Published: 26 January, 2024
Today we resume Best Practice Bulletin for the year, brought to you fortnightly. We have some great topics in store for you over the next few months and we are excited about some new resources we have been working on behind the scenes. We would love to hear from our readers to see what topics you would like us to cover this year, what type of resources you would like to see more of, and any other feedback you have: email firstname.lastname@example.org
New article: Melatonin is it worthwhile for sleep?
Getting a good night’s sleep is a priority for most people. Sleep deprivation or poor sleep quality can significantly influence our daytime functioning, mood and quality of life. Sleep disturbances, with multifaceted causes, can make achieving satisfactory sleep more challenging for some people.
Melatonin is a naturally occurring hormone that regulates circadian rhythm and sleep. Given its important biological functions, there has been interest in melatonin as a medicine, and patients often enquire about whether supplementation can help manage sleep disturbances. Inconsistent conclusions in the medical literature regarding melatonin’s efficacy may explain why the bpacnz melatonin article is frequently among our most popular resources. We have now re-examined the evidence and updated our article on the use of melatonin for sleep, but the conclusions remain the same. Evidence suggests that melatonin may provide some benefit for older adults with insomnia when dosed at the correct time, and it is generally well tolerated. However, melatonin is not a first-line treatment and use should not be prioritised over other forms of evidence-based care, such as behavioural interventions and prioritising good sleep hygiene.
The full article can be accessed here
January is Cervical Cancer Awareness Month
This month is Cervical Cancer Awareness Month. Cervical cancer is the third most common gynaecological cancer (after endometrial and ovarian cancer) and is largely preventable through the HPV vaccination and cervical screening programmes. Since the implementation of these programmes in New Zealand, fewer people are being diagnosed with, and dying from, cervical cancer. The move from cytology-based to HPV-based primary cervical screening in September, 2023, is predicted to further reduce the burden of cervical cancer over time.
Read more about the workup of a patient with clinical suspicion of cervical cancer
Most females with pre-cancerous cervical lesions are asymptomatic. Symptoms of cervical cancer if present, are often subtle and may be attributed to other gynaecological conditions. However, the presence of multiple symptoms and signs should raise clinical suspicion for cervical cancer:
- Abnormal vaginal bleeding, including inter-menstrual, post-menopausal or post-coital bleeding; bleeding is the most common symptom of cervical cancer
- Unusual and persistent vaginal discharge
- Non-specific pelvic or low back pain or pressure
- Abdominal pain
- Pain during sexual intercourse
- Loss of appetite, weight loss or fatigue
- Bladder changes, e.g. urinary tract infection, haematuria
- Bowel changes, e.g. haematochezia
- Unexplained laboratory results, e.g. low haemoglobin or ferritin, high white blood cell count (N.B. Biochemical changes are often not present.)
Perform a pelvic examination, including speculum examination, and take a liquid-based cytology sample for both HPV and cytology testing* for patients with suspicion of cervical cancer. Palpable inguinal or supraclavicular lymph nodes suggest advanced cancer. If the patient has symptoms or signs of cervical cancer or if the appearance of the cervix is visually abnormal, refer to or discuss with a colposcopy service, irrespective of HPV and cytology results. Check local HealthPathways for specific referral information.
*Note the presence of symptoms and that a co-test is required on the laboratory form otherwise cytology will not be performed unless HPV is detected.
This is a timely reminder to opportunistically check whether eligible patients are fully vaccinated against HPV and are up to date with cervical screening. A clinical audit is available for identifying patients who are not participating in regular cervical screening.
For further information on cervical cancer early detection and referral, see: https://bpac.org.nz/2022/cervical-cancer.aspx
Monitoring Communication: vildagliptin use may be associated with intestinal obstruction
Medsafe has issued a Monitoring Communication to seek more information from clinicians on the risk of intestinal obstruction, including ileus, with the use of DPP-4 inhibitors, e.g. vildagliptin. Responses are due by 15th June, 2024.
In the September, 2023 meeting of the Medicines Adverse Reactions Committee (MARC), the risk of intestinal obstruction with GLP-1 receptor agonists, e.g. dulaglutide, and DPP-4 inhibitors, e.g. vildagliptin, was reviewed. The Committee found sufficient evidence of an association between GLP-1 receptor agonists and an increased risk of intestinal obstruction, including ileus, and recommended that the data sheets of GLP-1 receptor agonists be updated to reflect this risk (as reported in Bulletin 89). Medsafe is now gathering more information on whether this risk also extends to DPP-4 inhibitors, as available evidence is limited. The evidence review can be found here.
Healthcare professionals should be alert for this potential risk with both GLP-1 receptor agonists and DPP-4 inhibitors, and report any suspected cases of ileus, especially with vildagliptin, to CARM.
For information on prescribing vildagliptin for type 2 diabetes, see: https://bpac.org.nz/2021/diabetes-vildagliptin.aspx
Proposal for pharmacists to administer many childhood vaccinations
Pharmac has released a joint proposal with Te Whatu Ora, Health New Zealand, that would allow pharmacists to administer selected childhood vaccinations, with the aim of boosting immunisation rates. It is proposed that from 1st March, 2024, Xpharm restrictions are removed in the Pharmaceutical Schedule, meaning that pharmacies would be able to claim reimbursement and therefore provide funded vaccination with the following childhood vaccines:
- Diphtheria, tetanus, pertussis and polio vaccine (Infanrix IPV)
- Diphtheria, tetanus, pertussis, polio, hepatitis B and haemophilus influenzae type B vaccine (Infanrix-hexa)
- Haemophilus influenzae type B vaccine (Hiberix)
- Pneumococcal (PCV13) conjugate vaccine (Prevenar 13)
- Rotavirus oral vaccine (Rotarix)
- Varicella (chickenpox) vaccine (Varivax)
It is also stated that pharmacists would be provided with training and resources to support this proposed change.
Submissions on this proposal are due by 5pm, Monday, 29th January, 2024.
Read the proposal here.
Reminder: Funded catch-up period for meningococcal B vaccines ending next month
Young people aged 13 to 25 years who are moving into a specified close living situation* are being encouraged to get immunised against meningococcal disease. Meningococcal ACWY (MenQuadfi) and meningococcal B (Bexsero) vaccines are funded for people aged 13 – 25 years currently in their first year of a specified close living situation or who will be moving into communal accommodation within the next three months.
Since March, 2023, a catch-up programme has been available which allows two doses of the meningococcal B vaccine to be funded for people aged 13 – 25 years at any year of living in a specified close living situation. Te Whatu Ora, Health New Zealand, is reminding eligible people to get immunised before 28th February, 2024, when this funded catch-up period ends.
*Close living situations include boarding schools, hostels, university halls of residence, military barracks and prisons
New COVID-19 vaccine to be available for winter 2024
Medsafe has approved an updated COVID-19 vaccine by Pfizer, which targets the Omicron XBB.1.5 subvariant, for use in people aged 12 years and older in New Zealand. The updated vaccine, Comirnaty Omicron XBB.1.5, is expected to be available for winter. There are currently no proposed changes to COVID-19 vaccine eligibility criteria. In the meantime, the Pfizer BA 4.5 booster vaccine remains available and should continue to be encouraged to reduce the risk of severe illness from COVID-19 for those who are eligible. For further information on COVID-19 boosters, see Bulletin 90.
The Comirnaty Omicron XBB.1.5 data sheet is available here, and further details about the vaccine will be released once information is available.
Medicines supply news: phenobarbitone, prazosin
The following issues relating to medicine supply, of particular interest to primary care, have recently been announced. This information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Phenobarbitone 15 mg tablet brand change
The funded brand of phenobarbitone 15 mg tablets is changing (the 30 mg tablet brand has already changed). From 1st March, 2024, phenobarbitone 15 mg tablets (Noumed) will be listed on the Pharmaceutical Schedule. Most clinicians will not have patients taking this medicine (it is prescribed to approximately 400 people in New Zealand); however, it is important to be aware of this brand change as alterations in medicine regimens for patients with epilepsy (the main use of phenobarbitone) may in some cases result in adverse outcomes. Patients undergoing the brand change will need to be assessed and monitored (see "read more" below).
Additionally, stat dispensing will be removed from phenobarbitone from 1st February, 2024, to align with Misuse of Drugs Regulations; it can still be prescribed for three months, however, the patient can only be dispensed one month’s supply of medicine at a time.
Prescribers are being asked to schedule appointments with patients taking phenobarbitone 15 mg tablets, approximately one month before and after the brand change; patient co-payments for these appointments will be funded by Pharmac. The patient will also require a series of laboratory monitoring tests to measure serum drug levels before and after the change. See full details of this on the Pharmac website.
As reported in Bulletin 73, API, the previous supplier of phenobarbitone 15 mg and 30 mg tablets, withdrew from the market and new suppliers of both phenobarbitone 15 mg and 30 mg tablets were sought. The Noumed brand of phenobarbitone 30 mg tablets has been funded since 1st July, 2023 and patients should have switched to the new brand by now. Other formulations of phenobarbitone remain unaffected.
Patient information regarding the phenobarbitone brand changes is available here
Prazosin 1 mg, 2 mg and 5 mg tablets brand change
There is an ongoing supply issue affecting prazosin 1 mg, 2 mg and 5 mg (Arrotex) tablets. The manufacturing facility that produces the active ingredient in prazosin has closed due to a fire and production is not expected to restart before the middle of 2025. A new brand of prazosin 1 mg, 2 mg and 5 mg tablets, Minipress, has been temporarily listed on the Pharmaceutical Schedule. Like the Arrotex brand, Minipress prazosin will need to be prescribed for supply under Section 29 of the Medicines Act 1981. Supply of the Minipress brand of prazosin is expected to last two to three months and an ongoing alternative supply is being sourced.
New Zealand-based online CBT courses for perinatal wellbeing
Just a Thought is a New Zealand organisation that offers free online cognitive behavioural therapy (CBT) courses and other resources for a range of mental health conditions. Two new online CBT courses have now been released for people experiencing perinatal distress: Pregnancy Wellbeing and Postnatal Wellbeing.
The courses use CBT that has been specifically designed for women experiencing perinatal distress and provides them with support and an effective treatment option during pregnancy or postpartum without barriers to access. The courses can either be completed by the patient in a self-guided manner or through prescription by a clinician.
View all the courses available from Just a Thought here.
NZF updates for January
Significant changes to the NZF in the January, 2024, release include:
You can read about all the changes in the January release here. Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Body weight fluctuations by season
It is well established that obesity is risk factor for numerous health conditions and is associated with increased morbidity and mortality. The effects of carrying excess weight are not just physical; people who are obese may also experience low self-esteem, depression and discrimination. The causes of obesity are often multi-faceted and differ between people. Individualised significant behavioural and lifestyle changes are necessary to achieve a meaningful reduction in body weight. The start of the year usually coincides with an increase in people seeking assistance to manage their weight, due to overindulgence during the festive season or New Year resolutions. Using this motivation as a starting point to support people in achieving sustainable weight loss can set them up to improve their long-term health outcomes.
A recent study published in JAMA Network Open examined the pattern of weight change in adults in Australia over 12 months. The authors found that body weight fluctuated throughout the year with a peak in the summer months around Christmas and the New Year holiday. There were also some interesting findings about weight fluctuations during a typical week – if you weigh yourself on a Monday, you are likely to be heavier than later in the week.
Do you see an increase in patients seeking support for weight loss at this time of the year? How would you rate your ability to have conversations about weight loss with patients that are positively received? Are you confident about delivering individualised advice and interventions for behavioural and lifestyle changes for patients to achieve meaningful and sustained weight loss?
- This study included 12 months of data from 368 participants (57% female) who were parents/guardians of a school-aged child in Adelaide, Australia. Participants had a mean age of 40.2 years and a mean weight of 84.0 kg at the start of the monitoring period.
- Participants were encouraged to weigh themselves daily (or at a minimum, weekly) under similar conditions (e.g. same time of day, minimal clothing) using a supplied body weight scale
- On average, weekly body weight varied by 0.3% (i.e. 252 g for a person weighing 84.0 kg). Participants recorded their highest weekly body weights on Mondays and Tuesdays with body weight reducing over the week (relative to their body weight on Monday) before increasing again over the weekend.
- Weekly fluctuations in body weight were similar for participants who remained a stable weight or gained weight over the year while participants who experienced a decrease in body weight had comparatively smaller fluctuations within a week
- The median body weight change for participants was 0.3% (218 g) across the 12 months (mean, -0.2%; range, -29% to 24%)
- Over the course of 12 months from December, participants body weight increased notably over Christmas and the New Year holiday (mean, 0.7% or 546 g), steadily decreased to April, spiked again at Easter (mean, 0.3% or 244 g), before gradually rising again until August (winter)
- This study was the first of its kind conducted in the southern hemisphere and potentially provides data that more accurately relates to the seasonal effects seen in New Zealand. However, this study was limited to one Australian city (Adelaide) in which the climate differs from most of New Zealand and may not be generalisable to the whole population.
- The study protocol encouraged daily weighing, but there was variation in the total number of measurements the participants took, ranging from 7 to 363 days (mean, 268 days)
- Individuals who were more consistent with weighing themselves regularly may also be more conscious of their health and more likely to take steps to control their body weight, e.g. limiting calorie intake, exercising
- The authors concluded that weight loss interventions may be more effective if targeted around key holiday periods throughout the year
Maher C, Ferguson T, Curtis R, et al. Weekly, seasonal, and festive period weight gain among Australian adults. JAMA Netw Open 2023;6:e2326038. doi:10.1001/jamanetworkopen.2023.26038
For further information on weight loss interventions, see: “Weight loss: the options and the evidence”, available from https://bpac.org.nz/2022/weight-loss.aspx
This Bulletin is supported by the South Link Education Trust
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