Published: 1st September, 2023
New heart failure audit available
A clinical audit focusing on the management of heart failure in primary care is now available on our website. This helps clinicians identify patients who have been diagnosed with heart failure for at least three months to assess whether they are receiving optimal care.
Recommendations for the treatment of heart failure have changed in recent years. While a stepwise approach has conventionally been applied in primary care (e.g. starting with an ACE inhibitor/ARB and beta blocker, up-titrating, and then adding spironolactone if further symptomatic control is required), new medicines are now available that are set to shift the management paradigm. This includes angiotensin receptor-neprilysin inhibitors (ARNIs) and sodium-glucose co-transporter 2 (SGLT-2) inhibitors.
International guidelines are increasingly recommending that most patients with heart failure and a reduced ejection fraction should be established on the “four pillars of heart failure treatment” as early as possible: ARNI, beta blocker, mineralocorticoid receptor antagonist (e.g. spironolactone) and SGLT-2 inhibitor. While the practical capacity to achieve this combination of medicines will depend on patient co-morbidities and funding restrictions, it should be encouraged where possible to decrease mortality and hospitalisation, and potentially support cardiac structure recovery.
For further information on the management of heart failure in primary care, see: https://bpac.org.nz/2022/heart-failure-part-2.aspx
Further HPV testing information released
As the “go-live” date for HPV testing nears, an additional information pack has been released by the National Cervical Screening Programme and Te Whatu Ora: Pack 2B – A Guide to Upcoming Changes. Pack 3 – Pre Go-Live Check is due out soon.
Pack 2B includes guides on the upcoming changes for administrators (e.g. receptionists), clinical cervical sample takers (e.g. doctors, midwives), clinical non-cervical sample takers (e.g. nurses who have not completed the NZQA cervical screening training) and for people working in colposcopy. The pack also includes a link to the “What’s changing for general practice guide” which is a useful summary.
Eligibility criteria for funded cervical screening have now been finalised and guidance has been published; a flow chart is also available. It has been clarified that follow-up testing will be free for everyone regardless of their eligibility for funded routine screening. Further details regarding the funding model are expected soon.
A webinar is being hosted by HealthPathways on Tuesday, 12th September, from 7 – 8 pm, that focuses on the role of general practice in the new cervical screening pathway. Topics include who, when and how to test, equity, eligibility and funding, self-testing and the key pathway components. To register, click here.
September is Cervical Screening Awareness Month. This provides an opportunity to encourage all eligible patients to be up to date with cervical screening. For a clinical audit on identifying patients who are not participating in regular cervical screening, click here.
Updated COVID-19 return to work guidance for healthcare workers
Te Whatu Ora, Health New Zealand, has released updated guidance for healthcare workers on returning to work after testing positive for COVID-19, being a close contact of someone who has tested positive or those who develop COVID-19-related symptoms but have not tested positive. There are four pathways that apply to workers who are either asymptomatic, mildly symptomatic or improving:
- Return to work from Day Four – once two negative RATs have been taken at least 24 hours apart
- Return to work from Day Eight – applies to those who have not tested or do not have two consecutive negative RAT results
- Return to work for a symptomatic healthcare worker testing negative for COVID-19
- Return to work for a household/high risk workplace exposure contact
For specific details relating to the pathways, including eligibility, click here.
Mask use guidance update for healthcare professionals
As reported in Bulletin 81, all COVID-19 public health requirements have been removed. The latest guidance for mask use within hospital and other health and disability care settings from Te Whatu Ora COVID-19 Clinical Advisory Group (August – September) still, however, largely recommends the use of masks for healthcare workers.
For primary care, including community pharmacies (except those in a supermarket), mask use is recommended for:
- Patients, support people and visitors
- Those working in clinical areas. P2/N95 particulate respirator masks may be recommended in high-risk settings, e.g. triage or during higher risk procedures.
- Non-clinical staff, including those in reception/the waiting room
- Staff in shared offices/meeting rooms and the dispensary
Healthcare workers interacting with patients who have respiratory symptoms should follow transmission-based precautions and wear PPE as required, e.g. P2/N95 particulate respirator masks and eye protection. Streaming patients according to respiratory infection risk is also recommended, if possible.
Click here to view current mask use recommendations from Te Whatu Ora for healthcare workers in aged and residential care facilities, hospital and other secondary care settings and psychotherapy, counselling and mental health and addiction services.
Dulaglutide moves to monthly dispensing amid stock shortage
There is currently very low stock of dulaglutide in New Zealand, and a significant shortage is expected over the coming weeks due to supply chain issues.
In a move to avoid an “out of stock” situation, dulaglutide has been switched to monthly dispensing from today (1st September, 2023). As reported in Bulletin 66, liraglutide (once daily injection) is now funded and is an alternative to dulaglutide (once weekly injection) for patients who meet existing eligibility criteria for GLP-1 receptor agonists. Once normal supply of dulaglutide has resumed, liraglutide will only be funded for patients who were initiated on it during the stock shortage (i.e. not for new patients). There is currently no supply issue affecting liraglutide stock.
Dulaglutide supply issues have been ongoing since September, 2022; to read more, see Bulletins 60 and 64.
For further information on prescribing dulaglutide and liraglutide, see: https://bpac.org.nz/2021/diabetes.aspx
Pharmac to fund trastuzumab biosimilar and widen access
Pharmac has announced that Herzuma, a biosimilar of intravenous (IV) trastuzumab (Herceptin), will be funded from 1st December, 2023. Herzuma will be the principal funded brand of trastuzumab available in New Zealand from 1st June, 2024 (as mentioned in Bulletin 77).
Trastuzumab is currently funded for people with metastatic HER2 positive breast cancer. From 1st December, 2023, funded access will be widened to include people with locally advanced or metastatic HER2 positive gastric, gastro-oesophageal junction and oesophageal cancer. Any relevant practitioner will be able to apply for Special Authority.
An additional change is that from 1st October, 2023 people being administered IV trastuzumab (either Herzuma or Herceptin), with or without IV pertuzumab (Perjeta), who have responded positively to treatment can opt for a “treatment holiday”. After a discussion with their prescriber, people can choose to pause treatment with the aim of increasing quality of life. If disease progression is detected while on a “treatment holiday”, the person remains eligible for funded treatment and the medicine could be reinitiated (they will need to restart on the Herzuma brand if after 1st December, 2023).
For further information on biosimilars, see: https://bpac.org.nz/2020/biosimilars.aspx
Use of surgical mesh for female stress urinary incontinence paused
The use of surgical mesh for managing female stress urinary incontinence has been temporarily paused in New Zealand due to patient safety concerns (as of 23rd August, 2023). This voluntary move was recommended by the Surgical Mesh Roundtable and is supported by the Director-General of Health. Many organisations also back the pause, including the Urological Society of Australia and New Zealand.
The pause will remain in place until the following four conditions have been met, which aim to minimise harm associated with the procedure:
- Mandatory credentialing of surgeons who can perform the procedure
- Establishment of a registry for female pelvic floor procedures including mesh
- Use of a structured informed consent process using a patient decision aid
- Patient case discussions at multidisciplinary team meetings
These four conditions are also included in the action points that were agreed upon from the restorative justice process associated with surgical mesh in 2019, outlined here.
Patients scheduled for this procedure through the public health system will be contacted by Te Whatu Ora, Health New Zealand, to discuss ongoing management which may include non-surgical interventions, e.g. pelvic floor physiotherapy, or a different surgical procedure. Surgical mesh will still be used if it is the only available procedure. Patients scheduled for private surgery will be contacted by their surgeon.
For further information, including a question and answer section, see: https://www.health.govt.nz/our-work/hospitals-and-specialist-care/surgical-mesh
Reminder: The Female Pelvic Mesh Service is now established in New Zealand to refer patients to if they have experienced complications after pelvic mesh surgery. See Bulletin 75 for details, including eligibility criteria.
Medical Council seeking feedback on disclosure of harm
The Medical Council of New Zealand is currently reviewing its official statement on “Disclosure of harm following an adverse event” and has issued a consultation seeking feedback on proposed changes. The statement is intended to help clinicians understand the purpose of open disclosure of harm and what is expected of them once patient harm has occurred. The consultation closes 22nd September, 2023.
New vaping and smoked tobacco regulations released
New vaping and smoked tobacco regulations have been released as New Zealand moves towards its goal of becoming Smokefree by 2025. The new regulations are designed to reduce the growing rates of youth vaping, including decreasing nicotine strengths in disposable vapes, only allowing generic flavour descriptions and banning specialist vaping stores from operating in the immediate vicinity of schools and marae. Smoked tobacco regulations establish the criteria used to approve tobacco retailers and the testing requirements to reduce the nicotine concentration of tobacco products sold in New Zealand.
Resources about vaping are available:
The Protect Your Breath programme aims to promote healthy life choices when it comes to young people and vaping. The programme was developed by Manatū Hauora, Ministry of Health, Te Whatu Ora, Health New Zealand and Te Aka Whai Ora. This youth-focused resource was first promoted on social media last year and includes online mindfulness tools. An interactive “Later Vaper Arcade” designed to challenge young people’s ideas around vaping will be available soon. Primary care clinicians may find these tools helpful to refer younger patients to when discussing problematic vaping behaviours.
For a timeline on the rollout of the new regulations, click here
Paper of the Week: Guidelines for deprescribing opioids
Opioids are effective short-term analgesics but there is no convincing evidence to support their use for chronic primary pain. Patients who use opioids are at increased risk of dependence-related harms and abrupt cessation can have significant consequences. While guidelines recommend short courses of opioids for acute pain management, small numbers of patients will end up taking regular opioids for extended periods making cessation significantly more challenging.
Clinical practice guidelines published in the Medical Journal of Australia provide general evidence-based recommendations for clinicians wanting to taper patients off higher opioids doses or withdraw them altogether. Discussing a deprescribing plan at opioid initiation, identifying appropriate individuals for deprescribing, slowly reducing the prescribed dose and regular follow-up during deprescribing are key elements to a successful outcome. Could these recommendations change the way you approach opioid prescribing/deprescribing in your practice?
Read more about the recommendations
- When initiating an opioid, discuss the expected treatment duration with patients and agree on a deprescribing plan
- Opioid deprescribing could be considered for:
- Patients taking long-term opioids (with the exception of pain associated with cancer) who have not shown clinical improvement in their pain, baseline function or quality of life, have not met agreed upon therapeutic goals or who are experiencing severe adverse effects associated with treatment
- Patients at risk of opioid-related harm due to higher opioid doses, concurrent medical conditions, e.g. sleep apnoea, COPD, or use of substances or other medicines that cause sedation, e.g. alcohol, benzodiazepines, antipsychotics
- Opioid deprescribing is not recommended for patients in their last days of life or those with severe opioid dependence (however, these patients should be referred to an appropriate service for management)
- A gradual reduction in opioid dose should be used to decrease the risk of withdrawal symptoms in patients undergoing opioid deprescribing
- The deprescribing plan should be individualised to the patient’s clinical condition, treatment goals and personal preferences
- Arrange consistent follow-up to monitor the patient’s mental health, assess symptoms and signs of withdrawal and confirm the person is meeting agreed upon treatment targets
- A multidisciplinary team should be involved in the patient’s deprescribing process, if locally available and practical
- Consider other interventions to support the process of deprescribing, e.g. cognitive behavioural therapy, acupuncture, alternative pain medicines. However, the decision to implement these needs to be made in conjunction with the patient as the evidence of benefit is limited and there may be financial barriers.
Langford AV, Lin CC, Bero L, et al. Clinical practice guideline for deprescribing opioid analgesics: summary of recommendations. Medical Journal of Australia 2023;219:80–9. doi:10.5694/mja2.52002
For further information on identifying and managing opioid dependence in primary care, see: https://bpac.org.nz/bpj/2014/october/opioid-addiction.aspx
For an analysis of opioid prescribing data in New Zealand between 2017 and 2021, see: https://bpac.org.nz/2022/opioids.aspx (Watch this space - updated data is coming soon)
A clinical audit reviewing patients using opioid medicines long-term for non-cancer pain, is available here
This Bulletin is supported by the South Link Education Trust
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