Published: 3 June, 2022
Contents
B-QuiCK: a new online tool from bpacnz
We are pleased to announce the launch of our new online tool: B-QuiCK! This tool, the name of which stands for bpacnz Quick Clinical Knowledge, provides short clinical summaries from some of the full articles available on our website. Relevant sections from these resources have been condensed into “notepad pages” or algorithms designed to offer rapid access to practical clinical information, such as what to ask, examine, investigate, prescribe and monitor when managing a condition.
Currently, all topics are initially displayed by default when you open the page. Topics can be filtered by category by clicking on the menu bar at the top. We will be regularly adding new topics to this resource with the aim of developing a comprehensive quick reference library for primary care clinicians. A future development will be to incorporate this tool directly into your practice management system.
N.B. A link to the full article is included at the end of each summary; it is strongly recommended to review the original resource at your convenience for full details of recommendations and evidence.
New article: Addressing heart failure in primary care
The incidence of heart failure is increasing in New Zealand, likely reflecting our ageing population as well as an increase in risk factors such as obesity, type 2 diabetes and ischaemic heart disease. Heart failure is also becoming more common in younger age groups, particularly among Māori and Pacific peoples. To help support primary healthcare professionals in managing patients with this complex clinical syndrome, we have developed a two-part series of articles:
We also outline the increasing evidence that supports sodium-glucose cotransporter-2 (SGLT-2) inhibitors as a candidate for the “cardio-protection toolbox”; this medicine class can improve prognostic outcomes in patients with heart failure, with or without diabetes. However, SGLT-2 inhibitors are currently only funded for patients with type 2 diabetes who meet the Special Authority criteria.
PHARMAC medicine supply issues
The following issues relating to medicine supply have recently been announced by PHARMAC. This information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Laxative products
PHARMAC has been advised that only limited supplies of laxsol (docusate sodium with sennosides) are currently available because of a shortage of one of the ingredients in this medicine. COVID-19 related supply issues are also affecting re-supply to some pharmacies, but supplies are expected to be back to normal levels by late-June, 2022.
There is an ongoing supply issue with Konsyl-D (Ispagula [psyllium] husk) which was covered in Bulletin 45. An alternative funded product (Macro Organic Psyllium Husk) was made available, however, PHARMAC advises that there are also shortages of this product, hoped to be resolved by mid-June, 2022.
Selegiline
A reminder that selegiline, a monoamine-oxidase-B inhibitor prescribed for some patients with Parkinson’s disease, will no longer be available from mid-2022. PHARMAC have previously advised that they have been unable to find an alternative supplier for selegiline, an Apotex product. Changes introduced last year mean that current patients should now have been transitioned to other treatments, e.g. rasagiline (for more information see Bulletin 30). Supplies of selegiline are expected to be exhausted soon and the product will be discontinued.
Potential interaction between levothyroxine and ciprofloxacin
A case report received by CARM describing a potential interaction between levothyroxine and ciprofloxacin was outlined in a recent Prescriber Update. Symptoms reported by the patient were fatigue, reduced heart rate and sensitivity to cold, i.e. features common in people with hypothyroidism. The patient improved after ciprofloxacin was discontinued and the dose of levothyroxine temporarily increased. There is a small amount of supporting evidence in the literature citing similar interactions. Ciprofloxacin is thought to potentially decrease the serum concentration of levothyroxine by limiting intestinal absorption when the medicines are used concomitantly.
It is recommended that if the two medicines are used together that:
- Administration is separated by six hours
- Patients are informed about the symptoms and signs that could occur
- Thyroid function be monitored
Information in the data sheets for both medicines will be updated to reflect this potential interaction.
Access to funded treatments for relapsing remitting multiple sclerosis to be widened
Following a proposal in May, 2022, PHARMAC has announced that they are to fund treatment earlier for people with relapsing remitting multiple sclerosis. From 1 July, 2022, the Special Authority criteria for eight treatments (see below) for multiple sclerosis will be updated to include the 2017 McDonald criteria. This will allow people to access funded treatment for multiple sclerosis after only one clinical attack (also known as clinically isolated syndrome, CIS), and it is hoped this will bring New Zealand in line with international guidelines. Currently, people with multiple sclerosis must wait until they have had two clinical attacks before they can access funded treatment. Earlier access to funded treatment may delay transition from CIS to clinically definite multiple sclerosis, delay transition to secondary progressive multiple sclerosis, reduce the frequency of attacks and reduce brain atrophy.
Read more
The following treatments will have widened access for people with multiple sclerosis:
- Dimethyl fumarate (Tecfidera)
- Fingolimod (Gilenya)
- Glatiramer acetate (Copaxone)
- Interferon beta-1-alpha (Avonex)
- Interferon beta-1-beta (Betaferon)
- Natalizumab (Tysabri)
- Ocrelizumab (Ocrevus)
- Teriflunomide (Aubagio)
Temporary top-up payments available to support MMR vaccination uptake
Immunisation coverage continues to be a key focus for the New Zealand health system, particularly given the lower rates consistently reported for Māori and Pacific peoples. The Ministry of Health has now established temporary top-up payment to help increase uptake of MMR vaccination, with a particular focus on these at-risk communities.
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For General Practices, a top-up payment of:
- $12.85 (ex. GST) per MMR vaccine will be made in addition to the Immunisation Administration Fee (bringing the total payment up to $36.05) when administered to Māori and Pacific peoples who are eligible for funded vaccination
- $1.80 (ex. GST) per MMR vaccine will be made in addition to the Immunisation Administration Fee (bringing the total payment up to $25.00) when administered to people eligible for funded vaccination who are not of Māori or Pacific ethnicity
Top-up payments will be made directly to PHOs, who in turn will pass these on to the respective providers. These will be made on July 20 for the period 16 May – June, and on August 20 for the month of July.
Sudden Unexpected Death in Infancy reports released
Sudden Unexpected Death in Infancy (SUDI) is the leading cause of preventable mortality in infants in New Zealand. In 2020, the Ministry of Health commissioned research to better understand the reasons behind SUDI rates and to identify potential improvements that could be made to the National SUDI Prevention Programme. Reports have now been released and can be found here.
Read more
Winter is a peak time for SUDI, so now is a great opportunity to reinforce appropriate messaging for the prevention of SUDI to parents/caregivers of infants, such as:
- Smoking cessation. Support and encourage parents/family members to stop smoking. Exposure to tobacco smoke is a significant risk factor for SUDI; in the reports, most cases of SUDI occurred in infants with mothers who were smokers who declined smoking cessation support.
- Safe sleep practices. Ensure the infant sleeps on a flat surface, on their back and with their face clear, i.e. not covered by anything.
- Support plans. Infants may be taken into the parental bed when they will not settle elsewhere, and sometimes exhausted mothers fall asleep while breastfeeding. Having a plan in place for when the mother is exhausted, and the infant is crying and unsettled can help to avoid situations where the infant may be at risk for SUDI.
- Know where to get help. Ensure the parents/family know where to get support, e.g. their general practice team, Plunket.
For further information on the recommendations and data from main report, see: https://www.health.govt.nz/system/files/documents/publications/sudden-unexpected-death-in-infancy-report-may2022.pdf
Podcast of the Week: The Good GP – Assessing dementia in primary care
This week’s podcast is from The Good GP, an Australian podcast series intended to fit into the busy schedules of general practitioners. In a recent 30-minute episode, The Good GP interviews Dr Hilton Koppe, Dr Marita Long and Dr Steph Daly who are GPs and also podcasters from the “Dementia in Practice” training series. The focus is on the assessment of patients with dementia in primary care and it includes discussion of a diagnostic framework to simplify the process. If you find this interesting and helpful, and you are ready for more, there are another 18 short podcasts on the Dementia Training Australia website covering all aspects of caring for people for dementia in primary care.
Listen to the full Good GP podcast here.
Read more
Dementia, now often referred to as major neurocognitive disorder, is a wide-ranging term used to describe a collection of symptoms that are caused by many underlying diseases or disease processes affecting the brain, for example, Alzheimer’s disease, vascular disease, Lewy body disease, Parkinson’s disease, Huntington’s disease and multiple sclerosis. General practitioners have a significant role in the assessment and diagnostic workup of people in whom there is suspicion of dementia and also in the ongoing management of patients with dementia. In The Good GP podcast the presenters provide tips for taking a comprehensive patient history and how to tease out the things that distinguish dementia from mild cognitive impairment, e.g. asking the patient specific questions about word finding, planning of events and how they are able to manage processes that require several steps to complete (executive functioning). If a couple attend an appointment together and one expresses concern about the other, an important thing to ask about is how their roles may have changed and why, although this can take some time to unravel.
The role of the whole primary care team in early detection is emphasised, e.g. the importance of reception staff and practice nurses, who may often pick up on subtle changes in behaviour in patients they know well. Spouses and family members will usually be the first to mention their concerns, with self-reporting of memory loss less common. We have all probably noticed the “head turning sign”, but who knew it was a real thing? Listen to the podcast to find out more.
A framework is provided that aims to simplify the process of diagnosis with the components grouped into five domains:
- Cognitive decline – the classic memory changes
- Functional decline – e.g. no longer able to perform usual activities of daily living (ADLs) or tasks that require executive functioning
- Psychiatric symptoms – which may include delusions, hallucinations, depression or anxiety
- Behavioural changes – e.g. anger or aggression that is out of character for the person
- Physical decline – such as changes in mobility or movement, swallowing difficulties
In addition, there are a number of inclusion and exclusion criteria to consider when making a new diagnosis of dementia. The four inclusion criteria are:
- There is a gradual onset of poor memory (not days or weeks)
- Things are getting worse (not just always losing your keys or forgetting names)
- There is a parallel decline in the patient’s level of functioning
- There is some evidence of cortical dysfunction which may include word finding problems or “empty speech”, often the loss of ability to name objects or increasing difficulties with tasks
Exclusion criteria are:
- Not to make a new diagnosis in the presence of a delirium – wait and reassess after six months
- Other organic causes have been excluded, e.g. management of iron or B12 deficiency, a CT scan of the head has been done to exclude mass lesions
- Any psychiatric illness, e.g. depression, is considered, treated and the patient reassessed
N.B. The recommendations given for screening tools for dementia in primary care are intended for an Australian audience. Mini-Addenbrooke’s Cognitive Examination (mini-ACE) is the screening tool currently recommended in New Zealand.
For further reading, bpac has published a series of articles on cognitive impairment and dementia, see:
This Bulletin is supported by the South Link Education Trust
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