Published: 15 July, 2022
Contents
New article: Recognising and managing OCD in primary care
Intrusive thoughts are experienced by most people, maybe even frequently. However, for some people these thoughts are all-encompassing and destructive to their ability to function in their everyday lives. Obsessive compulsive disorder (OCD) is characterised by unwanted, repetitive, intrusive thoughts, images or impulses (e.g. contamination, losing control, harm) that are highly distressing, and often lead to the performance of compulsive behaviours (e.g. checking, hand washing, seeking reassurance, rumination) to resolve the anxiety caused by the obsession. OCD affects approximately 2% of the population and can have a significant impact on quality of life, including relationships, education and employment. Diagnosis can be challenging due to the variable nature of presentation. We interviewed psychiatrist Dr Caleb Armstrong from Anteris NZ to learn more about OCD, including advice on how to manage patients in primary care.
Read more here
COVID Care app: free for Medtech users
An application to assist general practices in managing their patients with COVID in the community has just passed 3000 uses. Most patients (81%) have been triaged into self-management, but 4% of cases have resulted in a recommendation for urgent referral.
The Covid Care app, which was developed by the BPAC Clinical Solutions team, is free-of-charge for practices using Medtech Evolution or Medtech 32. It is designed to work seamlessly within your patient management system, integrating relevant patient information and using decision support to triage care and follow-up based on the patient’s symptoms and signs.
Covid Care is available now in your Medtech bestpractice dashboard. For further information, including a link to an instructional video, see: https://bpac.org.nz/2022/covidcare.aspx
Covid Care is provided to you free-of-charge by the South Link Education Trust and BPAC, supported by Medtech Global, as part of our ongoing commitment and service to general practice.
Anyone for flu vaccine?
There are still many eligible adults and children who have not received their funded influenza vaccination. The national target is for at least 75% of adults aged 65 years or over to be vaccinated this ‘flu season’. Currently, the overall vaccination rate in this group is 68.2%, but this rate is lower for Māori (62.9%) and Pacific peoples (59.3%). This year, Māori and Pacific peoples aged 55 years and over are also eligible for funded influenza vaccination, however, currently the vaccination rate for Māori aged 55 to 64 years is only 33.2% and 36.2% for Pacific peoples.
High risk groups with underlying health conditions, e.g. adults and children with chronic respiratory disease, people with serious mental illness, and all children aged 3-12 years are now eligible for funded influenza vaccination. All healthcare professionals are urged to discuss influenza vaccination at any healthcare interaction and ensure that people who are eligible for funded vaccination are aware of this.
The Ministry of Health publishes data on uptake of vaccinations by DHB, updated weekly: check out how your area is doing.
Patient information and resources about influenza vaccination are available here.
Nitrofurantoin recommended for Pharmacist supply
In the recently published minutes of the April meeting of the Medicines Classification Committee (MCC), it was recommended that modified release nitrofurantoin (Macrobid) be re-classified to be able to be sold by pharmacists for the first-line empiric treatment of uncomplicated urinary tract infection (UTI). This would bring pharmacist treatment in-line with current best practice recommendations for antibiotic choice for UTI. Currently pharmacists who have undergone specific training are able to supply trimethoprim for the empiric treatment of uncomplicated UTI. However, resistance to trimethoprim is increasing in many areas and in recent years this has no longer been the first-line recommended treatment for UTI.
Further details about the recommendation:
- Nitrofurantoin is to be supplied for oral use in packs of ten 100 mg modified release tablets
- The recommended eligible patient group is females aged 16-65 years with uncomplicated UTI
- To supply the medicine, the pharmacist must complete the Pharmaceutical Society of New Zealand training in the treatment of UTI; a particular feature of this training will highlight communication and management around adverse effects including hypersensitivity and renal impairment
- The MCC encourages the facilitation of data sharing between pharmacies and general practices to enable collaborative care and collection of population data on empiric antibiotic use
Read more about managing UTI in primary care here.
Don’t have time for that? See the B-QuiCK topic on UTI
Accuretic update
As reported in our previous Bulletin, patients taking Accuretic (quinapril + hydrochlorothiazide), and clinicians prescribing this medicine, were informed by PHARMAC on 30th June that they require a change in treatment due to contamination issues.
Key points and new information:
The problem
- Accuretic (quinapril + hydrochlorothiazide) supplied by Pfizer, has been found to contain small amounts of nitrosamines; long-term exposure to these substances is associated with a small cumulative increase in the risk of cancer
- This is a worldwide issue related to manufacturing processes and voluntary recalls have been taking place in other countries since March, 2022
- Patients are advised not to abruptly stop their medicine, but to discuss a change of treatment with their doctor
Actions
- There is no alternative brand of this medicine available; patients will need to be switched to losartan + hydrochlorothiazide combination tablets or switched to dual treatment with an ACE inhibitor or ARB and a thiazide or thiazide-like diuretic
Further information on selecting and prescribing ACE inhibitors and ARBs, including dosing, is available here
- Accuretic may still be supplied to patients from existing stock while arrangements are made to change their treatment
- Supplies of Accuretic are expected to begin to be disrupted from August, 2022
Payments
- PHARMAC will cover the cost of an initial consultation for patients switching treatment, patients should not be charged a fee; this payment is expected to come via your PHO
- PHARMAC is still considering funding for patients who require a follow-up appointment
- PHARMAC is offering a one-off payment to community pharmacies, which will include the prescription co-payment for two medicines and payment for work to support the medicine change, patients should not be charged a co-payment for the first dispensing of their replacement medicine(s)
New ACE on the horizon
PHARMAC is currently consulting on a proposal to fund ramipril, an ACE inhibitor that is commonly used in other countries, including Australia, for hypertension, heart failure and chronic kidney disease. If the proposal is accepted, from 1 November, 2022 ramipril will be fully funded without restriction, and available in four strengths of capsule.
Cilazapril is due to be delisted from the pharmaceutical schedule in mid-2023; currently no new patients may be initiated on this medicine and prescriptions for current patients must be endorsed.
Bupropion is available again
Recent supply issues have meant that patients who require pharmacological treatments for smoking cessation have had few options to choose from. As reported in Bulletin 48, varenicline has been unavailable since mid-2021 due to a supply issue – thought to be the same contamination problem with nitrosamines as with the recent recall of Accuretic. Bupropion has been subject to supply restrictions due to demand and global shortages, leaving nicotine replacement therapy as the remaining funded option.
PHARMAC has announced that the supply issue with bupropion has now resolved and stock is once again available. Varenicline remains unavailable.
Read more about smoking cessation treatments here.
Paper of the Week: Are low calorie beverages ‘sweet as’ for improving cardiovascular risk factors?
Recently, Coca-Cola ditched two of its popular Coke varieties and replaced them with Coke Zero Sugar. The jury is still out on taste, especially among the fervent fans of each of the previous brands, but the bigger question is – do low calorie/sugar free drinks actually offer any advantage over their sugary big sisters? A recent study in JAMA attempts to answer that question.
Read more
A 2014 paper in Nature cast doubt on the benefits of artificially sweetened drinks (i.e. as opposed to drinking the full sugared version) by demonstrating that they induce glucose intolerance by altering the intestinal microbiome (the study was in mice but with transferable results to humans). So, the very thing that people were reaching for to combat their cardiovascular risk, was actually making things worse, or at least offering no advantage. There have been many observational studies that have found increased body weight and type 2 diabetes in people consuming artificially sweetened drinks. However, this is somewhat of a “chicken v.s. egg” situation as this may be the reason they are drinking low-cal beverages in the first place.
A recently published systematic review and meta-analysis in JAMA, which included data from 17 randomised trials, attempted to settle the debate once and for all. They found that switching to low-calorie drinks in people who were overweight and at risk for (or had) diabetes resulted in small reductions in body weight (-1.06 kg), BMI (-0.32 points) and body fat (-0.6%), without evidence of harm. The effects on fasting blood glucose (-0.06 mmol/L), HbA1c (+0.12%) and total cholesterol (-0.1 mmol/L) were not significant. Interestingly, switching to water did not result in significant changes to these outcomes (but only three of the included trials studied this).
So, the bottom line is that a sugar-free drink is always going to be a better option than a drink with added sugar, and in the short-term the benefits of switching to sugar-free are similar to drinking water, albeit disappointingly small. However, long-term we don’t really know what effect artificial sweeteners may have on our metabolism and gut biome, therefore sticking to plain water is your best bet. Of course, the most significant results in improving cardiometabolic risk will come not just from what we drink, but in making better choices in the food we are eating, along with increasing exercise. So, ditching the full sugar Coke is just a first small step.
McGlynn N, Khan T, Wang L, et al. Association of low- and no-calorie sweetened beverages as a replacement for sugar-sweetened beverages with body weight and cardiometabolic risk. A systematic review and meta-analysis. JAMA Netw Open 2022;5(3):e222092. https://dx.doi.org/10.1001/jamanetworkopen.2022.2092
This Bulletin is supported by the South Link Education Trust
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