Published: 15th September, 2023
New resources available to help general practices support people in their last days of life
Delivering life-extending care is the conventional focus in general practice. However, death is an inevitable part of every person’s journey, and for many, the idea of spending their last days of life at home is important. The general practice team may be tasked with supporting a patient and their family/whānau during this time, either as the primary provider of end of life care services or in collaboration with a multidisciplinary team. Resource, time and funding constraints can make this process challenging to navigate.
We have published a comprehensive new resource aiming to educate and support primary healthcare professionals in delivering community-based care during the last days of life. This was developed with the support of Te Aho o Te Kahu, Cancer Control Agency, and contextualises information from the Ministry of Health, Manatū Hauora, “Te Ara Whakapiri: Principles and guidance for the last days of life” resources specifically for general practice. A series of supporting articles provide practical guidance on managing the most common symptoms that occur during this time, including:
We have also developed a patient management summary sheet to assist other acute healthcare providers should they be required, e.g. ambulance personnel.
This is an essential resource for all primary care health professionals. We are very grateful for the shared knowledge and expertise of our reviewers who assisted us in bringing this together: Dr Kate Grundy (Palliative Care Physician), Vicki Telford (Hospice Clinical Nurse Specialist), Dr Helen Atkinson (General Practitioner and Hospice Medical Officer), Fraser Watson (Extended Care Paramedic Clinical Lead) and Dr Robert Odlin (General Practitioner).
We will be releasing further additions to this resource in the coming months, including multimedia content and CME activities.
The full resource can be accessed here
HPV Primary Screening now live
As of 12th September, HPV testing is now the primary cervical screening test in New Zealand, replacing the previous cytology-based test. HPV testing detects the presence of DNA from certain high-risk HPV types that are known to cause cervical cancer. This can identify people who are more likely to have abnormal cell changes, and therefore those who require further testing.
To see previous bulletin items about cervical screening, use the A-Z keyword index at the top of the bulletin page.
An overview of the new cervical screening programme
- Eligibility to participate in the National Cervical Screening Programme (NCSP) remains the same, i.e. people with a cervix or vagina aged 25 – 69 years who have ever been sexually active. However, screening is extended for people aged 70 – 74 years who are unscreened or under-screened.
- The screening interval has changed to five-yearly for most people after a “HPV Not detected” result; people who are immune deficient should be screened three-yearly
- HPV testing can be performed from one of the following samples:
- A vaginal swab taken by the patient (i.e. a self-test)
- A vaginal swab taken by a clinician (cervical sample taker)
- Liquid-based cytology (LBC). This sample type will only be tested for HPV initially (in routine screening). If HPV is detected, reflex cytology will then be performed.
- All methods of testing require oversight by a cervical sample taker (record informed consent in patient notes)
- A vaginal swab sample is not appropriate for all participants, e.g. those with symptoms or who require a test of cure need a LBC sample for both HPV and cytology testing
- If HPV Type 16 or 18 is detected, refer for a colposcopy
- If HPV Type Other is detected on a vaginal swab, a return visit for a cervical LBC sample to be taken by a clinician is required. If the HPV test was initially performed on a cervical sample, cytology will automatically be reported, and a return visit is not required. Next steps are dependent on cytology results; click here for details.
- If HPV is not detected, no further action is required – place a recall for screening in five years (or three years if immune deficient)
- Cervical screening is funded for people who are unscreened, under-screened, Māori, Pacific or a Community Service Card holder, or for anyone requiring follow-up (including if a LBC sample needs to be taken after a HPV Type Other result on a vaginal swab): for further details of funding, click here.
Refer to the Clinical Practice Guidelines for Cervical Screening in Aotearoa New Zealand (June, 2023) for further information, including specific details on transitioning participants into the new screening pathway.
New opioid prescribing regulations from October
As reported in Bulletin 80, Manatū Hauora, Ministry of Health, has announced changes to opioid prescribing regulations. These have now been approved by Cabinet and will come into effect on 5th October, 2023.
Amendments to the Misuse of Drugs Regulations 1977 will reduce the maximum limit for all opioid prescriptions from three months to one month (excluding opioid substitution treatment, see below). Changes apply to both physical and electronic prescriptions through the New Zealand ePrescription Service.
- The maximum limit for Class B opioid prescriptions, e.g. morphine, oxycodone, fentanyl, will return to one month
- The maximum limit for Class C opioid prescriptions, e.g. codeine, tramadol (Class C from 1st October), will be reduced to one month
- Opioids prescribed as part of opioid substitution treatment, e.g. methadone, can be prescribed for a maximum of three months
- Class B controlled drugs used to treat ADHD, e.g. methylphenidate and dexamfetamine, can be prescribed for a maximum of three months
- The maximum dispensing amount for any controlled drug remains as one month
A FAQ sheet about the Misuse of Drugs Amendment Regulations (2023) is available here
Widened access to medicines for multiple sclerosis
Pharmac has announced that ocrelizumab (Ocrevus) will be funded for patients with primary progressive multiple sclerosis (MS) from 1st October, 2023. This pattern of disease occurs in around one in ten people with MS. As reported in Bulletin 52, ocrelizumab is already funded for the treatment of relapsing remitting multiple sclerosis (RRMS), which is the most typical pattern in early stage MS. Anyone currently taking ocrelizumab for RRMS will automatically be issued with a new Special Authority number by this date. Special Authority applications for any funded multiple sclerosis treatments will be able to be made by any relevant practitioner (rather than only a neurologist or general physician).
N.B. It was also announced that emicizumab (Hemlibra) will be funded for patients with severe haemophilia A without FVIII inhibitors. Currently, emicizumab is only funded as a prophylactic treatment in patients with haemophilia A who have developed inhibitors to Factor VIII.
Further information about these changes is available here
Medicine supply news: Rivastigmine patch shortage
There is a supply issue affecting stock of the currently funded brand of rivastigmine patches 4.6 mg/24 hours (BNM 5) and 9.5 mg/24 hours (BNM 10). Rivastigmine patch BNM 10 is out of stock and supplies of BNM 5 are likely to be exhausted by the end of October, 2023. Re-supply is expected in early 2024.
To ensure continued access, an alternative brand, Novartis Exelon, will be listed on the Pharmaceutical Schedule and funded from 1st October, 2023. Patients may need reassurance that despite differences in the product packaging, the alternative brand contains the same active ingredient and is used in the same way.
The two funded brands of aqueous cream are out of stock with re-supply not expected until early to mid-October. Pharmac is working to source an alternative brand, however, other funded emollients are available but would need to be on a new prescription.
There is limited stock of most strengths of methylphenidate; 18 mg, 27 mg and 36 mg extended release tablets are in very limited supply, but there is currently adequate stock of 54 mg extended release tablets.
Mental Health Awareness Week (18th – 24th September)
Next week (18th – 24th September) is Mental Health Awareness Week. The theme for this year is Five Ways, Five days. For each day of the work week, a new tool is highlighted that has been proven to enhance mental health: Take Notice (Monday), Give (Tuesday), Be Active (Wednesday), Connect (Thursday) and Keep Learning (Friday).
The principles emphasised in Five Ways, Five days can be a useful reminder for primary healthcare professionals to guide discussions around mental health with patients:
- Take Notice (Me Aro Tonu) – this refers to the practice of mindfulness, where people focus on being open and receptive to what is occurring in the present moment without judging them as being “good or bad”
- Give (Tukua) – performing actions based on kindness, altruism or generosity can in turn promote a person’s own happiness and life satisfaction
- Be Active (Me Kori Tonu) – being physically active not only has a strong influence on physical health, but can also significantly improve mood and decrease stress, depression and anxiety
- Connect (Me Whakawhanaunga) – maintaining and nurturing social connection is crucial for enhancing mental health. Sharing strong bonds with family/whānau, friends and the community can help people feel supported, understood and increase their sense of belonging.
- Keep Learning (Me Ako Tonu) – learning is a lifelong journey. In adults, continuing to learn can help set and achieve goals, which in turn promotes wellbeing. By remaining curious and open to change, people can discover ways to significantly shift their perspectives on life.
New Zealand-based online CBT course for panic
Just a Thought is a New Zealand organisation that offers free online cognitive behavioural therapy (CBT) courses and hosts other resources for a range of mental health conditions. A new online CBT course has now been released for people experiencing panic. A second course is also available which builds on the skills learnt during the first.
These courses use CBT specifically tailored for people experiencing anxiety and panic attacks, and provides people with the necessary knowledge, skills and strategies to overcome such challenges. They can be completed by the patient in a self-guided manner or under the supervision of a health professional.
View all the courses available by Just a Thought here
Shingles after first dose of Shingrix vaccine
In a recent email to the sector, the Immunisation Advisory Centre (IMAC) has noted reports of herpes zoster occurring in people who have received their first dose of Shingrix. The current funded vaccine, Shingrix, is a non-live vaccine and therefore cannot cause shingles; the association is coincidental.
The incidence of herpes zoster is increasing world-wide due to an ageing population. There have also been reports in the literature of an increasing incidence of shingles after SARS-CoV-2 infection (COVID-19). The development of shingles post-vaccination likely reflects this increasing incidence. Two doses of Shingrix are required (the second dose two to six months after the first dose) and although the risk of shingles is reduced after the first vaccination, some people will develop herpes zoster before they have their second dose.
The change in funded vaccine from Zostavax to Shingrix for people aged 65 years was reported in Bulletin 56 – this item has more information on the effectiveness of Shingrix.
Elevated iodine levels found in seaweed tonic: safety risk
The Ministry of Primary Industries (MPI) has issued a statement warning people about the consumption of unregulated seaweed tonic. This comes after the recent identification of a seaweed tonic marketed as “NZ Focuidan”, produced without meeting registration requirements under the Food Act 2014 and sold via informal sellers and local markets.
Seaweed is naturally high in iodine and can bioaccumulate other potentially harmful chemicals. Consuming seaweed products prepared without appropriate controls, processing and appropriate dosage information can increase the risk of harm, particularly if people have pre-existing thyroid conditions.
Clinicians are being advised to ask patients who present with symptoms or signs of a thyroid abnormality about the consumption of any supplements/tonics. Anyone who has purchased an unregulated seaweed product should avoid consumption and immediately dispose of it.
Latest edition of Prescriber Update released
The September edition of Prescriber Update has been published; particular items of interest include:
- Reports of persisting serious adverse reactions to fluoroquinolones
Medsafe is reminding prescribers that fluoroquinolones such as ciprofloxacin, moxifloxacin and norfloxacin have in rare cases been associated with disabling, prolonged and potentially irreversible adverse effects. These medicines should only be prescribed according to approved indications. Between 2015 and 2023, CARM has received 43 reports of fluoroquinolone-induced tendonitis, in addition to other adverse reactions such as tendon rupture, peripheral neuropathy, paraesthesias and dysaesthesias.
For information on limiting use of quinolone antibiotics, see: https://bpac.org.nz/2021/quinolone.aspx
- Antidepressant withdrawal: taper antidepressants slowly
A slow taper is recommended when stopping antidepressants to minimise the risk of withdrawal symptoms, e.g. dizziness, fatigue, nausea, irritability, asleep difficulties. For some people, withdrawal symptoms are severe and persist for a long period of time. All antidepressants can cause symptoms of withdrawal during or after discontinuation, but the risk appears to be highest when they are stopped abruptly, tapered too quickly or from a high dose, or if tapering occurs after a prolonged period of use.
View the full edition of Prescriber Update here
Paper of the Week: SGLT-2 inhibitors could also be beneficial for gout
The benefits of sodium-glucose co-transporter 2 (SGLT-2) inhibitors are well established in people with type 2 diabetes, and they are increasingly being used for protection against cardiovascular and renal disease. New research suggests that the clinical utility of SGLT-2 inhibitors may potentially extend further.
A retrospective cohort study published in JAMA Network Open has demonstrated that SGLT-2 inhibitors may also benefit people with type 2 diabetes and co-morbid gout, reducing the burden of flares and lowering mortality. While there are no calls at this stage for guidelines to be updated, these findings warrant further investigation, and may provide clinical justification for preferentially selecting a SGLT-2 inhibitor early in this patient group. Given the rising prevalence of gout and reports of sub-optimal treatment in New Zealand, expanding the treatment toolbox is as important as ever.
- This retrospective cohort study used medical records from a United Kingdom primary care database. A total of 5,931 people aged between 18 and 89 years with both gout and type 2 diabetes were selected.
- Participants were included in the study if they were initiated on a SGLT-2 inhibitor (e.g. dapagliflozin, empagliflozin or canagliflozin [n = 1,548]), or an active comparator (e.g. glucagon-like peptide 1 [GLP-1] receptor agonists or dipeptidyl peptidase-4 [DPP-4] inhibitors [n = 4,383]), between January 1, 2013, and December 31, 2021. The date of initiation was considered the index date.
- The primary study outcome assessed was the number of recurrent gout flares occurring after initiation a SGLT-2 inhibitor or an active comparator. Secondary study outcomes included the first recurrent gout flare and all-cause mortality during the follow-up period.
- A gout flare was defined as either (1) a Read code for a gout flare or (2) a Read code for gout in addition to a prescription for colchicine, or a prescription of either a NSAID, corticosteroid, intra-articular corticosteroid or adrenocorticotropic hormone within one week of the gout Read code entry
- No transient increase in recurrent gout flares was observed following initiation of either SGLT-2 inhibitors or any of the active comparators
- The relative rate of recurrent gout flares in people taking SGLT-2 inhibitors was 0.79 compared to people taking active comparators (95% CI, 0.65 - 0.97). Individual analyses comparing people taking SGLT-2 inhibitors against those taking either GLP-1 receptor agonists or DPP-4 inhibitors showed similar findings, however, these were not statistically significant.
- The incidence of the first recurrent gout flare was 32.4 per 1,000 person-years for people taking SGLT-2 inhibitors which was 19% lower than in people taking an active comparator (41.2 per 1,000 person-years)
- All-cause mortality for people taking SGLT-2 inhibitors was 18.8 per 1,000 person-years and 24.9 per 1,000 person-years for people taking active comparators. When stratified by individual active comparators, the lower risk of all-cause mortality with SGLT-2 inhibitors was mostly observed when comparing against DPP-4 inhibitors but not with GLP-1 receptor agonists.
- Several biological mechanisms are proposed for the observed treatment effect, including the idea that SGLT-2 inhibitors could reduce serum urate concentration by bolstering urate elimination via kidneys. Further investigation is required to corroborate these findings and elucidate the possible mechanism.
- Study authors highlighted that the way in which gout flares were identified (i.e. patients with a Read code for gout plus a corresponding treatment prescription within one week) may potentially lead to underestimation of flares. In addition, this analysis only included gout flares treated in primary care, when the patients may have also chosen to present to hospital for a gout flare.
Wei J, Choi HK, Dalbeth N, et al. Gout flares and mortality after sodium-glucose cotransporter-2 inhibitor treatment for gout and type 2 diabetes. JAMA Netw Open 2023;6:e2330885. doi:10.1001/jamanetworkopen.2023.30885
This Bulletin is supported by the South Link Education Trust
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