Published: 21 October, 2022
New article: Cervical cancer - early detection and referral
In the first article of our gynaecological cancer series, supported by Te Aho o Te Kahu, Cancer Control Agency, we discuss the latest guidance on prevention, early detection and referral of patients for investigation for cervical cancer.
The risk of cervical cancer is significantly reduced through HPV vaccination and cervical screening programmes, however, there are still 168 new diagnoses and 53 deaths caused by cervical cancer on average each year in New Zealand. Upcoming changes to the cervical screening programme in New Zealand in 2023, including moving to HPV primary screening, are predicted to further reduce the burden of cervical cancer.
Read the full article here: "Cervical cancer – early detection and referral".
Got no time for that? A B-QuiCK summary is available here
Accuretic stock to be withdrawn on 31 October, 2022
The supplier of Accuretic (quinapril + hydrochlorothiazide) has advised that all remaining stock will be withdrawn from distributors on 31 October, 2022. As first reported in Bulletin 53, patients taking Accuretic require a change in anti-hypertensive treatment due to contamination issues.
Prescribers can currently still claim for first consultation costs in relation to transitioning patients to an alternative medicine. The cost of follow-up consultations is not reimbursed. Accuretic will be delisted from the Pharmaceutical Schedule on 1 December, 2022.
For further information on selecting and prescribing ACE inhibitors, see: https://bpac.org.nz/2021/ace.aspx
Alternative brand of pregabalin to cover supply issue
Pharmac has been notified of a potential supply issue with Pregabalin Pfizer, in November 2022. Both the 25 mg and 75 mg capsules may be out of stock for a short period.
To minimise disruptions, Mipharm pregabalin 25 mg and 75 mg capsules will be funded from 1 November, 2022. Mipharm pregabalin is not approved for use in New Zealand by Medsafe and will need to be prescribed and supplied under Section 29. Patients should be advised the packaging and capsules will appear different.
For further information on prescribing pregabalin in primary care, see: https://bpac.org.nz/2021/gabapentinoids.aspx
Consultation to fund new medicines for inflammatory bowel disease
In Bulletin 59 it was reported that Pharmac was seeking feedback on a proposal to fund a new medicine for inflammatory bowel disease (IBD). There is now a proposal to fund another new medicine for IBD, ustekinumab (Stelara) and to extend funding of infliximab (Remicade) to people with IBD-associated arthritis. Submissions are due by 4 pm, Wednesday 26 October.
Ustekinumab is a biologic medicine that reduces cytokine activation in the inflammatory processes associated with IBD. The patient begins treatment with a loading dose via intravenous infusion, followed by self-administering of a maintenance dose via pre-filled syringes every eight weeks.
It is proposed that ustekinumab is funded with Special Authority approval from 1 February, 2023, for adults and children (unapproved indication), with application from any relevant practitioner, for patients who meet Special Authority criteria related to their condition and prior treatment.
Infliximab, an anti-TNF agent, is currently funded for various chronic inflammatory conditions. Patients can receive an intravenous infusion of infliximab either in hospital, outpatient clinics or infusion service providers. An extension to the funding of infliximab will offer patients with IBD-associated arthritis who meet Special Authority criteria an alternative biologic medicine, from 1 February, 2023.
N.B. This proposal would also include amendments to the Special Authority criteria for infliximab, aligning it with other funded anti-TNF agents, e.g. adalimumab, for Crohn’s disease and ulcerative colitis.
Do not prescribe vildagliptin and dulaglutide concurrently
There have been recent reports to the NZF of patients taking vildagliptin (alone or formulated with metformin) concurrently with dulaglutide. In some cases, patients have experienced adverse effects, although it is unknown if this was due to an individual medicine or the combination of treatment. Using these medicines concurrently is not recommended as they have a similar mechanism of action. Vildagliptin must be stopped before initiating dulaglutide.
Vildagliptin is a dipeptidyl peptidase-4 (DDP-4) inhibitor and dulaglutide is a glucagon-like petptide-1 (GLP-1) receptor agonist. They act via differing parts of the incretin hormone system to increase insulin secretion from the pancreatic beta-islet cells. DPP-4 inhibitors (e.g. vildagliptin) must be stopped before initiating a GLP-1 receptor agonist (e.g. dulaglutide) because the treatment becomes redundant and the patient is exposed to potential adverse effects without clinical benefit.
As this is a pharmacodynamic interaction (medicines with similar effects), it is not listed on Stockley’s Drug Interactions and is therefore not displayed when searching the interaction tool on the New Zealand Formulary (NZF). A caution about avoiding this combination is included in NZF monographs for vildagliptin, dulaglutide and other GLP-1 agonists and DPP-4 inhibitors.
Other glucose-lowering treatments can be continued when dulaglutide is initiated, if needed for glycaemic control or cardiovascular or renal protection. The dose of insulin or a sulfonylurea may need to be reduced to prevent hypoglycaemia.
For further information on prescribing dulaglutide in primary care, see: https://bpac.org.nz/2021/diabetes.aspx
Potential safety signal: gestational diabetes in association with quetiapine
Due to metabolic adverse effects, quetiapine and some other atypical antipsychotics can increase the risk of gestational diabetes if used during pregnancy. This issue was discussed at the most recent meeting of the Medicines Adverse Reactions Committee (MARC) in September, where it was recommended that the pregnancy section of the quetiapine data sheet should be updated to reflect this risk.
MARC also discussed the results from a 2018 study in New Zealand which suggested that quetiapine is widely prescribed for unapproved uses including sleep and anxiety, and use is increasing over time. This is a concern as prescribing quetiapine for an unapproved indication, without evidence of effectiveness and safety data, impacts the risk-benefit balance, particularly in pregnant women. Prescribers should take this into consideration when discussing treatment choices.
In response to this concern, bpacnz will publish an article on the metabolic adverse effects of atypical antipsychotics, including effects in pregnancy and discuss use of quetiapine for unapproved indications.
Reminder: be aware of medicine interactions with statins
We are reminding prescribers to be aware of medicine interactions when prescribing statins, particularly atorvastatin and simvastatin.
Statins can have serious interactions with some medicines, particularly potent CYP3A4 inhibitors such as macrolide antibiotics (e.g. erythromycin, clarithromycin), azole antifungals (e.g. itraconazole, ketoconazole) and ciclosporin, which can result in myopathy and/or rhabdomyolysis.
Check for medicine interactions prior to prescribing a statin to reduce the risk of adverse effects: https://www.nzf.org.nz/
For further information on statins, see:
Eating and drinking habits in New Zealand: report released
Manatū Hauora, The Ministry of Health, has published reports on the dietary habits of adults and children (aged 2 – 14 years) in New Zealand. The reports are based on information provided as part of the New Zealand Health Survey in 2018/19 and in 2019/20, therefore reflect eating habits prior to the COVID-19 pandemic.
The results were not unexpected; the eating habits of people in New Zealand often fall short of the Eating and Activity Guidelines for New Zealand Adults 2020. Consider any opportunity where you can incorporate healthier eating and lifestyle advice into interactions with patients, their caregivers and whānau.
- 33% of adults and 44% of children are eating the recommended daily intake of fruit and vegetables
- Females were more likely to eat a healthier diet than males
- Age had a significant impact on diet. Younger children were more likely to eat more vegetables and fruit, and less fizzy drinks and confectionery than older children. Older adults were more likely to consume less meat and takeaways but had increased biscuit and cake consumption.
- People living in low socioeconomic areas were less likely to eat the recommended number of servings of fruit and vegetables and were more likely to frequently eat takeaways and consume fizzy drinks.
- Ethnic disparities were present; just under half (44%) of all children met the recommended number of servings of vegetables and fruit but only 29% of Asian and 27% of Pacific children met the recommendations (42% of Māori and 51% of European children met the recommendations)
Specialise as a GP webinars
The Royal New Zealand College of General Practitioners are running webinars to provide doctors interested in general practice an opportunity to find out further details on the profession and the General Practice Education Programme.
The next webinar will be held on Wednesday 9th November, from 6.30 – 7.30 pm: register here. The transcript from the session held earlier this week will be available online: register here to view.
Find out more about the webinars here.
Call for GP participants in sports-related concussion study
Researchers at AUT are investigating general practitioners’ knowledge and perceptions of return to play care following sports-related concussions. Identifying obstacles general practitioners are currently facing can guide future approaches to concussion care.
Participation involves a 60 – 90 minute in-person or online interview discussing your knowledge of return to play guidelines, considerations when managing patients recovering from concussion and thoughts regarding multi-disciplinary working relationships with physiotherapists. Researchers are especially interested to hear from general practitioners who identify as Māori or work in rural communities given the current healthcare workforce shortages and issues facing ngā kiritaki hauora Māori (Māori health consumers) in Aotearoa/New Zealand.
For further information about the study, contact Colin Hancock at email@example.com or Phone: 027 697 0466
For bpacnz/ACC guidance on the management of concussion in primary care, see: https://bpac.org.nz/2022/concussion.aspx
Paper of the Week: Our wearable future
A recently published two-part Medscape series discusses the future of wearable technology for health monitoring. While most wearable technology has a long way to go before it becomes part of clinical practice, this series provides an interesting look into these possibilities.
Recent experience with COVID-19 lockdowns stimulated a rapid adoption of digital healthcare including telehealth and online consultations. The ability to remotely collect accurate and usable data is crucial for clinical decision and patient safety. There is significant potential for low-cost and non-invasive monitoring of patients allowing for early detection or intervention of acute, developing and chronic conditions. Current medical grade examples already in use include continuous glucose monitoring systems and electrocardiogram patches for detecting arrhythmias.
Some of this technology is filtering into consumer products with smart watches and smart rings now advertised as having the ability to measure pulse oxygenation or carry out an ECG. However, many of these products were originally designed as fitness gadgets and the majority of measurements that can be recorded at the wrist or finger are not considered reliable for clinical decision making, e.g. significant variability in peripheral pulse rate between different smartwatches or skin temperature recorded at the wrist does not accurately represent core body temperature.
While most wearable technology has a long way to go before it becomes part of clinical practice, this series provides an interesting look into these possibilities.
Jerilyn Covert. Our Wearable Future, Part 1: What Will New Tech Look Like? - Medscape - Aug 24, 2022 https://www.medscape.com/viewarticle/979687 and Jerilyn Covert. Our Wearable Future, Part 2: How Will New Tech Work? - Medscape - Aug 24, 2022 https://www.medscape.com/viewarticle/979705
This Bulletin is supported by the South Link Education Trust
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