Published: 17 February, 2023
Cyclone Gabrielle: medicine supply delays possible
Our thoughts are with everyone affected by Cyclone Gabrielle. A special mention to all the doctors, nurses, pharmacists and other primary care providers who are continuing to deliver essential services to their communities under exceptional circumstances. Kia kaha.
There has been significant disruption to the distribution and transport of medicines across New Zealand. Freight carriers and suppliers are working to re-establish their networks, however, it may be a while before service returns to normal. Pharmac is providing up to date information on supply and logistics here.
In response to the National State of Emergency, there have been temporary changes to medicines supply rules in some affected areas. This includes an extension to the maximum period of supply of emergency medicines.
In case you missed it: ovarian cancer – early detection and referral
February is Ovarian Cancer Awareness Month. On average, one person in New Zealand is diagnosed with ovarian cancer every day. It is no longer considered to be a silent disease as most people are symptomatic. Despite this, ovarian cancer can be difficult to diagnose as symptoms are often non-specific. We have published a new article, supported by Te Aho o Te Kahu, Cancer Control Agency, to raise awareness of the key symptoms and signs of ovarian cancer and to guide clinicians on when it is appropriate to initiate further investigations in primary care.
Read the full article here. A B-QuiCK summary is also available here.
Coming up next in this series: Endometrial cancer – early detection and referral
Opioid audit for prescribers
A new clinical audit has been published on appropriate prescribing of oxycodone for non-cancer pain in general practice. The audit aims to help identify patients who have been prescribed oxycodone (excluding those with cancer or another terminal condition) and then to consider whether or not this was the most appropriate analgesic medicine.
Opioids can be effective for relieving moderate to severe acute pain but carry a significant risk of harm with longer periods of use. Understanding the appropriate indications and reducing unnecessary opioid prescribing should therefore continue to be a key focus in New Zealand, as it is worldwide.
Oxycodone should only be prescribed for the treatment of moderate to severe pain in patients who are intolerant to morphine and when a strong opioid is the next best option. When considering initiation of oxycodone, always ask yourself if you would use morphine for this patient. If the answer is no, then do not prescribe oxycodone. Oxycodone should not be prescribed when a weaker opioid, e.g. codeine, dihydrocodeine or tramadol, would be more appropriate.
For further information on oxycodone, see: https://www.bpac.org.nz/BPJ/2014/July/oxycodone.aspx
This audit has been published to accompany the opioid prescribing report, now that clinicians have
had a chance to review their data. You can view the prescribing report here.
New search function added to the bpacnz website
A new filter by year function has been added to the bpacnz website. You can use this function when browsing the “Articles” or “Browse By Category” tabs. For Mybpac users, this feature is also available in “Your saved articles” and “Articles in your areas of interest”.
Articles are now arranged by year in descending order as you scroll down the page. Users can jump to a particular year, or search for articles over a custom range of years. By default, the page displays the last ten years of publications, i.e. from 2023 to 2013, but a longer period of time can be selected in the drop down box (back to 2006).
Previously, the “Articles” tab was called “Latest articles”, and only listed resources published in the past 12 months. Now you can view our entire catalogue of articles on one page or jump to a specific year(s). This feature should also make it easier to find the latest article published on a topic. N.B. The search box function remains available on the website.
We hope that you find this new feature useful, and welcome any feedback; email: email@example.com
Measles confirmed in New Zealand: MMR vaccination remains a priority
Measles has been confirmed in New Zealand for the first time since the 2019 outbreak. The case was infected overseas but became infectious once back in New Zealand. Exposure events are listed here.
Te Whatu Ora, Health New Zealand, is advising healthcare professionals to be alert for symptoms and signs of measles in patients, particularly those who are not vaccinated or are immunocompromised, and have a history of recent overseas travel. This announcement was prompted by a confirmed case of measles on an international flight from Abu Dhabi to Melbourne, where New Zealand-based contacts were onboard.
Consider the possibility of measles in a patient with the following:
- Generalised maculopapular rash, that starts on the head and neck and spreads down and out and fades
- Fever > 38℃ at the same time as the rash
- Cough, coryza, conjunctivitis or Koplik spots at the same time as the rash
All suspected cases of measles must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before notifying.
Is your patient population up to date with MMR vaccinations? This is a timely reminder to opportunistically check whether patients have received both doses of the MMR vaccine and to offer vaccination where appropriate. Some children may have missed out on their scheduled MMR vaccine during the last three years, due to the COVID-19 pandemic and lockdowns.
Also ensure that patients with upcoming international travel are fully vaccinated with MMR.
MMR vaccination is funded for people aged up to 32 years or anyone born after 1968 who has not received two doses. N.B. MMR vaccination is contraindicated during pregnancy.
For further information on MMR, see: https://bpac.org.nz/2021/mmr.aspx
Information about measles from the Immunisation Advisory Centre is available here.
Respigen (salbutamol) supply issue
A temporary supply issue affecting Respigen (100 microgram/actuation salbutamol inhaler) has been announced by the supplier. Stock is expected to be in short supply until the end of March, 2023, due to high demand and limited availability of manufacturing materials.
Supply of other brands of salbutamol inhalers is unaffected. SalAir (fully funded) or Ventolin (partly funded) 100 microgram/actuation salbutamol inhalers are suitable alternatives to Respigen.
COVID-19 vaccine now available for younger children at higher risk of severe illness
The Comirnaty (3 mcg) maroon cap COVID-19 vaccine is now available for children aged six months to four years at high risk of severe illness from COVID-19. As reported in Bulletin 66, it is not recommended for children in this age group who are not considered to be at risk for severe illness from COVID-19. Eligibility criteria can be found here.
The vaccine has been specifically formulated for children aged six months to four years and contains a lower dose (3 mcg) than the Comirnaty orange (10 mcg) and purple (30 mcg) cap vaccines that are used for children aged 5 – 11 years and those aged ≥ 12 years, respectively. Three doses are required; the second dose is given at least three weeks after the first dose, and the third dose given eight or more weeks after the second dose.
The Immunisation Advisory Centre recently hosted a webinar on everything you need to know about Comirnaty for high-risk children aged six months to four years, including safety and efficacy and eligibility. For those who missed it, the recording can be found here. A factsheet for healthcare professionals is also available.
Paper of the Week: A New Zealand approach to identifying potentially inappropriate polypharmacy in older people
As the prevalence of disease increases with age, so does polypharmacy, and while multiple medicines may be required to manage co-morbid conditions, there is also an increased risk of medicines interactions and medicines-related harms. Criteria for identifying harmful prescribing have been developed internationally, e.g. Beers Criteria, however, significant variation in healthcare systems and medicines use makes it difficult to apply these criteria to New Zealand primary care.
A 2023 article published in the Journal of Primary Health Care described the attempt to develop a New Zealand-specific system to identify medicines prescribing that puts patients aged over 65 years at higher risk of medicines-related harms. The expert panel were able to agree on 61 specific indicators of potentially inappropriate polypharmacy that form the basis for the New Zealand Criteria. Medicines of particular concern included NSAIDs, benzodiazepines, anticholinergics, antipsychotics and first-generation antihistamines.
- An expert panel of nine clinicians across primary and secondary care were chosen based on their experience relating to polypharmacy in older people. The group comprised two general practitioners, one geriatrician, two nurse practitioners and four clinical pharmacists.
- Members of the panel proposed specific indicators for inappropriate medicines prescribing in polypharmacy, then each voted for seven indicators they believed were most important. These were combined with specific indicators from the Beers Criteria that are relevant to New Zealand.
- Specific indicators were included if they represented a risk of harm to patients, and excluded if they did not relate to people aged over 65 years, or were not New Zealand-specific (i.e. unavailable or unapproved medicines). Indicators were also removed if extracting relevant data from healthcare records was not possible or if the indicator was directly related to difficulties with continuation/co-ordination of care.
- A two-round modified Delphi analysis was then performed on a total of 82 specific indicators (23 proposed by the expert panel and 59 from the Beers criteria):
- In the first round, panel members were sent a questionnaire asking them to rank the specific indicators on a four-point Likert scale (1 = ‘low importance’, 2 = ‘somewhat important’, 3 = ‘important’, 4 = ‘very important’) based on how important it was to alter the prescribing in the context of polypharmacy
- The second-round questionnaire included analysis of first-round responses that did not reach consensus, to allow panellists to reconsider their own responses (indicators that reached consensus in the first round were not voted on in the second-round questionnaire)
- A consensus was defined as agreement between six of the nine panellists (≥ 66%)
- Indicator importance was determined by the consensus percentage and mean Likert score
- A total of 61 indicators for inappropriate medicines prescribing in polypharmacy that are relevant to people aged over 65 years in New Zealand, were identified as important and form the “New Zealand Criteria”
- Indicators that were considered ‘very important’ or ‘important’ in New Zealand were similar to published international criteria
- Medicines that were identified as being of particular concern included NSAIDs, benzodiazepines, anticholinergics, antipsychotics and first-generation antihistamines
- There were two indicators that reached 100% consensus (mean Likert score of 4): a combination of three or more CNS active medicines (e.g. antidepressants, antipsychotics, antiepileptics, benzodiazepines, zopiclone, opioids); and the use of long-acting sulfonylureas (e.g. glibenclamide)
- Eight out of nine experts agreed that it was very important to correct the prescribing of alpha blockers in older patients with postural hypotension and NSAIDs in older patients with stage 4 chronic kidney disease or higher
- A complete list of potentially inappropriate medicines indicators is available in the full article
- Several limitations with this study were identified:
- The expert panel size was small
- While the response rate for both questionnaires was 100%, the expertise of panel members can influence study outcomes
- The consensus definition (≥ 66%) was less than other equivalent studies
- The authors acknowledge that the New Zealand Criteria are not exhaustive and do not replace clinical judgement
Liu L, Harrison J. Development of explicit criteria identifying potentially inappropriate polypharmacy in older adults in New Zealand primary care: a mixed-methods study. J Prim Health Care 2023; [Epub ahead of print]. https://doi.org/10.1071/HC22135
Read the full article here: https://www.publish.csiro.au/hc/pdf/HC22135
For further information on managing polypharmacy in primary care, see: https://bpac.org.nz/bpj/2014/october/polypharmacy.aspx
This Bulletin is supported by the South Link Education Trust
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