperhidrosis that is affecting their quality of life. Read the full article here.
• Medicine-induced interstitial lung disease
Medsafe is reminding prescribers of the potential for some medicines to cause lung injury, following reports to CARM. Interstitial lung disease is the most common pulmonary toxicity associated with medicines, including methotrexate, nitrofurantoin (see Bulletin 107 for further information), amiodarone, leflunomide and biologics. Advise patients taking medicines that are associated with interstitial lung disease of this risk, and to seek medical care if they experience any of the following symptoms: cough, chest pain, dyspnoea, shortness of breath, fever or chills. Read the full article here.
Medicines Monitoring reminder: be alert to potential mood changes in patients taking direct-acting oral anticoagulants; report any suspected cases to CARM. See Bulletin 105 for further information.
View the full edition of Prescriber Update here.
NZF updates for December
Significant changes to the NZF in the December, 2024, release include:
You can read about all the changes in the December release here. Also read about any significant changes to the NZF for Children (NZFC), here.
Decision to fund another triple medicine inhaler for COPD and palivizumab for RSV
A decision has been made following consultation on a proposal to fund medicines for the management of COPD and the prevention of RSV (as reported in Bulletin 108).
From 1st January, 2025:
Budesonide with glycopyrronium and formoterol (Breztri Aerosphere; pressurised metered-dose inhaler) triple medicine inhaler will be funded for patients with moderate to severe COPD who meet Special Authority criteria. This will provide an alternative triple medicine inhaler option to the recently funded Trelegy Ellipta (fluticasone furoate with umeclidinium and vilanterol; dry powder inhaler) as reported in Bulletin 97. The Breztri Aerosphere inhaler contains a different combination of LABA/LAMA/ICS medicines to the Trelegy Ellipta and is a different type of inhaler (pressurised metered-dose).
A 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. It is reserved for patients who are using either a ICS/LABA or LAMA/LABA inhaler and still experiencing symptoms or who are using multiple inhaler triple therapy and meet specific criteria. Special Authority criteria for Breztri Aerosphere can be found here (criteria are the same for Trelegy Ellipta).
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 (the new triple inhaler option will be added to the tool in January).
Palivizumab (Synagis), a humanised monoclonal antibody (administered as an IM injection), will be funded for the prevention of severe illness from RSV in infants and children aged under two years at high risk of RSV who meet Special Authority criteria, e.g. born at less than 32 weeks gestation, haemodynamically significant heart disease. Funding will only be available during the annual RSV season (typically May to October). Special Authority criteria can be found here. Palivizumab was previously funded during the 2022 and 2023 RSV seasons.
N.B. Osimertinib for non-small-cell lung cancer and trastuzumab deruxtecan for HER-2 positive metastatic breast cancer will also be funded from 1st January, 2025. Read more here.
bpacnz focus: Caution with colchicine
Colchicine, commonly used for the management of gout flares, can cause significant toxicity and death due to its narrow therapeutic index and limited treatment options in overdose. Acute overdose exceeding 0.5 mg/kg is usually fatal, and doses as low as 0.18 mg/kg have resulted in deaths in New Zealand. Medsafe published a Prescriber Update article in 2021, highlighting the safety issues of colchicine from poisoning data.
Reminder: Colchicine should only be prescribed as needed for acute flares of gout. Patients should be prescribed allopurinol (or another urate-lowering medicine) for gout prophylaxis. Colchicine may be prescribed short-term for the prophylaxis of gout while urate-lowering treatment is introduced (unapproved indication) but then discontinued and only used as needed during an acute flare.
Tips to reduce the risk of harm from colchicine
- Check the NZF to ensure you are prescribing at an appropriate dose (ideally the lowest effective dose), frequency and duration for the indication
- Check with patients what stock of colchicine they have at home before prescribing more, to avoid stockpiling. This is especially important for vulnerable patients, e.g. those with co-morbid mental health conditions, social issues.
- Limit prescriptions to the anticipated number of tablets required; use monthly prescribing
- Ensure dosing instructions are clearly understood by the patient; the NZF has a patient leaflet about colchicine (English and Te Reo Māori versions are available)
- Ensure patients are aware that colchicine is not an analgesic for general use and should not be used to manage other types of pain; it should not be given to anyone else to use
- Advise patients to stop taking colchicine and seek medical care if they experience nausea, vomiting, diarrhoea or abdominal pain, unusual bleeding or bruising, muscle pain or weakness or numbness or tingling in their fingers or toes
- Discuss appropriate storage of the medicine with the patient, including whether a child-resistant closure might be appropriate
- Inform patients that they can take any unused medicine to their local pharmacy for safe disposal
For further information on safer prescribing of colchicine, see: “Safer prescribing of high-risk medicines: Colchicine – extremely toxic in overdose” (bpacnz, 2014; updated 2021)
For further information on how to minimise the risks of colchicine, see: “Colchicine: the good, the bad, the ugly and how to minimize the risks” (2023)
For information on the use of colchicine for the management of gout flares, see: “Managing gout in primary care: Part 1 – Talking about gout: time for a re-think and Part 2 – Controlling gout with long-term urate-lowering treatment” (bpacnz, 2021)
Evidence update: large study shows colchicine has no effect on cardiovascular events post-myocardial infarction
Low-dose colchicine has been shown in clinical trials to reduce cardiovascular risk (as reported in Bulletin 87), which has led to some cardiology guidelines recommending colchicine for secondary prevention in certain patents (e.g. AHA/ACC guidelines on the management of patients with chronic coronary disease). However, a recently published study involving more than 7,000 participants showed no significant benefit of colchicine (taken for a median of three years) in reducing cardiac events post-myocardial infarction. This study appears to be the largest trial of colchicine in patients after acute myocardial infarction and the findings cast doubt on its role. A Medscape commentary is available here. The use of colchicine for the secondary prevention of CVD in New Zealand is not approved, nor is it common practice in primary care.
In brief: Medical aspects of fitness to drive webinar recording, melanoma counselling service and more
Medical aspects of fitness to drive webinar recording
As reported in Bulletin 113, RNZCGP Medical Director, Dr Luke Bradford, recently facilitated a webinar with speakers from the NZTA, highlighting the significant changes to the Medical aspects of fitness to drive: a guide for health practitioners and outlining healthcare professional’s responsibilities when undertaking driving assessments. The question and answer section in particular provided clarification of some aspects. If you missed it, you can view a recording of the webinar here.
Melanoma New Zealand Counselling service
Paramedics and audiometrists to become ACC treatment providers
The list of ACC treatment providers has been updated following consultation on proposed changes in April (as reported in Bulletin 98). A summary of the submissions can be found here. From 19th December, 2024, paramedics and audiometrists will be funded by ACC to provide treatment to patients through the ACC Cost of Treatment Regulations.
Preliminary Notice of Deaths to be required
From 15th December, 2024, medical and nurse practitioners who complete a paper Medical Certificate of Death or Medical Certificate of Causes of Fetal and Neonatal Death will be required to send a Preliminary Notice of Death (PNOD) to the Registrar-General of Births, Deaths and Marriages to advise that someone has died. If a death certificate is completed online (Death Documents) rather than paper-based, a PNOD is automatically generated and sent; no additional action is required. Click here for further information.
Medical Factorium: Attack of the earworms - Why do we get songs stuck in our heads?
Every now and then, patients ask “why?” and the answer alludes us. In this occasional bulletin segment, we attempt to answer some of those curious questions.
The question: We all get songs stuck in our heads. “Crazy frog”, “With arms wide open” and “Always on my mind” are repeat offenders in the bpacnz office. Sometimes you only need to hear the opening chords, and the tune is stuck with you for the rest of the day. Christmas carol season seems the right time to ask, why does this happen, and is there a physiological explanation for infectious music?
Read more
Musical intrusions, or earworms as they are commonly known, are repeating fragments of music that involuntarily play in your mind.1 These music fragments are often catchy tunes or parts of songs you have recently listened to and typically last 15 to 30 seconds. Earworms are a normal cognitive occurrence and differ from musical hallucinations associated with hearing impairment, tinnitus or psychological conditions, e.g. schizophrenia.1
Almost everyone experiences earworms, however, the exact neural physiology underlying earworms is unknown.1, 2 It likely involves subconscious activation of auditory semantic memory.1 One potential theory is that the brain phonological loop that stores auditory information in the left side of the primary auditory cortex is undermined by certain “catchy” tunes leading to repeating loops.1 It is also unclear why earworms occur but aside from hearing the song, other conditions which may trigger earworms include certain moods, nostalgia and inattention.3
If you do find yourself with “O little town of Bethlehem” or “Jingle bell rock” stuck in your head this Christmas, suggested methods to suppress earworms include doing a puzzle, listening to talk-back radio, chewing gum or even listening to the offending song.1
- Lees AJ, Lawson S. Earworms—a narrative review of infectious music. JAMA 2024;331:1075. doi:10.1001/jama.2024.2780.
- Taylor S, McKay D, Miguel EC, et al. Musical obsessions: a comprehensive review of neglected clinical phenomena. Journal of Anxiety Disorders 2014;28:580–9. doi:10.1016/j.janxdis.2014.06.003.
- Williamson VJ, Jilka SR, Fry J, et al. How do “earworms” start? Classifying the everyday circumstances of involuntary musical imagery. Psychology of Music 2012;40:259–84. doi:10.1177/0305735611418553.
View previous Medical Factorium items here.
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: “Don’t worry, it’s dark chocolate…”
Chocolate is synonymous with Christmas; think scorched almonds and chocolate Santas. It is typically high in calories and lacks nutritional benefit, however, chocolate also contains high levels of flavonoids, compounds that may lower type 2 diabetes risk via antioxidant, anti-inflammatory and vasodilatory effects. Dark chocolate has the highest levels of flavonoids compared with milk or white chocolate. Chocolate consumption for health benefits is a contentious subject, given the link between foods with high saturated fat and sugar content and obesity, and the fact that diet is one of the single biggest risk factors for type 2 diabetes. Previous studies investigating the association between chocolate consumption and type 2 diabetes have been inconsistent, and few have considered the different types of chocolate, i.e. milk, dark or white.
Just in time to inform our collective Christmas consumption, an article has been published in the British Medical Journal investigating the effect of chocolate consumption on type 2 diabetes risk among three cohorts of health professionals (female nurses and males from various health professions). An inverse association between consumption of dark chocolate and type 2 diabetes was found; compared with no or infrequent consumption, five or more servings of dark chocolate per week was associated with a lower risk of type 2 diabetes. This finding was not observed for the consumption of milk chocolate, which instead was associated with long-term weight gain (dark chocolate was not). While excess intake should generally be avoided, these findings suggest that dark chocolate may be a more palatable option (excuse the pun…) over milk or white chocolate for anyone with a sweet tooth during the festive season and beyond.
Have you ever been asked about the health benefits of eating dark chocolate? If patients have mentioned their chocolate intake, would you consider recommending they switch to dark chocolate?
Read more
- Three prospective cohort studies of health professionals were included in this analysis: the Nurses’ Health Study (NHS; 1986-2018), Nurses’ Health Study II (NHSII; 1991-2021), and Health Professionals Follow-Up Study (HPFS; 1986-2020)
- Participants were predominantly Caucasian with an average age of 52 years in NHS, 36 years in NHSII and 53 years in HPFS when total chocolate consumption was first assessed (baseline 1). The average ages when chocolate subtype consumption was first assessed (baseline 2) were 70 years in NHS, 52 years in NHSII and 68 years in HPFS.
- Total chocolate consumption was assessed for approximately 190,000 participants and chocolate subtype analysis occurred for 110,000 participants
- Food frequency questionnaires conducted every four years were used to measure chocolate consumption. Participant health and lifestyle information (including type 2 diabetes status and body weight) was assessed every two years.
- In the total chocolate cohort (i.e. people who ate any chocolate), more than 18,000 cases of type 2 diabetes were identified over almost 5,000,000 person-years of follow-up. Approximately 5,000 cases of type 2 diabetes were identified over 1,200,000 persons-years of follow-up in the chocolate subtype cohort (i.e. people stratified by the type of chocolate they ate).
- Participants who consumed five or more servings of any chocolate per week had a 10% lower relative risk of type 2 diabetes compared to those who did not or rarely ate chocolate (hazard ratio [HR] = 0.90, 95% confidence interval [CI] = 0.83 to 0.98)
- When assessed by subtype, consumption of dark chocolate was shown to be inversely associated with type 2 diabetes; participants who consumed five or more servings of dark chocolate per week had a 21% reduced relative risk of type 2 diabetes (HR = 0.79, 95% CI = 0.66 to 0.95), after adjusting for confounders, e.g. personal, lifestyle, and dietary risk factors
- No association was observed for milk chocolate consumption and type 2 diabetes risk, however, an association between increased milk chocolate consumption and long-term weight gain was identified
- Dark chocolate consumption was not associated with long-term weight gain
- The study cohorts were all health professionals which, along with their age and ethnicity profiles, limits the generalisability of these findings. Participants who reported high total chocolate consumption were also more likely to consume higher levels of added sugar and saturated fat, potentially confounding these results. No standard definition for a serving of chocolate was included, which makes applying these findings in everyday life difficult.
Liu B, Zong G, Zhu L, et al. Chocolate intake and risk of type 2 diabetes: prospective cohort studies. BMJ 2024;:e078386. doi:10.1136/bmj-2023-078386
This Bulletin is supported by the South Link Education Trust
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