Published: 3 June, 2022
Coeliac Awareness Week
Next week (6 – 12th June) is coeliac disease awareness week. The theme for this year is “Thriving: living your
best coeliac life”. Click here for more information. Coeliac disease is a chronic inflammatory condition of the
small intestine that causes villous atrophy and results in nutrient malabsorption. This condition occurs in genetically susceptible people and involves an autoimmune response to gluten –
the major protein found in varieties of wheat, rye and barley. It is not an allergy to gluten. People with untreated coeliac disease have an increased risk of long-term health conditions
such as osteoporosis, lymphoproliferative disorders and gastrointestinal malignancy.
Coeliac disease is a relatively common condition affecting 1 in 82 adults in Australasia, however, it is often unrecognised as symptoms can be vague and non-specific and are not always
related to the gastrointestinal tract. A strict gluten-free diet is the only effective treatment for people with confirmed coeliac disease. Being diagnosed with coeliac disease can have
a significant impact on a person’s life as they navigate the challenges of being gluten-free. Patients should be provided with ongoing support, education and reassurance when they are
required to change to and sustain a gluten-free diet. Adherence to a strict gluten-free diet is challenging, even in ideal circumstances and can be complicated by family and professional
commitments as well as fears of social isolation or being different.
For further patient-orientated information about coeliac disease, see: https://coeliac.org.nz/
Stay tuned for an upcoming article on coeliac disease from the bpacnz team
Antiviral treatment for COVID-19 – access criteria assessment tool
Last month, access criteria to COVID-19 antiviral treatments was
widened. To make it easier for clinicians to assess a patient’s eligibility for funded treatment, PHARMAC has released an online tool,
which helps users work through criteria 4 of the 5-part access criteria, i.e. the patient must also meet criteria 1, 2, 3 and 5 to be eligible for funded treatment. For some patients,
you will still need to determine their eligibility based on the number of high-risk medical conditions they have – there is a link to this list
within the tool
For further information, see: https://pharmac.govt.nz/news-and-resources/news/covid-19-antiviral-access-criteria-assessment-tool/
Pharmacist prescribers can now prescribe antivirals
A number of COVID-19 medicines have been added to the schedule for pharmacist prescribers, including nirmatrelvir with ritonavir (Paxlovid), casirivimab and imdevimab (Ronapreve) and
molnupiravir (Lagevrio). Widening the range of prescribers for antiviral medicines is expected to improve community access to COVID-19 treatments and enable timely access to treatment
for people who are at risk of severe illness with COVID-19. Click here
for more information.
Changes to liquid paracetamol
Changes to prescribing and dispensing - PHARMAC has advised
that limits have been placed on the amount of oral liquid paracetamol that can be prescribed or dispensed.
This action has been taken to ensure that there are sufficient supplies of the currently funded Paracare brand due to the supplier, API Consumer Brands, leaving the market and
because there is still significant worldwide demand due to COVID-19.
From 1 June, 2022:
- Stat dispensing for both strengths of the Paracare brands will be removed
- The maximum amount able to be prescribed per prescription will be 600 mL. Patients who require regular daily dosing, e.g. those with long-term conditions can be
prescribed more by endorsement.
- The maximum amount able to be dispensed at one time (other than for patients with endorsement) will be 200 mL with repeat dispensing allowed if the amount
prescribed exceeds this limit.
Brand and pack size changes – PHARMAC has secured ongoing supply of liquid paracetamol but it will mean that the brand and pack sizes will change.
The new brands will have the same flavours as the current funded brands, however, they will only come in 200 mL bottles.
The upcoming changes are:
- From 1 November, 2022, the funded brand of paracetamol 250 mg per 5 mL oral liquid will be Pamol
- From 1 January, 2023, the funded brand of paracetamol 120 mg per 5 mL oral liquid will be Paracetamol (Ethics)
Infant formula recall
The Ministry for Primary Industries has issued a safety notice
about three brands of infant formula. Similac, Alimentum and EleCare brands of powdered infant formula are being recalled over concerns for the possible presence of Cronobacter.
These brands are not available for purchase in New Zealand, however, they can be purchased from online platforms. Encourage parents or caregivers who source their infant formula
online to check the batch information.
N.B. EleCare is funded in New Zealand but is currently out of stock
and batches sourced via a prescription through a pharmacy are not affected.
On another note, infant formula shortages continue to be reported internationally due to manufacturing issues and recalls. Stocks of most brands of infant formula in New Zealand are
currently unaffected, however, general measures such as not stockpiling and only prescribing in appropriate quantities, should continue. N.B. There are still ongoing
Nutricia supply issues affecting some products such as extensively hydrolysed formula.
You can keep up to date with the latest medicine supply issues here.
Updated guidance on doctor to doctor complaints
The Medical Council of New Zealand has released updated guidance on what to do when you have concerns about another doctor’s conduct, performance, competence or health. The guidance sets out a tiered approach and recommends that the concern be raised directly with the doctor in the first instance, if appropriate. It also addresses how to raise a concern about another health professional who is not a doctor.
Key points include:
- Find out the facts without delaying the issue to minimise the risk of harm to the patient
- Raise concerns directly with the doctor (if appropriate) and document your actions and the doctor’s response
- Follow your organisation’s procedure for reporting concerns if the matter requires escalation
- Notify Te Kaunihera Rata o Aotearoa I Medical Council of New Zealand as appropriate, i.e. if you remain concerned that the conduct, competence or health of the doctor might pose a risk of harm
- Notify the Health and Disability Commissioner if you have concerns about the standard of care another doctor has provided to a patient
Read the full statement here
NZF updates for June
Significant changes to the NZF in the June, 2022, release include:
- Type 1 diabetes (high risk of diabetic ketoacidosis) has been added as a contra-indication for empagliflozin and empagliflozin + metformin hydrochloride
- A new caution, serotonin syndrome, has been added to the monograph for phentermine. There is potential risk for serotonin syndrome with concomitant use of other serotonergic medicines.
- The monograph for testosterone and esters has been updated, e.g. updated contra-indications, pre-treatment screening, monitoring requirements and patient advice. N.B. Testosterone cypionate 1 g/10 mL injections are out of stock until September, 2022.
- New patient information leaflets have been added for adapalene, pioglitazone, remdesivir and rosuvastatin
- Health Navigator leaflets in English, Te reo Māori, Samoan, Tongan, Cook Islands Māori and Niuean have been added for paracetamol and Paxlovid (nirmatrelvir with ritonavir). Chinese (simplified) has also been added for Paxlovid.
Paper of the Week: Monkeypox – the latest virus to surface
This week it is not “paper of the week”, more a look at the “virus of the week”. With various reports about monkeypox circulating in the media and growing case numbers worldwide, we thought that it would be interesting and potentially helpful to provide a general overview and some background on this zoonotic virus. With recent reports of up to five cases in Australia, sooner or later, we may see a case here.
You don’t catch monkeypox from monkeys – it was so named because it was first described in 1958 in monkeys kept for polio vaccine research. Monkeypox is caused by a virus belonging to the genus Orthopoxvirus. This genus also includes variola virus which causes smallpox, cowpox and other related viruses. The first human case of monkeypox was identified in 1970 in the Democratic Republic of the Congo and it is now endemic in West and Central Africa (two separate strains) with the reservoir of the virus thought to be rodents such as African squirrels, pouched rats and dormice. Intermittent outbreaks have occurred since 1970, generally in other African countries or in countries outside of Africa due to international travel or the importation of animals. For example, a 2003 outbreak of over 70 cases in the USA was linked to the importation of rodents (including squirrels, giant rats, porcupines and dormice) from Ghana for the exotic pet trade, who were housed in close proximity to native prairie dogs sold as pets. The prairie dogs were highly susceptible to monkeypox and transmitted the virus to humans.
The 2022 outbreak is rapidly evolving with cases of monkeypox increasing daily. There have been 190 confirmed cases in the UK (as of 31 May, 2022) and 19 cases in the USA (as of 1 June, 2022). Australia has two confirmed cases, one diagnosed by a general practitioner, and there are now unconfirmed reports of more. In total, as of late May, over 257 cases have been confirmed worldwide with up to 127 further suspected cases. Cases have been reported in many other countries including the Netherlands, Portugal, Italy, Spain, France, Germany, Belgium, Israel, Mexico, the United Arab Emirates and Canada.
The incubation period for monkeypox is approximately 12 days but can range from 5 – 21 days. Initial symptoms include fever, chills, headache, myalgia, fatigue and enlarged lymph nodes. The characteristic rash appears within 1 – 3 days after the onset of fever and tends to start on the face and spread to the rest of the body (often on the hands and feet). Genital and peri-genital lesions have been reported during the 2022 outbreak. The rash starts with small 2 – 5 mm maculopapules which then develop into vesicles and then pustules which start to crust and scab over around day seven. The scabs take another week to resolve during which time the person remains infectious.
Monkeypox generally causes mild, self-limiting symptoms lasting a total of 2 – 4 weeks. The virus can cause severe disease in some people, e.g. those who are immunocompromised, malnourished or at the extremes of age. Deaths have been reported in Africa with a case fatality ratio of between 3 – 6 % depending on the strain. All cases outside of Africa in 2022 have been identified as the less virulent West African strain and not the more virulent Congo basin strain.
The virus is spread by person-person contact usually via:
- Direct contact with monkeypox skin lesions
- Sexual or close contact with an infected person
- Contact with linen or clothing used by an infected person
- Respiratory droplets from an infected person
Community transmission is now occurring in Europe and America in this latest outbreak. The number of cases in the UK has risen quickly in just over three weeks with the first case only confirmed on 6 May, 2022. Most of the infections in the UK have occurred in people who live in London (around 86%). Most cases are male and the majority are aged from 20 to 49 years. A growing proportion of the cases have been identified amongst men who have sex with men (MSM). Therefore, in addition to being vigilant for characteristic symptoms amongst travellers recently returned from overseas, clinicians in the UK are being reminded that they also need to be aware of the potentially increased risk in individuals who identify as MSM or those with multiple sexual and/or casual sexual partners.
Treatment for monkeypox is supportive with consideration for the use of antiviral medicines* only in those at high risk or with severe disease. People suspected of having monkeypox should be advised to isolate (for up to 21 days) and seek medical advice remotely if possible, to reduce the risk of transmission. The disease is confirmed by polymerase chain reaction (PCR) testing. Vaccination with smallpox vaccination may provide protection against the monkeypox virus (stated to be 85%) and in countries where the vaccines are available, this is recommended for high-risk close contacts. The UK Health Security Agency (UKHSA) who is monitoring the outbreak in the UK has purchased supplies of Imvanex, a smallpox vaccine, which is being offered as post-exposure prophylaxis for close contacts of confirmed cases.
* Such as tecovirimat, an orthopoxvirus-specific antiviral medicine. Tecovirimat has been licensed in 2022 by the European Medicines Agency (EMA) but is not widely available (and not available in New Zealand) or cidofovir – an unapproved, unfunded antiviral medicine supplied under Section 29, indicated in New Zealand for the treatment of cytomegalovirus (CMV) in people with acquired immunodeficiency syndrome (AIDS)
If clinicians in primary care in New Zealand are suspicious that their patient may have monkeypox, contact your local Medical Officer of Health. Consider telemedicine where possible or ensure adequate PPE.
This Bulletin is supported by the South Link Education Trust
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