Published: 13th October, 2023
In case you missed it: latest from bpacnz
We regularly add new content to our website – browse resources under the “articles” tab or search for a topic you are interested in. Here are some of our most recently published resources:
Prostatitis: diagnosis and management in primary care
The term prostatitis describes four distinct conditions: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and asymptomatic inflammatory prostatitis. In acute bacterial prostatitis, prompt treatment and appropriate antibiotic choice are crucial to avoid severe complications. Chronic bacterial prostatitis requires a longer course of treatment. Treatment interventions for CP/CPPS vary depending on the symptom(s) most concerning to the patient and focus on improving quality of life. Read the full article here.
B-QuiCK summaries for acute and chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are also available.
HPV testing guide for general practice
HPV testing is now the primary cervical screening test in New Zealand, replacing the previous cytology-based test. HPV Primary Screening is expected to improve cervical screening participation and equitable outcomes, and further reduce the incidence and mortality from cervical cancer over time. bpacnz has produced a summary to help practices become more familiar with the changes; full information is available on the Te Whatu Ora, Health New Zealand, website.
Navigating the last days of life: a general practice perspective
Last chance to have your say. In the previous bulletin we asked for feedback on aspects of care in the last days of life that you would like us to explore in more detail or any personal experience you would like to share. Thank you to those who have responded, your feedback has been valuable. If anyone would still like to have their say, send us your questions now; responses will be anonymised if published. Email: email@example.com.
Breast Cancer Awareness Month
October is Breast Cancer Awareness Month. In New Zealand, breast cancer is the most commonly diagnosed cancer in females, and it can also rarely occur in males. 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.
Take this opportunity to encourage patients to perform regular self-checks, and to book a consultation if there are any concerns. Check that you have a system in place to invite eligible patients to participate in the national breast screening programme (BreastScreen Aotearoa). Remind women 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 if they haven’t yet, 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.nsu.govt.nz/health-professionals/breastscreen-aotearoa
October is also Health Literacy Month
Health literacy is defined as the capacity to obtain, process and understand basic health information and services in order to make informed and appropriate health decisions. Many adults in New Zealand have low health literacy and this can have wide ranging implications for their wellbeing and the provision of health services. Older people, people with limited education or language proficiency and those with socioeconomic deprivation often have lower levels of health literacy. Māori and Pacific peoples tend to have lower heath literacy than non-Māori and non-Pacific peoples, which contributes significantly to health disparities.
Health literacy month is an opportunity to consider how you communicate health information. Effectively communicating health information in a way that confirms and builds on people’s knowledge and understanding, in a context that is relevant to them, is key. Improving health literacy is about more than enhancing the readability of information. It is about developing the skills and knowledge of individuals, whānau and communities so that they can evaluate, synthesise and act on the information they receive, to improve their health outcomes.
For information on what healthcare professionals can do to develop people’s health literacy knowledge and skills, see: https://bpac.org.nz/bpj/2012/august/upfront.aspx
Additional resources on health literacy are also available from Te Whatu Ora|Health New Zealand, Health Quality & Safety Commission, Healthify and Health Literacy NZ.
Changes to online ACC45 claim submissions
ACC has made the following changes to its online ACC45 claim submissions:
- The choice of “bilateral” has been added to the existing left and right injury side options
- “Another gender” has replaced the previous “Gender Diverse” category
- The character limit in the patients first, middle and surname fields has doubled
- “Admitted to Hospital” field is now visible to frontline teams
These changes will be active once your PMS provider has updated their software.
Medicine supply news
The following issues relating to medicine supply, of particular interest to primary care, have recently been announced. This information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Liraglutide now also in short supply
The global supply issue affecting GLP-1 receptor agonists now includes liraglutide. Dulaglutide supply issues in New Zealand have been ongoing since September, 2022 (see Bulletins 60, 64 and 82), and in response, liraglutide has been funded since March, 2023, as an alternative glucose-lowering medicine for people who meet eligibility criteria for GLP-1 receptor agonists (Bulletin 66). However, the suppliers of both dulaglutide and liraglutide have now advised that they can only secure enough stock for patients with a current prescription. Supply pressures are likely to continue for the rest of the year.
Pharmac is strongly urging healthcare professionals to consider prescribing other glucose-lowering medicines for new patients diagnosed with type 2 diabetes. Empagliflozin (with or without metformin), an oral SGLT-2 inhibitor, is a suitable alternative to a GLP-1 receptor agonist and the same Special Authority criteria apply.
For further information on the management of type 2 diabetes, including lifestyle interventions, oral glucose-lowering medicines, e.g. empagliflozin, vildagliptin, initiating insulin and monitoring for complications, see: https://bpac.org.nz/2021/diabetes-management.aspx. A B-QuiCK summary is also available here.
Cilazapril delisting date moved to mid-2024
Pharmac has announced that the delisting date for cilazapril has been moved from the end of 2023 to mid-2024. This change has been made to allow time for stock to be exhausted. Prescribers should continue to identify any patients still taking cilazapril and switch them to an alternative.
For further information on selecting an ACE inhibitor or ARB, see: https://bpac.org.nz/2021/ace.aspx
Methylphenidate supply issue: further information now available
There is currently a supply issue affecting all strengths of methylphenidate extended-release tablets (Teva) as reported in Bulletin 84. Resupply is expected throughout November.
Patients prescribed methylphenidate (Teva) can switch to either Concerta or Rubifen SR (only 20 mg strength available) brands. Pharmacists can dispense the Concerta brand for active repeats of methylphenidate (Teva) without contacting the prescriber, Special Authority approval, however, is required (see below) and the prescription must be annotated with the new brand, strength and formulation.
Patients with an existing Special Authority approval for methylphenidate (Teva) are being automatically provided with Special Authority approval for Concerta. If a patient has not received automatic Special Authority approval for Concerta, a waiver (new) application must be completed by the prescriber so a new Special Authority number can be issued.
Also see the Medsafe Prescriber Update article about switching brands of long-acting methylphenidate products.
Hydroxocobalamin (vitamin B12) supply issue
There is a supply issue affecting stock of Vita-B12 and Panpharma brands of hydroxocobalamin (vitamin B12) injections. The Panpharma brand is currently out of stock and supplies of Vita-B12 are limited.
Supply issues affecting hydroxocobalamin (vitamin B12) injections have been ongoing throughout 2023. Initially three alternative brands (Vita-B12, Cobal-B12 and Cobalin-H) were listed earlier in the year to cover potential shortages, as reported in Bulletin 73. Cobal-B12 and Cobalin-H brands are still available and funded but are not currently approved by Medsafe and so must be prescribed and dispensed under Section 29.
An alternative brand of hydroxocobalamin injections has been secured and is expected to be listed on the Pharmaceutical Schedule from 1st November, 2023.
Salbutamol inhaler (Respigen) being discontinued
The Respigen brand of salbutamol inhaler is being discontinued, as the manufacturing plant has closed. There is limited stock left in New Zealand, which is expected to be depleted within two to three months. Respigen inhalers were previously out of stock earlier this year, as reported in Bulletin 68.
Patients currently prescribed Respigen will need to change to an alternative brand; the SalAir (funded) and Ventolin (partly funded) brands of salbutamol inhaler are still available. Patients changed to the SalAir brand should be made aware that their new reliever inhaler will be grey, i.e. a different colour than they are used to, but reassured that the medicine is the same. There may, however, be a difference in taste or “mouth feel”. Patients accustomed to a using a blue reliever inhaler may prefer the Ventolin brand but they will need to pay a part-charge as it is not fully funded.
Some patients or parents/caregivers may be concerned about the presence of alcohol in asthma inhalers; they can be reassured that asthma inhalers have < 10 mg* of ethanol per actuation, which will not have any clinical effect – for context a small ripe banana contains approximately 40 mg of ethanol.
*Respigen has 4.5 mg ethanol/actuation, SalAir has 1.5 mg ethanol/actuation and Ventolin does not contain alcohol
Use the opportunity when changing brands of inhaler to discuss/review inhaler technique.
For further information of management in asthma in primary care, see: https://bpac.org.nz/2020/asthma-children.aspx and https://bpac.org.nz/2020/asthma.aspx
Oxycodone 5 mg and 10 mg controlled-release tablets out of stock
The funded brand of 5 mg and 10 mg oxycodone controlled-release tablets (Sandoz) are out of stock, with resupply not expected until the end of November, 2023. Supply of other strengths of oxycodone are currently unaffected.
The OxyContin brand of 5 mg controlled-release tablets is funded, and some stock will be available in pharmacies soon. However, this brand is not approved by Medsafe and so must be prescribed and dispensed under Section 29. An alternative brand of the 10 mg controlled-release tablets is currently being sourced.
Pharmac advise that morphine long-acting tablets (m-Eslon) or oxycodone 5 mg/5 mL oral liquid may be a suitable alternative for some people. However, a new prescription will be needed, and caution is advised if switching from a controlled-release formulation to immediate-release. Opioid conversion guides are available from the New Zealand Formulary here.
Reminder: Morphine is the first-line strong opioid for moderate to severe pain. Oxycodone is a second-line option if morphine is contraindicated or not tolerated. A range of opioid resources are available from bpacnz, including:
Change of brand causing oral contraceptive pill colour confusion
Since August, 2023, the funded brand of levonorgestrel 150 microgram + ethinyloestradiol 30 microgram + inert tablets has changed from Levlen ED to Oralcon 30 ED. Oralcon contains different coloured pills than Levlen which has reportedly caused confusion among people taking this oral contraceptive.
Patients should be advised that their Oralcon 30 ED active pills are white, and the inactive pills are tan/yellow coloured (this is the opposite to the Levlen brand). Unlike Levlen, all Oralcon pills are the same size. A patient handout is available here to help with these changes.
For further information on oral contraceptives, see: https://bpac.org.nz/2021/contraception/oral-contraceptives.aspx
Measles outbreak update
The latest measles outbreak, reported in Bulletin 84, has escalated. Te Whatu Ora, Health New Zealand, has issued a nationwide alert after a student with measles attended several activities in Wellington and then flew to Auckland. Exposure events can be found here.
Healthcare professionals should be alert for symptoms and signs of measles in patients, particularly those who are not vaccinated or are immunocompromised, and have a recent history of overseas or domestic travel to locations of interest.
All suspected cases of measles must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before notifying.
Information about measles from the Immunisation Advisory Centre is available here.
MMR vaccination remains a priority
MMR vaccination is funded for all children in New Zealand and anyone born from 1969 onwards who has not received two doses. Some people born overseas prior to 1969 are considered susceptible to MMR and so may be eligible for funded vaccination (click here for further information). N.B. MMR vaccination is contraindicated during pregnancy.
Opportunistically check whether patients have received both doses of the MMR vaccine and offer vaccination where appropriate. Also ensure that patients with upcoming international travel are fully vaccinated with MMR.
For further information on MMR, see: https://bpac.org.nz/2021/mmr.aspx
Additional COVID-19 booster guidance
The Immunisation Advisory Centre (IMAC) has released guidance on who is most likely to benefit from a further COVID-19 booster dose in the coming months. People at risk of severe COVID-19 likely received their last additional booster dose in April, which means they will almost be due to receive another. Additional booster doses are usually given at least six months apart, or six months after a positive COVID-19 test, however, clinical discretion can be applied (but there should be a minimum of five months between the primary course and first booster, four months between booster doses and a minimum of three months after infection with COVID-19). Eligibility criteria for an additional booster dose are available here.
People who are most likely to benefit from a further COVID-19 booster dose from late 2023 include:
- People aged 75 years and older (particularly those living at aged residential care facilities, or people who are at increased risk of frailty if they become even mildly unwell)
- People aged 65 years and older of Māori or Pacific ethnicity (particularly those with chronic and multiple co-morbidities)
- People aged 16 years and older with severe immunocompromise (particularly those who were eligible for a third primary dose)
- People aged 30 to 74 years with significant complex health needs (particularly those with health needs that increase the risk of frailty, e.g. multiple long-term medical conditions, living in aged residential care facilities)
Webinar on skin problems in people living in aged residential care
The Health Quality & Safety Commission is hosting a webinar on preventing and managing skin problems in people living in aged residential care facilities. This free webinar, which is aimed at all health professionals who are involved in the care of residents in these facilities, will cover:
- How to prevent and manage skin tears
- Pressure injuries
- Incontinence dermatitis
- Fungal infections
- Defining skin infections
The webinar will be held on 15th November, 2023. To register, click here.
Paper of the Week: Insomnia and sleep apnoea – a double whammy
Insomnia and sleep apnoea are two common sleep conditions, and some people experience both concurrently. Global estimates suggest 30 – 40% of people with insomnia also have sleep apnoea and 30 – 50% of people with sleep apnoea have some form of insomnia. Compared to the general population, people with co-morbid insomnia and sleep apnoea (COMISA) experience reduced overall sleep duration, and the limited sleep they do get is often of poor quality and not refreshing, creating a vicious cycle. COMISA is associated with a 50 – 70% increased risk of all-cause mortality over 10 – 20 years of follow-up, compared to people without insomnia or sleep apnoea.
An article published in the Australian Journal of General Practice provides an overview of the diagnosis and management of people who experience both insomnia and sleep apnoea. While continuous positive airway pressure (CPAP) is accepted as the first-line management for severe sleep apnoea (alongside lifestyle advice and weight management), wearing a face mask to bed is often a significant adjustment. There is potential for an initial reduction in sleep quality and people who also experience insomnia may be more likely to reject CPAP as they considered it to be another barrier to falling asleep. Initiating cognitive behavioural therapy for insomnia (CBT-i) before introducing CPAP may improve the initial acceptance and long-term use of the face mask, while improving insomnia as well.
How do you approach patients with sleep disruption in your practice? Do you always consider and assess for sleep apnoea in patients with insomnia (and vice versa)? What interventions have you found effective for increasing CPAP adherence?
- Although the prevalence of insomnia is higher in females and sleep apnoea is more common in males (prevalence in females is around the same after menopause), COMISA is equally prevalent in males and females
- Sleep disruption and non-specific daytime symptoms are a hallmark of both insomnia and sleep apnoea; people who present with symptoms of sleep disruption should be assessed for both conditions
- Also ask about sleep disturbances in patients diagnosed with cardiovascular disease or depression as rates of COMISA are higher in these groups
- Symptoms of sleep apnoea may differ between sexes; females often report non-specific daytime symptoms (e.g. fatigue, lethargy, low mood, or symptoms of insomnia), instead of more conventional symptoms, e.g. loud snoring and daytime sleepiness
- As a result, sleep apnoea is often underdiagnosed in females
- Non-specific symptoms may be attributed to other causes (e.g. depression), resulting in unsuitable treatment
- Validated questionnaires can be used to assess sleep disruption (e.g. Pittsburgh Sleep Quality Index), insomnia (e.g. Insomnia Severity Index), daytime impact (e.g. Epworth Sleepiness Scale) and risk for sleep apnoea (e.g. OSA50 and STOP-Bang). The Auckland Sleep Questionnaire is another assessment tool produced in New Zealand.
- The gold standard assessment for sleep apnoea is a sleep study; see local HealthPathways for referral criteria
- Cognitive behavioural therapy for insomnia (CBT-i) is the first-line management option for people with insomnia. A 2023 systematic review and meta-analysis involving more than 1,000 participants found that CBT-i was associated with a significant improvement in the symptoms of insomnia in people with untreated sleep apnoea and in those receiving treatment. A free New Zealand-produced CBT-i programme is available from Just a Thought.
- A combination of lifestyle advice, weight loss and continuous positive airway pressure (CPAP) is recommended for obstructive sleep apnoea. Second-line interventions include devices designed to increase respiratory air flow, e.g. dental splints or limiting time in the supine position.
- Wearing a facemask to bed is often a significant adjustment and can negatively impact sleep. Patients are likely to require regular support and advice to address any issues affecting adherence including facial irritation, nasal obstruction and feelings of claustrophobia or anxiety.
- In patients with COMISA, treatment for both conditions should be offered, and evidence suggests the order of interventions should be guided by the symptoms of most concern, risk of sleepiness-related accidents and patient preference. However, in practice, initiating CBT-i in patients with COMISA before commencing CPAP may potentially reduce immediate CPAP rejection and increase long-term CPAP use (lifestyle advice and weight management should be initiated concurrently with CBT-i in this situation)
- Avoid prescribing hypnotics for insomnia in patients with comorbid sleep apnoea as they are contraindicated due to the potential for respiratory depression
- Close monitoring of the response to intervention (e.g. increased daytime sleepiness) is recommended in patients at higher risk of negative sleepiness-related effects, e.g. people who are employed to drive or operate heavy machinery
- Referral to a sleep physician is recommended for people with COMISA and significant co-morbidities or complications, e.g. cardiac or respiratory conditions, neuromuscular disease, heavy alcohol or opioid use
- Referral to a sleep psychologist (e.g. a private sleep clinic) may be beneficial for people with COMISA who are shift workers, drive/operate heavy machinery, with severe daytime sleepiness or any other specific circumstances that may require tailored treatment, however, cost may be a barrier
Sweetman A, Frank O, Stocks N, et al. General practitioner management of comorbid insomnia and sleep apnoea. Aust J Gen Pract 2023;52:607–21. https://doi.org/10.31128/AJGP-12-22-6648
For a free online cognitive behavioural therapy resource for people with insomnia (produced in New Zealand), see: https://www.justathought.co.nz/insomnia
For further information on diagnosing and managing insomnia in primary care, see: https://bpac.org.nz/2017/insomnia-1.aspx and https://bpac.org.nz/2017/insomnia-2.aspx
An article on obstructive sleep apnoea in primary care is also available, however, some content may no longer be current: https://bpac.org.nz/bpj/2012/november/apnoea.aspx
This Bulletin is supported by the South Link Education Trust
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