Published: 3 February, 2023
Contents
In case you missed it: latest articles
Hypertension in adults: the silent killer
Hypertension is a common finding among patients in primary care; ideal pharmacological treatment, however, continues to be debated. What is agreed is that chronic hypertension can cause a wide-range of cardiovascular disease and end-organ damage if left untreated or insufficiently controlled. Management often requires medicines in addition to lifestyle changes to achieve blood pressure targets and reduce overall cardiovascular risk.
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A B-QuiCK summary and quiz are available for this topic.
Revisiting opioid use in New Zealand: how does your prescribing compare?
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.
This resource examines national trends in opioid use between 2017 – 2021. An editable and printable pain management plan and opioid treatment contract are also included as potential tools to support safe and effective use of these medicines. If you are a primary care prescriber, you can log in to see your personalised opioid prescribing snapshot, including how your prescribing weighs up against your peers and national trends. So... how do you compare?
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A B-QuiCK summary is available for this topic.
Liver function tests in primary care
Liver function tests (LFTs) are among the most commonly requested laboratory investigations in primary care. However, as with all other laboratory tests, it is essential that clinicians consider whether LFTs are being requested for the right patient at the right time, and have a clear understanding of how results will be interpreted based on the specific clinical context.
This is a comprehensive resource on understanding and interpreting LFTs (and yes, we do discuss use of this misnomer), along with a spotlight on the key causes of liver disease: metabolic-associated fatty liver disease, alcohol-related liver disease and hepatitis B- and C-related liver disease.
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A B-QuiCK summary is available for this topic.
February is Ovarian Cancer Awareness Month
This month is Ovarian Cancer Awareness Month. Ovarian cancer is the second most common gynaecological cancer after endometrial and has a higher mortality than all other gynaecological cancers in New Zealand combined.
There is no effective screening test for ovarian cancer, so diagnosis relies on the prompt recognition and investigation of suspicious symptoms. While ovarian cancer was historically considered to be a silent disease in its early stages, evidence suggests that 90 – 95% of people are symptomatic, although symptoms are often vague and non-specific. Clinicians should be alert for potential symptoms of ovarian cancer and have a low threshold for initiating further investigations in people with suspicious symptoms.
Symptoms of ovarian cancer may include:
- Abdominal bloating or distension
- Abdominal or pelvic pain
- Early satiety or loss of appetite
- Increased urinary frequency or urgency
- Changes in bowel habit*
- Fatigue
- Unexplained weight loss
- Post-menopausal bleeding
*New symptoms suggestive of irritable bowel syndrome in females aged > 50 years are unusual; consider the possibility of ovarian cancer in these patients
Symptoms are more likely to be associated with ovarian cancer if they are in a post-menopausal female and/or if they are new, severe, unusual, recurrent or persistent, e.g. occurring 12 or more days per month.
This month we will be publishing an article on the early detection of ovarian cancer. This article is part of a series on gynaecological cancers, supported by Te Aho O Te Kahu – Cancer Control Agency. The first article of this series, Cervical cancer: early detection and referral was published last year; keep an eye on our website and watch your inbox for new resources as they are published.
Fluoxetine 20 mg capsules supply issue: dispensing limit in place
It has previously been announced that the funded brand of fluoxetine 20 mg capsules is changing from Fluox to Arrow-Fluoxetine, with Fluox to be delisted on 1 June, 2023. However, Pharmac reports that stock of Fluox has now been exhausted; the brand change has therefore occurred earlier than expected causing a supply issue with Arrow-Fluoxetine.
Limited supply of Arrow-Fluoxetine is likely to continue throughout February, 2023. Stock is expected to arrive this month; however, it may take time to restock all pharmacies.
A dispensing limit (see “Read more”) is now in place until 28 February, 2023, when it is anticipated that the supply issue will be resolved. The situation will be monitored, and the limit removed earlier if supply becomes available.
Read more
- Pharmacists can dispense a maximum of seven days’ supply of fluoxetine at one time (a change from the current monthly dispensing). This applies to all three funded fluoxetine products (i.e. Arrow-Fluoxetine 20 mg, Fluox 20 mg capsules, Fluox 20 mg dispersible tablets).
- Pharmacists must clearly annotate on the prescription the words “out of stock” or “OOS” AND initial the annotation in their handwriting
N.B. A brand-switch fee is currently unavailable, but Pharmac is looking into possible payments to pharmacies.
What if a patient needs more than the seven days’ supply?
Pharmac advises that pharmacists may use their discretion to dispense more than seven days’ supply when it is difficult for a patient to get to a pharmacy, e.g. if the patient:
- Has limited physical mobility
- Lives and works a long distance from the pharmacy
- Is moving away
- Will be travelling when they need to pick up the repeat
However, Pharmac has stated that blister packaging is not an acceptable reason for dispensing more than seven days’ supply at one time.
N.B. Fluox 20 mg dispersible tablets are still available and may be an appropriate substitution for Arrow-Fluoxetine or Fluox 20 mg capsules. The dispersible tablets may be swallowed whole or dissolved in water. Pharmacists can dispense Fluox 20 mg dispersible tablets in place of Arrow-Fluoxetine 20 mg capsules or Fluox 20 mg capsules (dispensing limit still applies). The prescription should be processed as endorsed for everyone, regardless of the Pharmaceutical Schedule criteria (due to timeframes, the Online Schedule cannot be updated to reflect this change)
Reminder: reporting hazardous substances-related diseases and injuries
By law, injuries and diseases due to hazardous substances (see below) must be notified to the Medical Officer of Health. BPAC Clinical Solutions, in association with EHINZ and funded by Manatū Hauora, Ministry of Health, has developed a Hazardous Substances Disease and Injury Reporting Tool (HSDIRT), for electronic reporting of all hazardous substance exposures. It is available via Medtech, Indici, MyPractice and Profile practice management systems. Electronic reporting meets the legal requirement for notifying the Medical Officer of Health. Clinicians who do not use electronic reporting must contact the Public Health Unit directly.
What is classified as a hazardous substance
As defined in the Hazardous Substances and New Organisms Act 1996, a hazardous substance is anything that can:
- Explode
- Catch fire
- Oxidise
- Corrode
- Be toxic to humans
This definition does not include:
- Medicines in finished dose form (and therefore over-the-counter and prescription drug overdoses)
- Alcohol (when classified as a food)
- Chemical toxins associated with food
- Radioactive materials (covered by different legislation)
Manufactured articles, other than those including substances with explosive properties such as fireworks, are also not included, e.g. batteries.
Click here to view a short video explaining how to access and complete HSDIRT notification forms
To get bestpractice Decision Support software for your practice, contact the BPAC Clinical Solutions Helpdesk:
Phone: 0800 633 236
Email: itservicedesk@bestpractice.org.nz
Website contact form: https://bpacsolutions.co.nz/contact/
A practical example of using HSDIRT: 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. It would be appropriate to use the HSDIRT tool following many of these scenarios.
Contact the National Poisons Centre if there is any uncertainty in the management of a child who has been poisoned.
A B-QuiCK summary is available for this topic.
NZF updates for February
Significant changes to the NZF in the February, 2023 , release include:
- Updated contraception and conception advice and patient advice for anti-epileptic medicines
- New cautions added (folate-dependent tumours, elderly) to the folic acid monograph. Adverse effects have also been updated.
- An alternative dose of disulfiram has been added. Contraindications and cautions have been updated in the naltrexone monograph.
- A new caution added (predisposition to urinary retention) to the cetirizine monograph. Adverse effects have also been updated.
- A new caution added (hypophosphataemia) to the ferric carboxymaltose monograph. New sections on monitoring, renal impairment and patient advice have been added. Pregnancy information, adverse effects and the dose regimen have also been updated.
- Updated breastfeeding advice for metronidazole (systemic)
You can also read about any significant changes to the NZFC, here.
Revised Mental Health Act Guidelines: e-learning modules and resources now available
Te Pou, a national workforce centre for mental health, addiction and disability in New Zealand, has developed a suite of resources, supported by Manatū Hauora, Ministry of Health, for people being assessed and treated under the Mental Health Act, and for their family/whānau. These resources have been developed in response to the 2022 revised Mental Health (Compulsory Assessment and Treatment) Act 1992 Guidelines.
A series of free e-learning modules have also been released to support healthcare professionals in applying the changes to the Mental Health Act, particularly in adopting a person-centred, human-rights based approach to situations where the Mental Health Act is used. Three modules are available:
- Module 1: A general introduction to the changes for anyone in the health workforce
- Module 2: For the mental health workforce
- Module 3: For specialist mental health workforce who implement the Mental Health Act
Paper of the Week: New study may help determine which older people with vague symptoms have cancer
This week we depart from our usual paper of the week to share with you a short interview-style podcast from the British Journal of General Practice, with the lead author of a 2023 paper that studied cancer risk in patients with fatigue and other vague symptoms.
Fatigue is a relatively common and non-specific symptom that most people experience at some point in their life. For many people, the underlying cause is benign, but for some, the cause of their fatigue is something more concerning. The optimal investigation and management of a patient with vague and non-specific symptoms is often challenging in primary care. It is also difficult to judge which patients require investigation for cancer when there are no red flags or specific symptoms present to guide this decision.
The study was conducted using clinical records of patients who presented to primary care in the United Kingdom with fatigue and no red flag symptoms of cancer. The study looked at whether patients had other vague symptoms present, e.g. weight loss, abdominal pain, in addition to fatigue. During a nine-month follow-up period, researchers analysed how many patients were diagnosed with cancer to identify which sex, age group and combination of symptoms were associated with the highest risk of disease. All diagnoses of malignant neoplasms were included in this study except non-melanoma skin cancers.
The author of the paper explains in the podcast that among patients without red flag symptoms for malignancy, the risk of cancer was > 3% for older males and females with fatigue and another vague symptom, in particular weight loss, abdominal pain or abdominal bloating. The risk of cancer exceeded 6% in some older male patients with fatigue and weight loss or fatigue and abdominal pain. The study did not differentiate which specific cancers or organ sites were associated with fatigue, or other vague symptom combinations.
If an older patient presents with fatigue, ask about the presence of any other vague symptoms, particularly weight loss or abdominal pain, and if present, consider the possibility of malignancy even if there are no red flag symptoms of cancer.
Listen to the full podcast here: https://bjgplife.com/episode-102-combining-vague-cancer-symptoms-to-improve-referrals-for-suspected-cancer/ (15 minutes)
Read the full article here: https://bjgp.org/content/73/727/e75
This Bulletin is supported by the South Link Education Trust
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