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Published: 2 December, 2022


Latest from bpacnz: Childhood poisonings: hazardous substances around the home

The natural curiosity of young children about their surroundings can sometimes lead to unintentional exposures to hazardous substances around the home. In this article, we take a general look at the triage and management of children exposed to common household poisons, including household-related chlorine exposure. Contact the National Poisons Centre if there is any uncertainty in the management of a child who has been poisoned.

All exposures to hazardous substances should be reported to the Hazardous Substances Surveillance System (HSSS) via the Hazardous Substances Disease and Injury Reporting Tool (HSDIRT) on your practice management system, or by contacting your local Public Health Unit.

Got no time for that? A B-QuiCK summary is available here.

Article update: Prescribing ACE inhibitors: time to consider old habits

As of 1 December, Ramipril is now fully funded for people with hypertension, heart failure, progressive kidney disease and for the prevention of cardiovascular events in people with heart disease (as reported in Bulletin 62). bpacnz has updated the article “Prescribing ACE inhibitors: time to consider old habits” with information about ramipril, including starting and maintenance doses for hypertension and heart failure (unapproved indication). An approximate dose equivalency table has been included to aid clinicians when switching between ACE inhibitors or an ACE and an ARB. Further updates will be made when cilazapril is delisted in mid-2023. N.B. Accuretic (quinapril with hydrochlorothiazide) will also be delisted by 1 February, 2023.

Be aware of rare adverse effects with SGLT-2 inhibitors (e.g. empagliflozin)

In the latest edition of Prescriber Update (December, 2022), Medsafe is reminding clinicians to be alert for two rare, but serious adverse effects associated with SGLT-2 inhibitors (e.g. empagliflozin): diabetic ketoacidosis and Fournier’s gangrene. Medsafe has requested that updates be made to the data sheets for empagliflozin and dapagliflozin (not funded).

We first alerted clinicians about these adverse effects in Bulletin 33, where at the time (up to 30 June, 2021) there were three reports to CARM of diabetic ketoacidosis associated with empagliflozin use and two reports of Fournier’s gangrene. As of 30 September, 2022, CARM has now received 24 reports of diabetic ketoacidosis with empagliflozin (22 for empagliflozin; 2 for empagliflozin + metformin), and six reports of Fournier’s gangrene (four in males, two in females).

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

Monitoring Communication: risk of seizures with clonidine

Medsafe has issued a Monitoring Communication to seek more information from clinicians on the possible risk of seizures with clonidine. This safety signal has been made following a report to the Centre for Adverse Reactions Monitoring (CARM) of a male aged 15 years who experienced new onset non-epileptic seizures and somnolence after starting clonidine. N.B. Clonidine is not approved for use in children or adolescents and has been associated with severe adverse reactions in this group.

Currently, seizures are not listed as an adverse effect in clonidine data sheets. However, seizures have been reported by some patients following clonidine use. The mechanism of this reaction is unknown.

Healthcare professionals are encouraged to report any cases of seizures (new onset and increased seizure frequency) associated with clonidine use to CARM.

Reminder: no new patients to be started on dulaglutide

As reported in Bulletin 60, there is an ongoing global supply issue affecting stock of dulaglutide (Trulicity), an injectable GLP-1 receptor agonist for people with type 2 diabetes. Supply is likely to remain affected in New Zealand throughout 2023.

Pharmac recommends that existing stock of dulaglutide is prioritised for those who are already taking it. Empagliflozin (with or without metformin), an oral SGLT-2 inhibitor, is the primary funded alternative treatment for patients who meet the Special Authority criteria (also see item: Be aware of rare adverse effects with SGLT-2 inhibitors). Other funded alternatives for people with type 2 diabetes include vildagliptin, metformin, sulphonylureas and insulin.

bpacnz has published a Diabetes Special Edition Best Practice Journal – Diabetes Toolbox. This suite of resources covers all aspects of management for people with type 2 diabetes, including lifestyle interventions, oral glucose-lowering medicines, initiating insulin and monitoring for complications. Individual articles can be found here.

PCV13 pneumococcal vaccine update

As mentioned in Bulletin 63, the pneumococcal conjugate vaccine PCV13 (Prevenar13) has replaced PCV10 (Synflorix) on the childhood immunisation schedule, from 1 December, 2022.

The Immunisation Advisory Centre (IMAC) notes that there is a supply delay of PCV13 and has issued interim advice for vaccine providers:

  • Clinics with sufficient stock of PCV13 should start using this
  • Clinics with limited stock of PCV13 should prioritise it for children classified as high risk of pneumococcal disease
  • Clinics with no stock of PCV13 should continue to offer PCV10 or give the choice to delay the immunisation and receive PCV13 when stock arrives (set a recall). Stock of PCV10 should not be returned until the clinic has sufficient PCV13 stock.
  • Administration of PCV10 after 1 December, 2022, will not be regarded as a medication error; previous official communications have stated that use of PCV10 after 1 December, 2022, is considered a medication error, but given the issues with delayed stock, this caution does not currently apply.
  • Contact 0800 IMMUNE (0800 466 863) if further clinical guidance is required

IMAC has produced both a written resource and a webinar explaining the change from Synflorix (PCV10) to Prevenar (PCV13) for health professionals.

New brand of meningococcal ACWY vaccine to be funded

From 1 December, MenQuadfi replaces Menactra as the funded brand of meningococcal ACWY vaccine. MenQuadfi is approved for use in adults and children aged over 12 months; Menactra is approved for use in adults and children aged over nine months. MenQuadfi will be available in New Zealand once supplies of Menactra are exhausted (likely February – March 2023). There will be no changes in eligibility criteria for this vaccine.

NZF updates for December

Significant changes to the NZF in the December, 2022 release:

You can also read about any significant changes to the NZFC, here.

Paper of the Week: Recognising and responding to domestic and family violence in general practice

The upcoming holiday period can be a difficult time for many people. With the ongoing COVID-19 pandemic and the increasing cost of living, the added emotions and responsibilities associated with the Christmas and New Year period are putting households under even more stress. Domestic and family violence has been shown to increase during this time and it is often difficult to recognise. A recent paper published in the Australian Journal of General Practice outlines the role of general practitioners in recognising and responding to domestic and family violence.

The trusting relationship between a patient and a clinician puts general practitioners in a unique position to identify and respond to domestic and family violence. Eliciting a history of violence is often a challenging task; consider ways that you and your team can create a safe space for discussion/disclosure, recognise the patterns of domestic violence, be aware of phrasing when questioning a patient, perform appropriate risk assessment and safety planning, make referrals and take appropriate notes.

Domestic and family violence often goes unnoticed; any disclosure of violence is an opportunity to improve the patient’s safety and long-term wellbeing.

Lynch J, Stone L, Victoire A. Recognising and responding to domestic and family violence in general practice. Aus J Gen Pract 2022;51(11):

For further information, see: Family Violence Assessment and Intervention Guideline: child abuse and intimate partner violence and Family violence screening and intervention

This Bulletin is supported by the South Link Education Trust

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