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Published: 4 August, 2023


Latest from bpacnz: Polymyalgia rheumatica (PMR) – look before you leap

New on our website this week is the diagnosis and management of polymyalgia rheumatica (PMR). This update features audio commentary from Professor Simon Stebbings, Consultant Rheumatologist and Head of the Rheumatology Research Unit, Dunedin School of Medicine, University of Otago.

PMR is an inflammatory rheumatological condition that causes a specific pattern of joint pain and morning stiffness; it almost never occurs in people aged under 50 years. Treatment requires long-term oral corticosteroids which can be associated with significant adverse effects, so diagnostic certainty is important. Other conditions that can mimic PMR should be first ruled out, and the patient should be assessed for giant cell arteritis, as this has a strong association with PMR and is a diagnosis not to miss.

A B-QuiCK summary is available here, and a PMR themed peer group discussion and quiz are also available to further support learning and reflection.

U-turn on opioid legislation

Manatū Hauora, Ministry of Health, has announced a reversal of previous changes to the Misuse of Drugs Act 1975. The maximum limit for Class B opioid prescriptions, e.g. morphine, oxycodone, fentanyl, is to return to one month. Class B controlled drugs used to treat ADHD, e.g. methylphenidate and dexamfetamine, can still be prescribed for three months.

The original decision was that there would be extended prescriptions limits for all Class B controlled drugs from one to three months, if on an electronic prescription (through the New Zealand ePrescription Service). These changes were designed to increase access to treatments for people with ADHD, cancer and other long-term conditions as well as those requiring palliative care. Concerns, however, were raised regarding whether increasing access to opioids may lead to an increase in opioid-related harms. As a result of this, Manatū Hauora, Ministry of Health, sought feedback on the current regulation of opioid prescribing and several proposed changes (see Bulletin 77).

N.B. The new changes to the legislation also affect prescribing limits of Class C opioids, e.g. codeine and soon tramadol (to become a Class C controlled drug from 1 October), which are also being reduced to one month to align with Class B opioid prescribing limits. No specific date has been announced yet for the changes to come into effect.

For further information on opioid prescribing in New Zealand, click here

COVID-19 antivirals: Molnupiravir remains a funded option

Pharmac has announced that molnupiravir (Lagevrio) will continue to be funded for people with COVID-19 who are at high risk of severe symptoms but unable to take other antiviral options. New access criteria will be introduced on 15 August, 2023; patients will qualify for funded molnupiravir if the first-line option, i.e. nirmatrelvir with ritonavir (Paxlovid) is unable to be used for clinical reasons (e.g. medicine interaction, contraindications) and remdesivir (Veklury) is unable to be prescribed due to lack of availability or because it is impractical to administer in the community setting.

Detailed access criteria for molnupiravir can be found here

Pharmac is currently seeking feedback on proposed changes to the access criteria for all funded COVID-19 antiviral medicines. Submissions are due by 21 August, 2023.

For a downloadable patient information sheet for managing COVID-19 symptoms at home, click here

HPV screening update

From 12 September, 2023, HPV testing will become the primary cervical screening test in New Zealand (as reported in Bulletin 79). In the lead up to “go-live” date, The National Cervical Screening programme, Te Whatu Ora, is progressively releasing information packs to support HPV screening providers through the changes. The second information pack, which was released at the end of July, contains information on training and responsibility changes for clinical and administration staff involved in the HPV primary screening process.

Key points from the second information pack:

  • From 12 September, 2023, only primary care clinicians who are accredited to perform cervical screening will be able to offer HPV testing (including offering self-testing); this includes nurses and nurse practitioners who have completed NZQA training in cervical screening as well as doctors and midwives
  • Requirements to allow those not currently accredited to perform cervical screening to offer HPV testing are being developed by the National Screening Unit
  • A summary of required training for specific roles is included
  • Information on changes to cervical screening funding will be released soon
  • Be prepared for a potential increase in uptake of cervical screening due to funding for some groups and the ability to self-test

For further information on the transition to HPV screening, click here

Small for gestational age and fetal growth restriction guidelines released

ACC and Te Whatu Ora have released updated clinical practice guidelines that “aim to reduce rates of stillbirth and neonatal mortality and morbidity associated with fetal growth restriction”. The guideline is intended for health care professionals who are involved in pregnancy, birth or postpartum care. These guidelines are applicable to primary care clinicians, including general practitioners, nurse practitioners, practice nurses and pharmacists, particularly in terms of pre-conception care, risk assessment and implementing interventions to reduce risk before pregnancy and in the early stages of fetal development, and postnatal assessment and monitoring in the child’s first months.

The full guideline can be found here

For further information on the role of the primary health care team in pregnancy, click here

Safe areas around abortion providers

From 25 August, 2023, Safe Areas of up to 150 m will be established and enforced around certain abortion service providers under the Contraception, Sterilisation and Abortion (Safe Areas) Amendment Act 2022. Abortion service providers can apply to Manatū Hauora, Ministry of Health, to establish a Safe Area at their premises. They are designed to prevent harassment and other prohibited behaviours by individuals towards people accessing or providing abortion services. The first approved Safe Areas will be located in Auckland (two), Wellington, Greymouth, Christchurch and Dunedin. The second round of applications are currently under review meaning more locations are likely to be established over time.

When discussing abortion services with a patient, primary care clinicians should identify any concerns regarding possible discrimination and work through these. If applicable, reassure patients that Safe Areas are in place around these facilities to prevent harassment or other situations that could cause distress.

Further details including maps showing specific Safe Areas can be found here

For further information on abortion services in primary care, click here

Latest STI surveillance report from ESR

The Institute of Environmental Science and Research (ESR) has released the latest sexually transmitted infection (STI) surveillance report, including data up to 31 December, 2022. Syphilis and gonorrhoea infections have increased but have not yet exceeded levels seen pre-COVID. The number of chlamydia cases has remained relatively stable; it is the most prevalent STI in New Zealand. STIs continue to disproportionately affect Māori and Pacific peoples.

NZF updates for August

You can read about all the changes in the August release here. Also read about any significant changes to the NZF for Children (NZFC), here.

Thoughts on AI in health

The use of AI has grown exponentially in recent times due to the availability of software such as ChatGPT to the general user. You don’t have to be an IT expert to utilise this technology to answer any question, limited only by the bounds of your own knowledge and imagination in formulating what questions to ask. One of the most interesting aspects of AI to us is how it can be, and is already, used in health. A certain level of cautiousness is warranted while these programmes are in their early days (just compare the utility and robustness of an AI programme two years ago to now and consider where that will be in another two years), but it is important to learn how AI can be used for the good of patients.

In the Medscape podcast Medicine and the Machine, Doctors Eric Topol, Abraham Verghese and Robert Wachter discuss their thoughts on AI in medicine, how far have we come and where are we heading. As Robert says: “We have an obligation to figure out how to use these technologies in ways that help us do what we're here to do. And we're here to make care better and safer and more equitable and more accessible and less expensive. There's not that much doubt in my mind that the technologies will help us do that.

N.B. At the beginning of this podcast, Robert details his recent experience of a severe case of COVID after being a “NOVID” for three and a half years – it involved a trip to the ER, but not for what you might expect. If you want to skip ahead to the discussion on AI, it begins at 08:40 (total length around 30 minutes).

The Medicine and the Machine podcast also has several other episodes about AI, e.g. AI comes to medicine: this time it’s serious; How AI and chatbots can make us healers again; Hidden in plain sight: if AI can detect race, what about bias?.

If you would prefer an analysis of AI closer to home, check out the eHealthTALK NZ podcast from Health Informatics New Zealand (HiNZ): Episode 37 - AI in health – what does ChatGPT mean for me? This webinar (57 minutes) features commentary from Professor Albert Bifet, Director of Artificial Intelligence institute, University of Waikato; Dr Chris Paton, Director of Online Digital Health postgraduate programmes, University of Otago and head of Global Health Informatics research group, University of Oxford; Nick Kemp, Chief Executive of Wild Bamboo, a charitable software development company; and Dr Tania Moerenhout, General Practitioner and Lecturer in Bioethics, University of Otago.

Paper of the Week: Asthma exacerbations increasingly managed in primary care?

New Zealand has one of the highest rates of asthma in the developed world. Exacerbations are a potential risk for anyone diagnosed with asthma, and if not appropriately managed, can have a significant impact on quality of life. Māori and Pacific peoples and people with significant socioeconomic deprivation are more likely to be diagnosed with asthma and admitted to hospital because of an exacerbation.

Policy makers and health professionals rely on epidemiological studies to guide fair allocation of resources and reduce health inequities. A 2023 article in Respiratory Medicine has examined rates of asthma exacerbations in New Zealand between 2010 and 2019, as well as medicine use and hospital admissions, to form an accurate picture of the impact asthma has on our population. Increasing rates of asthma exacerbations and decreasing hospital admissions in the ten-year period suggest primary care is playing a bigger role in the management of asthma exacerbations. The challenge moving forward is to reduce asthma exacerbations for patients who are at the highest risk, e.g. pharmacological management and primary care-led discussions on the importance of medicine adherence and avoiding potential exacerbation triggers.

Chan A, Tomlin A, Beyene K, et al. Asthma exacerbations in New Zealand 2010-2019: A national population-based study. Respiratory Medicine 2023;217:107365. doi:10.1016/j.rmed.2023.107365

For further information on the management of asthma in adolescents and adults, click here

This Bulletin is supported by the South Link Education Trust

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