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Published: 5th April, 2024


New article – A progressive approach to managing atrial fibrillation

Atrial fibrillation (AF) is the most common form of sustained cardiac arrhythmia in adults, but people with AF are often asymptomatic. Detection in primary care therefore mostly relies on opportunistic assessment in patients aged ≥ 65 years, or sooner in those with other risk factors, e.g. Māori or Pacific peoples, previous TIA, hypertension.

Early action is essential as AF significantly increases the risk of stroke. However, the approach taken should not expose patients to an unnecessary risk of harm. Unless the onset of AF occurred within the past 12 hours, referral for electrical cardioversion is usually not appropriate in haemodynamically stable patients without prior anticoagulation due to the risk of thromboembolic complications. In most cases, treatment using direct oral anticoagulants (DOACs) and rate control medicines, alongside relevant lifestyle changes, is sufficient in primary care. AF will often spontaneously resolve without the need for intensifying management.

Nevertheless, the management of AF is an evolving discipline. There is ongoing debate in the literature regarding the merits of rhythm control, which is usually initiated in secondary care, and may be warranted early in younger or more symptomatic patients. In particular, catheter ablation is being increasingly recommended in guidelines, particularly for patients with AF and heart failure with a reduced ejection fraction, due to evidence that it improves symptoms and quality of life.

The full article can be accessed here. A B-QuiCK summary is also available.

Calls to ban engineered stone in New Zealand

The Royal Australasian College of Physicians (RACP) has called for the government to ban the use of engineered (artificial) stone in New Zealand or to implement strict controls on engineered stone importers and fabricators due to the unacceptable risk of accelerated silicosis, a deadly occupational disease. The RACP is also calling for a Registry to be established which would allow long-term follow-up and support for people already exposed to silica dust. From 1st July, 2024, Australia will become the first country to ban the manufacture, supply, processing and installation of engineered stone (as reported in Bulletin 90).

Accelerated silicosis is a progressive respiratory condition caused by exposure to high concentrations of respirable crystalline silica (RCS). This mainly affects people involved in fabricating artificial stone into benchtops, where the RCS concentration in dust can be more than 80%. WorkSafe New Zealand is currently encouraging workers to contact their primary care clinic for assessment. bpacnz has published an article covering the pathology and diagnosis of accelerated silicosis, and referral into the Accelerated Silicosis Assessment Pathway, as well as workplace safety recommendations to reduce risk.

Influenza vaccination programme has begun

The Influenza Immunisation Programme has begun for this year. Influvac® Tetra is the sole funded influenza vaccine for 2024 for people who meet eligibility criteria. It is also available to purchase for those not eligible for funded vaccination.

Four other non-funded influenza vaccines are also available for purchase this year: Flucelvax® Quad and FluQuadri™ for use in children aged six months and over and adults, Fluad® Quad for use in adults aged 65 years and over and Alfuria® Quad for use in children aged three years and over and adults.

Two common questions that patients may have:

  • Can I have an influenza vaccination at the same time as a COVID-19 vaccination?
    Yes – this is considered safe and will not compromise the effectiveness of either vaccination
  • Can I have an influenza vaccination if I have had COVID-19?
    Yes, as soon as you have recovered

The 2024 Flu kit booklet for health professionals is available here

IMAC recently hosted a webinar on the 2024 Influenza Immunisation Programme. If you missed it, a recording of the webinar can be found here.

Be alert for potential mumps cases

Health New Zealand, Te Whatu Ora, has asked travellers to be vigilant for mumps, following a reported case involving an infected person who flew from Chennai (India) to Singapore on 13th March, and then onwards to Auckland on 14th March. Healthcare professionals should be alert for potential symptoms and signs of mumps in patients, e.g. swollen salivary glands, headache, fever, tiredness and jaw pain, particularly those with relevant travel history. The incubation period can be up to 25 days following contact with a positive case (i.e. symptoms may develop up until 8th April after contact with the index case, or later if subsequent cases have occurred).

All suspected cases of mumps must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before notifying.

Check MMR vaccination status

This is a reminder to opportunistically check whether patients have received both doses of the MMR vaccine and offer vaccination where appropriate. Also ensure that patients with upcoming international travel are fully vaccinated with MMR (unless their age means that they are considered immune, i.e. born prior to 1969).

MMR vaccination is funded for all children in New Zealand and anyone born from 1969 onwards who has not received two doses. Some people born overseas, including remote island nations, prior to 1969 are considered susceptible to MMR and may be eligible for funded vaccination (see the Immunisation Handbook for further information). N.B. MMR vaccination is contraindicated during pregnancy.

For further information on MMR vaccination, see:

Reminder: Fournier’s gangrene with SGLT-2 inhibitors

Medsafe is reminding clinicians to be alert for Fournier’s gangrene, a rare, but serious adverse effect associated with SGLT-2 inhibitors, e.g. empagliflozin. Fournier's gangrene is a necrotising fasciitis of the perineum. It has been reported in both males and females taking empagliflozin, and the most serious cases can result in death.

Patients taking a SGLT-2 inhibitor should be informed of this rare adverse effect, be given advice about good hygiene of the genital and perianal area, and be advised to seek immediate medical attention if they have pain, tenderness, erythema or swelling of the genital or perineal area, fever or malaise. The SGLT-2 inhibitor should be stopped if Fournier’s gangrene is suspected. A consumer information leaflet can be given to patients.

For further information on empagliflozin and associated adverse effects, see:

Proposal to fund continuous glucose monitors, insulin pumps and consumables

Pharmac has released a proposal to fund a range of devices for people with type 1 diabetes. If the proposal is accepted this would mean that all people with type 1 diabetes would have access to funded continuous glucose monitors, as well as access to new brands of insulin pumps (and automated insulin delivery system algorithms) and associated consumables. Funded access to these products for people with type 2 diabetes is not included in the consultation. Submissions are due by 4 pm, Friday 26th April, 2024.

Read more about the proposal here. A summary of the proposal is also available, here.

For further information on the role of insulin in the management of patients with type 1 diabetes, see:

Medicine supply news: fluticasone, omeprazole

The following news relating to medicine supply, of particular interest to primary care, has 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.

Annual diabetes foot examination: overcoming barriers to attendance

Diabetes-related foot complications are reported to affect more than one-third of people with diabetes in New Zealand. However, attendance rates at annual diabetes reviews to prevent and detect these complications are low in some areas. A recently published small New Zealand based study looked at patient-reported barriers to attending an annual diabetes review in primary care, including a foot examination, and offers some practical solutions for overcoming certain modifiable barriers.

For further information on the annual diabetes review, see:

NZF updates for April

Significant changes to the NZF in the April, 2024, release include:

  • Withdrawal advice updated in the gabapentin and pregabalin monographs
  • Breast feeding and patient advice updated in the HIV infection monographs
  • Age bands updated in the dosing table for the emergency treatment of anaphylaxis in the therapeutic notes for intramuscular adrenaline (epinephrine)
  • S7 (Narcotics) use in sport category added for tramadol
  • Information updated for the following categories in the Drugs and sport therapeutic notes: S3 Beta-2 agonists, S5 Diuretics and masking agents, S6 Stimulants, S8 Cannabinoids, S9 Glucocorticoids and P1 Beta blockers

You can read about all the changes in the April release here. Also read about any significant changes to the NZF for Children (NZFC), here, including a new dosing regimen added to the amitriptyline monograph for neuropathic pain in children aged 2 - 12 years.

Paper of the Week: Using medicines to combat obesity

Obesity is an increasing global health concern. In New Zealand, approximately one in three adults and one in seven children are obese (BMI ≥ 30 kg/m2), with significantly higher rates among Māori and Pacific peoples. It is well established that excess body weight increases the risk of numerous conditions (e.g. type 2 diabetes, hypertension and other cardiovascular disease) and reduces overall life expectancy. First-line strategies for maintaining a healthy weight include appropriate nutrition and regular exercise. However, primary healthcare professionals will be well aware that such lifestyle changes can be challenging for many patients to make, and even more difficult for them to maintain.

Given the expanding knowledge base around physiologic processes underpinning weight regulation, many international societies are considering the place of medicines in the long-term management of obesity. A recent review in the BMJ examines evidence regarding the effectiveness and safety of “anti-obesity” medicines, and provides guidance around their prescribing.

Some of these pharmacological options are already approved for weight loss in New Zealand (e.g. naltrexone + bupropion, liraglutide, phentermine, orlistat) but none are funded for this indication. Unprecedented global demand for GLP-1 receptor agonists for weight loss has contributed to stock shortages and concern about reserving these medicines for people who require them for type 2 diabetes management. Liraglutide has been temporarily funded in New Zealand to offset stock shortages of dulaglutide, but its popularity as a weight loss adjunct may potentially place further pressure on the already constrained supply. Semaglutide (Ozempic) is arguably the most talked about GLP-1 receptor agonist that is being used internationally (off-label) for weight loss: it is not yet available in New Zealand although it is now approved here for use in type 2 diabetes. It is important that the right people are getting the right medicines for their individual circumstances; weight loss medicines may not be the “simple solution”.

How often do patients ask you about the use of weight loss medicines? At what point would you consider recommending them for obesity management? Do you feel confident in prescribing them?

Henderson Lewis K, Sloan CE, Bessesen DH, et al. Effectiveness and safety of drugs for obesity. BMJ 2024;384:e072686. doi:10.1136/bmj-2022-072686

For further information on weight loss, see:

This Bulletin is supported by the South Link Education Trust

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