Published: 3 March, 2023
Latest from bpacnz – Tinnitus: the sound of silence
Today (3 March) is World Hearing Day. This year’s theme focuses on the importance of integrating ear health into primary care. Hearing loss can have a significant impact on a person’s ability to interact with the world around them. This week we have published an updated article on tinnitus, a condition that can be associated with hearing loss.
Tinnitus is heterogenous in both its presentation and its causes. It can be frustrating for patients and clinicians as there is much misinformation and misunderstanding around its aetiology and treatment options. In some people, tinnitus can cause significant distress, reduced quality of life and may even contribute to suicidal ideation. However, most cases of tinnitus can be treated successfully, and patients can be reassured that there are many management techniques that can reduce its impact including sound therapy, stress reduction and treatment of other underlying causes.
This article features guidance on how to minimise or prevent noise-induced hearing loss; consider how this may form part of a patient discussion around ear health.
Read the full article here.
B-QuiCK summary is also available here.
Peer group discussion – Hypertension in adults: the silent killer
In January, we kicked the year off with an update to one of our most popular articles “Hypertension in adults: the silent killer”. This was accompanied by a B-QuiCK summary and quiz. We have now published a peer group discussion for this topic, to be used among peer/study groups or for self-reflection of practice. For example, what do you think about the updated recommendation to initiate most patients on two low-dose antihypertensives if pharmacological treatment is indicated? How low do you think blood pressure targets should be set? Ask your colleagues if they agree, or perhaps they have a different take on these questions.
View peer group discussion
Cyclone Gabrielle: Changes to dispensing rules
In the wake of Cyclone Gabrielle last month, Pharmac has applied rule 5.5 of the Pharmaceutical Schedule, allowing pharmacies in affected areas* to adjust the frequencies and quantities of medicines dispensed depending on patient requirements and their supply of medicines on hand. This rule will apply until 21 March, 2023. The supply of medicines under Rural Practitioner’s Supply Order (PSO) has been extended to all affected areas* as well, allowing any medicine (that meets all requirements of Section B of the Schedule) to be supplied on a Practitioner’s Supply Order to prescribers (including non-rural prescribers).
Other changes implemented by Te Whatu Ora, Health New Zealand, in affected areas include:
- Prescription co-payments removed
- Emergency supply provisions extended
- Locum support
- Free telehealth consultations (and prescriptions) through HealthLine
*Northland, Coromandel, Tairāwhiti, Tararua and Hawke’s Bay
Cyclone Gabrielle caused major interruptions to the transport of medicines around the country, compounding problems for patients and pharmacists. The following issues relating to medicine supply have recently been updated by Pharmac:
There is ongoing uncertainty regarding supply of dulaglutide because of increased global demand. It is believed that existing stock will be adequate to supply patients currently prescribed duIaglutide. In case of a further increase in demand, Pharmac is funding liraglutide (Victoza) from 1 March, 2023, as an alternative treatment for patients with type 2 diabetes who meet eligibility criteria for glucagon-like peptide 1 (GLP-1) receptor agonists. Liraglutide is expected to be available in New Zealand from mid-March 2023. This was previously reported in Bulletin 66.
As previously reported in Bulletin 67, there is a seven-day dispensing limit in place for fluoxetine 20 mg capsules. This was put in place because of supply issues caused by switching from the brand Fluox to Arrow-Fluoxetine earlier than expected. The dispensing limit was due to be removed at the end of February, 2023, however, it has been extended to 12 March, 2023. More stock was due to arrive this week but will take time to be distributed to pharmacies.
Further information on medicine supply issues can be found on both the NZF website and the medicines notices page on the Pharmac website
Latest edition of Prescriber Update released
The March edition of Prescriber Update has been published; particular items of interest include:
View the full edition here
Monitoring Communication: reports of pericarditis following mpox vaccination
Medsafe has issued a Monitoring Communication to seek more information from clinicians on possible cases of pericarditis following mpox vaccination. This safety communication has been made following two reports to the Centre for Adverse Reactions Monitoring (CARM) of pericarditis suspected to be related to vaccination with mpox. Pericarditis has previously been reported following COVID-19 vaccination.
Healthcare professionals should discuss this potential adverse effect with patients receiving mpox vaccination and advise them to seek medical attention if they experience any symptoms or signs of pericarditis. Any cases of pericarditis after mpox vaccination should be reported to CARM.
GOLD 2023 COPD guidelines are available
Chronic obstructive pulmonary disease (COPD) is underdiagnosed in New Zealand and estimated to be the fourth leading cause of death among adults. National guidelines on the diagnosis and management of COPD were published by the Asthma + Respiratory Foundation NZ in February, 2021. These were largely informed by guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the Lung Foundation Australia in 2020.
GOLD has now released updated 2023 guidelines which include a number of key changes, most notably concerning the use of long-acting bronchodilators in treatment.
Key changes in the GOLD 2023 guidelines include:
- A revised definition of COPD has been proposed: “COPD is a heterogeneous lung condition characterised by chronic respiratory symptoms (dyspnoea, cough, sputum production, exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive airflow obstruction”. This new definition describes symptoms more comprehensively and emphasises the heterogeneity of COPD as previous iterations had mostly only focused on exposure to particles or other pollutants (e.g. smoking). While these are the most common causes, there are other important contributing factors to COPD, including exposure to by-products of biomass fuel (e.g. coal or wood soot), genetics, abnormal lung development and infections.
- An updated and more specific definition for COPD exacerbations; this emphasises a timeframe for distinguishing whether increased symptoms are an exacerbation or overall worsening of disease severity, and offers a better framework for assessment and identification
- Changes to the recommended assessment tool for predicting patient outcomes and making treatment decisions. Previously, an “ABCD” criteria was used. Now, a revised “ABE” assessment tool is proposed to recognise the clinical relevance of exacerbations, regardless of the patient symptom severity (i.e. categories “C” and “D” are combined into a single “E” category).
- Revised guidance around pharmacological treatment of COPD:
- LABA/LAMA combination treatment is now recommended as the first-line option in patients requiring a long-acting bronchodilator, including those who are more symptomatic or at high exacerbation risk. This supersedes previous guidance to use LAMA or LABA monotherapy first.
- Use of an ICS + LABA alone is now discouraged throughout COPD management unless prescribed for a concurrent diagnosis such as asthma, and a more targeted approach for ICS use is suggested
Given the significant changes in the GOLD 2023 report, we plan to update our COPD prescribing tools on our website, particularly to align with the new “ABE” criteria which prioritises initial use of a combination LABA/LAMA in patients requiring long-acting bronchodilator treatment. However, we will await any revision of New Zealand guidelines in accordance with the GOLD 2023 report. In addition, current Special Authority approval criteria for LABA/LAMA combinations still require patients to be stabilised on LAMA monotherapy first, making these recommendations difficult to apply equitably in practice. Watch this space.
Paracetamol recommended for under 2s prior to Bexsero vaccination
As reported in Bulletin 65, access to the meningococcal B vaccine, Bexsero, has widened from 1 March, 2023, to include all children aged up to 12 months and people aged 13 to 25 years in their first year of a specified close-living situation.
The Immunisation Advisory Centre recently hosted a webinar covering meningococcal disease and the Bexsero vaccine. Click here to watch the recording.
Although not routinely given with vaccinations, prophylactic paracetamol is recommended thirty minutes before administering Bexsero (on its own or with other vaccines) in children aged under two years to treat injection site pain and fever. This may present some practical challenges; consider your strategy for managing this, e.g. asking parents to give the dose before they arrive for the appointment, utilising MPSO for a supply of paracetamol at the practice. Parents should be advised to give a further two doses of paracetamol six and 12 hours after vaccination.
For further information including paracetamol dosing instructions for parents/caregivers, see: https://www.immune.org.nz/vaccine/bexsero
COVID-19 vaccine updates
- The Pfizer BA.4/5 COVID-19 bivalent booster vaccine (grey cap 15/15 mcg original/omicron; for use in people aged ≥ 16 years) has replaced the original Pfizer booster vaccine; people who are eligible for a first or second COVID-19 booster dose will now receive the bivalent vaccine. Bivalent vaccines include a component of the original strain of SARS-CoV-2 and an omicron strain.
- An additional booster dose will be available from 1 April, 2023, for people aged 30 years and older, and for those at higher risk of severe illness from COVID-19 if it has been at least six months since their previous dose or positive COVID-19 test. Eligibility criteria for second boosters and additional boosters (from 1 April) can be found here.
- The Comirnaty purple cap vaccine (30 mcg; for use in people aged ≥ 12 years) has been replaced with two Comirnaty grey cap vaccines:
- Comirnaty 30 mcg grey cap (for use in people aged ≥ 12 years) replaces the purple cap and is used for primary courses
- Comirnaty original/omicron 15/15 mcg grey gap (BA.4/5 bivalent vaccine; for use in people aged ≥ 16 years) is used for boosters
Extra attention must be given when preparing these vaccines due to their similar appearance. Grey cap vaccines do not require dilution. Resources, including a fact sheet are available here.
The Immunisation Advisory Centre recently hosted a webinar on this change, including differences between the vaccines, safety and efficacy and practical issues. For those who missed it, the recording can be found here.
Flu season starts next month
The 2023 Influenza Immunisation Programme is just around the corner, beginning 1 April. Access to funded influenza vaccination has been widened this year to include children aged six months to 12 years, and Māori and Pacific peoples aged 55 – 64 years. Funded access will remain for people aged > 65 years or with chronic health conditions.
A summary of the influenza vaccines available in 2023 can be found here. Further information and resources will be available soon.
The Immunisation Advisory Centre is hosting a symposium about influenza and COVID-19 on 9 March, 2023. This may be attended in person or online.
NZF updates for March
Significant changes to the March, 2023 release include:
- A new brand and indications (type 2 diabetes; to reduce the risk of cardiovascular events in those with type 2 diabetes and established cardiovascular disease or multiple risk factors) have been added to the liraglutide monograph. New contraindications (type 1 diabetes; treatment of diabetic ketoacidosis; inflammatory bowel disease or diabetic gastroparesis) and a caution (severe congestive heart failure) have also been added. Drug action, monitoring requirements, renal impairment, adverse effects, dosing regimen and patient advice sections have been updated.
- Section on GLP-receptor agonists has been updated to include liraglutide for the treatment of type 2 diabetes
- New indication added (Chlamydia trachomatis conjunctivitis, trachoma) to the azithromycin monograph
- Updated breastfeeding section in the clindamycin (systemic) monograph (further breastfeeding advice – present in milk and monitor infant for adverse gastrointestinal effects [e.g. diarrhoea, blood in faeces], candidiasis and rash)
- Updated section on self-administration of adrenaline
- 2023 vaccines and dosing regimens added to the influenza vaccines monograph
You can read about all the changes in the March release here. Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Could listening to your favourite tunes reduce pain?
A 2023 observational study among voluntary participants in the Netherlands evaluated the effect of preferred music versus disliked music on pain thresholds and perceived pain intensity. Previous studies have shown that music affects pain perceptions and thresholds but the mechanism of this is currently unclear. Possible mechanisms include that music acts as a distraction, it induces release of endogenous opioids which can be associated with beneficial effects and that it can modulate pain by inducing positive emotions.
The study found that listening to preferred music during painful stimuli was associated with a significantly higher pain threshold and lower perceived pain intensity compared to listening to disliked music. The highest pain thresholds were achieved when the preferred music was preceded by disliked music.
While this study was not conducted in a clinical setting, the findings could be easily applied in general practice. During a painful procedure, offer to play music of the patient’s choice (or ask if they would like to use their phone or earphones); if you really want to replicate the study for an optimal reduction in pain, play some music they don’t like first! (Our suggestion: Baby shark, doo-doo, doo-doo….)
More on the study
- 415 healthy adults participated in this observational study. Participants were recruited over three days from a music and performing arts festival in the Netherlands.
- Quantitative sensory testing was used to measure pain thresholds. Participants were randomly assigned to either an electrical pain tolerance threshold group or a pressure pain threshold group in a 1:2 ratio (due to equipment availability) to assess their pain response when listening to preferred and disliked music.
- 138 participants were assigned to the electrical pain tolerance threshold group (average age 27.8 years). 277 participants were assigned to the pressure pain threshold group (average age 28.4 years).
- Half of each group were then assigned to music protocol A (preferred music first then disliked music) and the other half to protocol B (the opposite)
- Pressure or electrical pain stimuli was applied to the participant’s forearm, initially without music to obtain a baseline measurement. Participants then listened to 60 seconds of their preferred or disliked music (depending on which protocol they were assigned to), before pressure or electrical pain stimuli was applied while they continued to listen to music. Once the participant signalled that they were at their maximum pain level, the stimuli and music were stopped. Participants were then asked to rate their perceived pain intensity using the Likert numerical rating scale (ranging from 0, no pain, to 10, worst pain imaginable). The process was repeated with the other type of music.
- In both groups, preferred music was associated with a significantly higher pain threshold than disliked music (p < 0.001) and lower perceived pain intensity (p = 0.003). The highest pain thresholds were achieved in participants when preferred music was preceded by disliked music.
- The data show that mean pain thresholds when listening to disliked music was lower than when listening to no music. The authors suggested that these results might indicate that the endogenous opioid system was likely to be responsible for the underlying mechanism of pain modulation, as opposed to distraction.
- Several limitations with the study were identified:
- The study population consisted mostly of younger adults which may not adequately represent demographics of the general population. Research has demonstrated that increasing age may affect sensitivity to stimuli.
- Participants only received one kind of stimuli which makes intraindividual comparison between the two types of stimuli impossible
- As participants were not blinded in this study, those who first listened to disliked music may have had higher anticipation for the preferred music, which could have resulted in a stronger sense of reward and higher pain thresholds
- Thresholds in participants without music were assessed first which may have resulted in an over- or under-representation of reality due to habituation or sensitisation
Timmerman H, van Boekel RLM, van de Linde LS, et al. The effect of preferred music versus disliked music on pain thresholds in healthy volunteers. An observational study. PLOS ONE 2023;18:e0280036. doi:10.1371/journal.pone.0280036
This Bulletin is supported by the South Link Education Trust
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