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).
As covered in the Diabetes Special Edition Best Practice Journal – Diabetes Toolbox, diabetic ketoacidosis (DKA) has been reported among people taking empagliflozin (ranging from one in 1,000 to one in 3,000 people), particularly within the first few months of initiation or peri-operatively. Patients should be given advice on the symptoms and signs of DKA and when to seek medical attention, i.e. if they experience nausea, vomiting, abdominal pain, excessive thirst or difficulty breathing. The SGLT-2 inhibitor should be stopped if DKA is suspected.
If a patient taking an SGLT-2 inhibitor has risk factors for DKA (e.g. low carbohydrate diet, acute illness), consider monitoring for DKA and stopping treatment temporarily. The SGLT-2 inhibitor should also be temporarily stopped in patients who are hospitalised for major surgical procedures. In addition to ketone monitoring, patients may require higher doses of other glucose-lowering treatments during this time. The SGLT-2 inhibitor may be restarted once ketone levels are normal, and the patient’s condition has stabilised.
Fournier's gangrene (necrotising fasciitis of the perineum) has been reported in both males and females taking empagliflozin, and in the most serious of cases it can result in death. Patients should be informed of this rare adverse effect, ensure good hygiene of the genital 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:
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.
Meningococcal ACWY immunisation (Menactra and MenQuadfi) is funded for people with conditions associated with immunosuppression, e.g. pre- or post-solid organ transplant, bone marrow transplant, close contacts of people with meningococcal disease and people aged 13 to 25 years living in a boarding school hostel or university hall of residence, military barracks or prison. Meningococcal ACWY immunisation is recommended (but not funded) for all infants, young children, adolescents and young adults.
An important difference is MenQuadfi is only approved for use in children aged over 12 months. Menactra is approved for use in children aged over nine months. Current advice is that children aged over nine months who require immunisation can receive the meningococcal C vaccine (Neisvac-C*) as their first dose, followed by MenQuadfi for any subsequent doses.
*Children aged < 9 months currently receive Neisvac-C for their first dose. Neisvac-C is approved for use in people aged > 8 weeks.
For further information on specific groups eligible for funded meningococcal ACWY vaccination, see the Pharmaceutical Schedule
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.
Listen, Inquire, Validate, Enhance Safety and Support (LIVES): an approach to domestic and family violence
- Listen – It is important not only to listen to the words that the patient is saying, but also to what is not said and observe for any signs of physical and psychosocial distress. If appropriate, remind patients that they can use or bring in an interpreter.
- Inquire – The use of gentle questioning is recommended with sensitive, open and direct questions. Questions may focus on a variety of aspects including relationships, physical injuries and unspoken harms such as sexual abuse. For example, “Your injuries are unusual for the incident you described – can you tell me again what happened?”, “What do you need in order to feel safe?”, “Have you ever been forced to do sexual behaviours you are not comfortable with?”.
- Validate – Validating the patient and their experience is an important part of the recovery process. Phrases may include “everyone deserves to feel safe at home”, “it is not OK that you have been treated like this” “this is not your fault”.
- Enhance Safety – Assess the patients safety risk and establish a safety plan. In an acute situation, follow-up in 36 – 48 hours may be appropriate to reassess the patient’s physical condition or social situation.
- Support – Patients may not always be receptive to outside advice regarding their current situation. Consider offering repeat/follow-up appointments to maintain regular communication, even if the patient is not in acute distress. Provide contact details for Shine, a national helpline, available 24/7: 0508 744 633.
If a patient is in acute distress, clinicians can respond to this by slowing their rate of speech and lowering their tone of voice in an empathetic manner. The patient can be encouraged to use relaxation techniques such as deep breathing and other simple grounding exercises. Routine assessments, e.g. taking blood pressure, or asking more light-hearted questions (with humour, if appropriate), can be effective distractions for upset patients.
Tips for general practitioners on recording domestic and family violence
Recording detailed clinical notes, including clearly documenting examination findings and any patterns of abuse, is important as they can be used as evidence for legal proceedings.
- Obtain consent prior to taking notes and confirm the patient understands that their records, although confidential, can be used in court. It is best practice to confirm which details they are comfortable with being documented by reading out your notes for them to check.
- Reinforce confidentiality and avoid entering the phrase ‘domestic violence’ into their clinical record or diagnosis field (as this may compromise confidentiality)
- Keep notes specific, factual and accurate – expanded detail or clarification can be added in an explanatory note after the consultation
- Notes should be objective; avoid emotive language or documenting your own conclusions
- Validate the patient by asking questions that focus on their capacity and experience, e.g. what was the most difficult part of this experience for you?
- Record the name and date of birth of the person alleged to have carried out the violence
- Clearly document any physical injuries including anatomical location as well as the patients general appearance and demeanour. Consider photographing injuries (with consent) at the time of presentation if you feel the patient may delay or avoid talking to the police.
- Refer to an appropriate service or community support group (if required)
Lynch J, Stone L, Victoire A. Recognising and responding to domestic and family violence in general practice. Aus J Gen Pract 2022;51(11): https://www1.racgp.org.au/ajgp/2022/november/recognising-and-responding-to-domestic-and-family
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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