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.
Opioid prescribing changes timeline
- November, 2022, In response to the announcement by Manatū Hauora, Ministry of Health, about amendments to section 37 of the Misuse of Drugs Act allowing prescription limits for Class B controlled drugs to be extended to three months, if using an electronic prescription, Pharmac sought feedback on a proposal to amend the Pharmaceutical Schedule to allow funding of extended prescribing limits of Class B controlled drugs
- 21 December, 2022, Pharmac decided not to alter the Pharmaceutical Schedule to reflect all of the changes, meaning extended prescribing limits for Class B opioids would not be funded
- 22 December, 2022, Amendments to section 37 of the Misuse of Drugs Act came into effect allowing prescription limits for Class B controlled drugs to be extended to three months, if using an electronic prescription (this had a limited practical effect on prescribing of Class B opioids given that the Pharmaceutical Schedule did not change)
- March, 2023, Manatū Hauora, Ministry of Health, asked for public feedback on several proposals regarding Class B controlled drug policy after initial concerns were raised about extended prescribing limits for Class B opioids
- June, 2023, Manatū Hauora, Ministry of Health, released a summary of public feedback regarding extended prescription limits for Class B opioids
- July, 2023, Manatū Hauora, Ministry of Health, announced that the prescribing limits for Class B opioids are changing back to one month and will come into effect later in the year
N.B. In December 2022, Manatū Hauora, Ministry of Health, announced several new classifications or reclassifications of prescription medicines, including: fentanyl being up-scheduled to a Class B1 controlled drug and zopiclone becoming a Class C5 controlled drug on 1 July, 2023; and tramadol becoming a Class C2 controlled drug on 1 October, 2023.
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.
Read more on molnupiravir
The COVID-19 Therapeutics Technical Advisory Group had, on two occasions, recommended that the funding of molnupiravir be stopped and current clinical guidance from Te Whatu Ora does not recommend molnupiravir use for people with COVID-19 to prevent hospitalisation. This is based on emerging evidence that molnupiravir has not shown benefit in preventing hospitalisation or death in people at higher risk of severe symptoms with COVID-19 (see Bulletin 70 and Bulletin 72).
After considering feedback, Pharmac has decided to limit funded access for the general population but continue molnupiravir for the small group of people who are unable to take other funded antiviral medicines. These people are generally aged over 80 years with reduced renal function and significant medicines interactions meaning nirmatrelvir with ritonavir (Paxlovid) and remdesivir (Veklury) are not suitable.
Available molnupiravir stock is expected to expire between January and May 2024 and there are currently no plans to order more.
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.
Read more on assessing and reducing risk of fetal growth restriction
- Discuss pre-conception lifestyle advice with people considering becoming pregnant, e.g. diet and exercise, maintaining a healthy body weight, folic acid supplementation, smoking cessation
- Clinical risk assessment for fetal growth restriction should be performed in early pregnancy and repeated at regular intervals throughout gestation
- Major risk factors for small for gestational age and fetal growth restriction include:
- Maternal factors, e.g. age greater than 40 years (if nulliparous), currently smoking > 10 cigarettes/day, recreational drug use
- Maternal medical history, e.g. hypertension, diabetes with vascular disease, reduced renal function, antiphospholipid syndrome
- Concerns from previous pregnancy, e.g. small for gestational age and fetal growth restriction, gestational hypertension, stillbirth
- Concerns during current pregnancy, e.g. heavy bleeding after 20 weeks gestation, gestational hypertension, pre-eclampsia, antepartum haemorrhage, placental abruption
- Other risk factors with a less significant causative relationship include nulliparity, maternal age greater than 40 years if multiparous, reproductive technology-assisted conception, BMI < 18.5 kg/m2 or > 30 kg/m2
- Primary care clinicians are well placed to manage the increased long-term cardiovascular disease risk (hypertension and ischaemic heart disease) in people who have given birth to an infant with fetal growth restriction
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.
Syphilis infections in 2022 increased 8% from the previous year to 486 cases (also see Bulletin 71) while the number of reported gonorrhoea infections also increased by 8% with a total of 6,970 cases. The number of cases of chlamydia in 2022 was 25,039 which is similar to the previous year (25,012).
The highest rates of syphilis and gonorrhoea were reported in men who have sex with men (MSM). Chlamydia is most commonly seen in females aged 15 – 29 years. Lower reported rates of chlamydia in males may be explained by testing rates being three times lower than females.
Data continue to show Māori and Pacific peoples are disproportionately affected by STIs, with significantly higher rates of syphilis (including during pregnancy and congenital syphilis), gonorrhoea and chlamydia infections than other ethnic groups.
Prioritise opportunistic sexual health discussions and STI screening in these high-risk groups. A sexual health audit may be an effective strategy to increase awareness in your practice about STI screening. The bpacnz Sexual health checks in younger males audit provides a structured plan and can also be customised to different demographic groups.
NZF updates for August
Significant changes to the NZF in the August, 2023, release include:
- COVID-19 booster dose recommendations and the meningococcal B vaccine (Bexsero®) information have been added to therapeutic notes for the immunisation of special groups
- New monograph has been added: cannabidiol (indicated for adjunctive therapy of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome under neurologist supervison)
- New indication added to the nitrofurantoin monograph: prophylaxis of urinary-tract infection following surgery or procedures involving the genito-urinary tract
- Updated dosing information added to clonazepam monograph: further information on dosing 2.5 mg/mL oral liquid
- Updated dosing information added to beclomethasone dipropionate (inhalation) and budesonide (inhalation) monographs: lower recommended doses for most patients, based on the NZ Adolescent and Adult Asthma Guidelines 2020
- New caution added to the formoterol fumarate dihydrate and salmeterol monographs: must be used in combination with a maintenance inhaled corticosteroid (ICS) in the management of asthma—the use of a combination ICS + LABA inhaler is preferred to a single component long-acting beta2 agonist (LABA) inhaler
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.
- National health databases were used to gather information on the dispensing of asthma medicines and oral corticosteroids, as well as hospital admissions for asthma in a 12-month period. This information was used as a proxy for asthma diagnosis and asthma exacerbations.
- The total number of people with asthma in New Zealand increased from 447,797 in 2010 to 512,627 in 2019, however, due to an increase in total population the overall estimated prevalence of asthma remained stable at 10.3%
- Māori and Pacific peoples still have the highest rates of asthma compared to other ethnicities (13% and 11% respectively, in 2019)
- Between 2010 and 2019 the dispensing of inhaled corticosteroids in combination with long-acting beta agonists has increased (35% in 2019) while the dispensing of inhaled corticosteroids reduced (26% in 2019). These changes are likely the result of updated recommendations for the management of asthma.
- Short acting beta agonists dispensing remained stable over the ten-year period (> 80%)
- There was a significant increase in the incidence of asthma exacerbations (defined as a person who was discharged from hospital with a diagnosis of asthma, or dispensed a course of oral corticosteroids) with 376 exacerbations per 1,000 patient years in 2010 rising to 438 exacerbations per 1,000 patient years in 2019
- Children aged under five years and people aged over 65 years are at highest risk of asthma exacerbations
- Pacific people are most significantly impacted by asthma exacerbations compared to other ethnic groups (539 exacerbation per 1,000 patient years in 2019)
- Between 2010 and 2019, the number of people admitted to hospital for asthma reduced by 25%, however, Māori and Pacific peoples still made up more than 50% of those hospital admissions while only accounting for 25% of total asthma diagnoses in New Zealand
- Study authors suggest that the decrease in hospitalisation but increase in exacerbations could be "an artefact of an increased willingness of prescribers to prescribe oral corticosteroids rather than a true increase in exacerbations and/or better management of asthma in primary care, leading to reduced hospitalisations since a greater proportion of asthma exacerbations is being managed in an outpatient setting"
- This change could also be explained by an increase in health-seeking behaviour
- Potential limitations of this study relate to the use of medicines dispensing records to estimate asthma diagnosis and exacerbation, e.g. asthma medicines may be prescribed to children with symptoms of bronchiectasis, and older people who may have other chronic lung diseases, and oral corticosteroids may be prescribed for reasons other than asthma exacerbation, e.g. gout
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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