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Published: 9 June, 2023


New article: Appropriate use of tumour markers

The appropriate use of serum tumour marker testing is complex and patient harm can occur when testing is requested but not clinically indicated. This overview article covers the most frequently used tumour markers, and when they should, and should not, be requested. The main role for a tumour marker test is in the management of a patient with a known malignancy. However, there are some tumour markers that are useful in the detection of specific cancers, e.g. CA 125 in ovarian cancer.

Read the full article here

New cervical screening guidelines published

New Clinical Practice Guidelines for Cervical Screening in New Zealand (2023) have been published. These guidelines are to be used from 26th July, 2023, when HPV testing (with the option of self-testing using a vaginal swab) is introduced as the primary cervical screening test. Read the new guidelines here.

A video providing a basic overview of HPV Primary Screening has been produced by the National Cervical Screening Programme. Click here to watch.

Training modules will also be available and are expected to be online from mid-June. The first training module includes information on HPV, an overview of the cervical screening pathways and how to support decision-making by participants.

Alert Communication: sodium valproate use in males

Medsafe has issued an Alert Communication on the use of sodium valproate (Epilim) in “people who can father a child”. Evidence from a retrospective observational study in Europe revealed a potential increased risk of neurodevelopmental disorders in children after paternal use of sodium valproate at the time of conception, compared to lamotrigine or levetiracetam. The data sheets and consumer medicine information leaflets have been updated to reflect this.

Medsafe is advising healthcare professionals to inform male patients who are taking sodium valproate about this potential risk, and to consider switching those who are planning parenthood soon to an alternative treatment. At the time of prescribing sodium valproate to a male patient, discuss the need for effective contraception (if relevant), and revisit this conversation annually. A letter for healthcare professionals from the manufacturer about this risk is available here.

A guide has been produced for males taking sodium valproate, and it is recommended that this is provided to patients.

N.B. The risk of adverse effects of antiepileptic medicines for females of reproductive age is already well documented, and precautions around effective contraception for females also apply. Read more here.

Latest edition of Prescriber Update released

The June edition of Prescriber Update has been published; particular items of interest include:

View the full edition here

ACE inhibitors and angioedema

Angiotensin-converting enzyme (ACE) inhibitors are widely prescribed in primary care. While these medicines are generally well-tolerated, rare serious adverse effects can occur in some patients, even after long periods of use without incident. A Medsafe reminder published in the latest Prescriber Update has highlighted a fatal case of ACE inhibitor-induced angioedema recently reported to The Centre for Adverse Reactions Monitoring (CARM). This involved a patient who had previously exhibited minor tongue swelling with ACE inhibitor use and was subsequently initiated on a different ACE inhibitor at a later date.

Reminder: patients currently taking cilazapril should be switched to another appropriate medicine before the end of 2023 (as reported in Bulletin 74)

For further information on prescribing ACE inhibitors, see:

SGLT-2 inhibitors and the risk of polycythaemia

As covered in the June edition of Prescriber Update, Medsafe is warning of the potential risk of polycythaemia with SGLT-2 inhibitor use (e.g. empagliflozin) based on a recent case report to CARM. SGLT-2 inhibitors are recommended not only for patients with diabetes but also in the management of other long-term conditions, e.g. chronic kidney disease, heart failure. Given their recent emergence and application in daily practice, the evidence around potential adverse effects is still evolving. In Bulletin 64 we discussed two other rare, but serious adverse effects associated with SGLT-2 inhibitors: diabetic ketoacidosis and Fournier’s gangrene.

Coeliac Awareness Week

Next week (12 – 18th June) is coeliac disease awareness week. The theme for this year is “My coeliac challenge – take charge, get diagnosed and find help” which aims to encourage people with coeliac disease to think about different ways to overcome some of the challenges they encounter, which are often daily. Click here for more information.

Raising awareness of coeliac disease can prompt people with symptoms or risk factors to get tested. Coeliac Awareness Week may provide an opportunity for clinicians to refresh their knowledge about the condition and to consider whether they are testing appropriately. For your patients with known coeliac disease, it might be a chance to check how they are managing with a gluten-free diet and whether they have any new or persistent symptoms that require further investigation.

For further information on the investigation and management of coeliac disease in primary care, see:

Medicine supply issues

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.

NZF updates for June

Significant changes to the NZF in the June, 2023, release include:

  • New contraindication added to ACE inhibitor monographs: concomitant use of sacubitril + valsartan
  • Caution added to the cephalosporin monographs: concomitant nephrotoxic medicines, e.g. aminoglycosides (high dose cephalosporins may potentiate nephrotoxic effect). Reversible neurotoxicity (including seizures, myoclonus, agitation, delirium) has also been added as an adverse effect. For further information on the risk of neurotoxicity with cephalosporins, see Bulletin 70
  • Cautions, pre-treatment screening and monitoring requirements updated in the pamidronate disodium monograph
  • New indication added to the secukinumab monograph: non-radiographic axial spondylarthritis that is unresponsive to, or where there is intolerance of non-steroidal anti-inflammatory treatment
  • Medsafe Monitoring Communication: interleukin inhibitors and the possible risk of pancreatitis has been added to the interleukin inhibitor monographs. See Bulletin 74 for further details.

You can read about all the changes in the June release here. Also read about any significant changes to the NZF for Children (NZFC), here.

GP CME Conference Rotorua: It’s on!

If you are attending the GP CME conference in Rotorua this weekend, come see our colleagues on the South Link Education Trust stand. The South Link Education Trust is the Diamond Sponsor of the GP CME conferences, and is home to South Link Health Services, BPAC Clinical Solutions, bpacnz Publications and the New Zealand Medicines Formulary (NZF and NZFC). The team will be presenting the new Smart Care products, along with showcasing the full range of activities and services.

Grab yourself a copy of the special conference edition Best Practice Journal or The Little Book of Thinking: a guide to peer group discussions. We would love to hear your feedback on our resources.

Paper of the Week: "Is laughter really the best medicine?"

Everyone has heard the phrase “laughter is the best medicine” but whether this statement counts as evidence-based medicine is up for debate. Previous studies have shown the potentially beneficial effects of laughter on cardiovascular health and type 2 diabetes, but there is limited evidence that laughing reduces endogenous cortisol levels. Given that everyday life is becoming more stressful for a lot of people, could taking some time out of the day to laugh really make a difference?

A 2023 systematic review and meta-analysis was carried out with the aim of determining the impact of spontaneous laughter on endogenous cortisol levels. The study found an approximately 32% reduction in cortisol levels for participants who took part in a laughing intervention such as watching a humorous video or receiving laughter therapy. This suggests there may be a therapeutic role for spontaneous laughter alongside established management interventions to improve patient outcomes.

Could you incorporate these findings into “behavioural activation” recommendations in your practice? By encouraging patients to regularly make time for an activity they enjoy, specifically something that makes them laugh or even just smile, whether it be watching a comedy, playing a game/sport, interacting with a pet, hanging out with friends or family, there is the potential to reduce ruminating negative emotions and make sustained improvements to their mood and resilience.

Kramer CK, Leitao CB. Laughter as medicine: a systematic review and meta-analysis of interventional studies evaluating the impact of spontaneous laughter on cortisol levels. PLoS ONE 2023;18:e0286260. doi:10.1371/journal.pone.0286260.

This Bulletin is supported by the South Link Education Trust

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