Published: 20 January, 2023
Contents
Liraglutide funded from March, 2023
Liraglutide (Victoza), an alternative GLP-1 receptor agonist to dulaglutide, will be funded from 1 March, 2023, for people with type 2 diabetes who meet existing eligibility criteria for GLP-1 receptor agonists. This decision is in response to the global supply issue affecting stock of dulaglutide (Trulicity), as reported in Bulletin 60 and 64. Supply of liraglutide is expected to be available from early-to-mid March and it will be listed for the duration of the stock issue with dulaglutide.
Once normal supply of dulaglutide has resumed, liraglutide will only be funded for patients who were initiated on it during the stock shortage (i.e. not for new patients).
Read more
Liraglutide is administered as a once daily subcutaneous injection using a titratable pen.* It has a similar efficacy and safety profile to dulaglutide. The usual dose of liraglutide for glycaemic control is 1.2 mg/day (usually initiated at 0.6 mg/day for the first week to minimise gastrointestinal symptoms) to a maximum of 1.8 mg/day. Doses for type 2 diabetes are significantly lower than those used for weight loss. A maximum of one pack of three prefilled 3 mL pens (6 mg/mL) will be funded per month.
*A supply of disposable pen needles will also be required; restrictions applying to funded pen needles will be amended to include liraglutide
A once daily injection may be easier to tolerate for some patients who have experienced adverse gastrointestinal effects from the weekly injections of dulaglutide. However, for others, daily injections may be intolerable or unsuitable; fewer people are expected to take liraglutide because of this.
N.B. Patients who meet eligibility criteria may only be prescribed one funded SGLT-2 inhibitor or GLP-1 receptor agonist at a time.
For further information on managing type 2 diabetes, see: https://bpac.org.nz/2021/diabetes-management.aspx
COVID-19 vaccine for immunocompromised and high-risk children aged < 5 years
The Director-General of Health has recommended the paediatric Comirnaty COVID-19 vaccine (Pfizer/BioNTech), maroon cap, for use in children aged six months to four years who have complex chronic medical conditions (including neurodevelopmental conditions), severe immunocompromise, e.g. undergoing treatment for cancer or transplant, or risk factors for severe illness from COVID-19. The decision has been approved by Government Ministers and has received provisional approval from Medsafe.
The vaccine that will be used for this age group is a modified version of the vaccine used in children aged 5 to 11 years. The vaccine is expected to be available in February, 2023, and will be given in three doses. The second dose is given three weeks after the first dose, and the third dose given eight or more weeks after the second dose.
The paediatric Pfizer COVID-19 vaccine is not recommended for children aged six months to four years who are not considered at risk for severe illness from COVID-19.
Vaccinators will need to have previously completed online education for both Comirnaty (30 mcg), purple cap, and Comirnaty (10 mcg), orange cap, to administer this vaccine to children at high-risk aged under five years.
Further information will be made available once the delivery of vaccine stock is confirmed.
The Immunisation Advisory Centre is hosting a webinar on Thursday 2nd Feb at 5.30 pm on everything you need to know about Comirnaty for high-risk children aged 6 months to four years, including safety and efficacy and eligibility. Click here to register. There will be no specific online course available for vaccinators administering the vaccine to eligible children.
Increased risk of polio
Te Whatu Ora, Health New Zealand, is advising clinicians about an increased risk of polio entering New Zealand due to an international outbreak. Poliomyelitis is commonly transmitted via the faecal-oral route or by droplet spread.
Clinicians are being asked to:
- Review the polio vaccination status of children (assigning priority to those aged < 5 years and then to those aged < 16 years) and recommend vaccination with IPV if required (and other missed vaccines)
- Recommend polio vaccination to unvaccinated or partly vaccinated adults
- Ensure that patients who are travelling internationally in the coming year are fully vaccinated against polio (and MMR)
Up to three doses of the polio vaccine are funded for people who are unvaccinated or partly vaccinated, or for re-vaccination in people following immunosuppression.
Consider poliomyelitis in a patient with “flu-like” symptoms, although many are asymptomatic, and a history of recent overseas travel to an outbreak country/area. Any rapidly evolving symptoms such as muscle weakness, difficulties with swallowing or breathing can indicate the development of paralysis. Urgent notification and hospital assessment is required for a patient with acute flaccid paralysis.
For further information on poliomyelitis, see: https://www.health.govt.nz/our-work/immunisation-handbook-2020/17-poliomyelitis
Mpox vaccine now available
A vaccine for mpox (Monkeypox) is now available for eligible people (see below) at dedicated clinics. The vaccine protects against smallpox and mpox for post-exposure vaccination of close contacts of cases and pre-exposure vaccination for high-risk groups. Current stock levels are sufficient to vaccinate up to 20,000 people; additional supplies are expected later this year.
The vaccine is not currently approved by Medsafe, so must be prescribed under Section 29. For close contacts of people infected, the vaccine is most effective if administered within four days of exposure, but it can be administered up to 14 days after.
Two doses of the vaccine are required for full protection, administered at least 28 days apart (can be up to two years after the first dose). In the initial phase of the vaccine rollout, priority is being given to eligible people who are receiving their first dose.
Current eligibility criteria
- Close physical contacts of people infected with mpox, e.g. sexual partners, members of the same household
- Gay, bisexual and other men who have sex with men who have multiple sexual partners, transgender, non-binary people and cisgender females who are in intimate relationships with eligible men
- People recommended by a clinician to be vaccinated
- People whose occupation might put them at increased risk of mpox, e.g. some laboratory or healthcare workers
Information for clinicians about mpox is available here.
An online tool is available from the Burnett Foundation for people to check if they are at risk of monkeypox.
Ibuprofen liquid (Ethics) supply issue
Due to high demand and delivery delays, the supplier is currently rationing stock of 20 mg/mL ibuprofen liquid (Ethics) to ensure equitable access. There is limited stock available and while orders are still being filled, they may not be complete. Rationing will continue until new stock arrives in New Zealand (resupply expected in late January or early February, 2023), at which time, back orders will be filled.
Clinicians can take steps to reduce pressure on available stock by ensuring that only appropriate quantities of ibuprofen liquid are prescribed, e.g. 100 mL, considering whether repeats are necessary and asking what medicine supplies patients already have at home before prescribing.
For further information on prescribing appropriate quantities of medicines, see: https://bpac.org.nz/bpj/2015/august/pills.aspx
New Zealand-based online CBT course for OCD released
Just a Thought is a New Zealand organisation that offers free online cognitive behavioural therapy (CBT) courses and hosts other resources for a range of mental health conditions. A new online CBT course has now been released for people with obsessive compulsive disorder (OCD). The course has been adapted for New Zealand from an Australian online CBT course for OCD. The Australian course by This Way Up has been evaluated in a randomised controlled trial showing good efficacy.
In many areas across New Zealand, there are significant wait times to access publicly funded psychological or psychiatric services, or even sometimes private services. Online therapy courses for OCD may have a role in supporting patients while they await access to secondary care services.
The course can either be completed by the patient in a self-guided manner or through prescription by a clinician. Adherence rates are higher when a clinician prescribes the course and incorporates it into their follow-up consultations.
For further information on the recognition and management of a patient with OCD, see: https://bpac.org.nz/2022/ocd.aspx
Reminder: annual cervical screening required for some people with immune deficiency
The National Cervical Screening Programme currently recommends three-yearly cervical cytology screening for females aged between 25 and 69 years who have ever been sexually active. People who are immune deficient, however, may require more frequent screening due to evidence of an increased risk of persistent HPV infection and cervical lesions, and because established lesions may progress more rapidly. Clinical Practice Guidelines for Cervical Screening in New Zealand 2020 state that based on current evidence, people with immune deficiency can be divided into two groups with regard to screening intervals:
- Annual screening is required for people with HIV and those who have had a solid organ transplant due to definitive evidence of increased risk
- Annual screening is recommended for people who are immune deficient for other reasons such as a disease causing immune deficiency, those taking immunosuppressant medicines or with congenital (primary) immune-compromising disease
The evidence base for those in the second group is thought to be not definitive enough to require (rather than recommend) annual screening and clinicians are advised to make an individualised decision for people in this group. The guidance is considered to represent a cautious approach until further evidence is available.
The threshold for referral for colposcopy for a person with immune deficiency and an abnormal cytology result should also be lower than for the general population.
Reminder: Young people who have been sexually active and who have been immune deficient for more than five years should start cervical screening before age 25 years.
Ensure that an appropriate recall is set on your PMS for patients eligible for cervical screening who have immune deficiency. You can also contact the National Cervical Screening Register Central team (0800 506 050) to add immune deficiency as a medical condition on a patient’s record which will flag them as requiring annual screening, otherwise the default recall will be three years.
For information on specific cervical screening recommendations for people with immune deficiency, see: https://www.nsu.govt.nz/system/files/resources/final_ncsp-guidelines-for-cervical-screening-new-zealand-5_june_2020.pdf#page=50
For further information on cervical screening, including what to expect with the move to HPV testing in July, see: https://bpac.org.nz/2022/cervical-cancer.aspx
Paper of the Week: Kiwifruit for constipation: RCT evidence supports use
Kiwifruit is a commonly suggested treatment for constipation in New Zealand and previous studies
(here and here) examining
the effects of kiwifruit on patients with constipation have demonstrated potential benefit. However, clinical guidelines favour the use of soluble fibre bulking agents as first line management options for patients with constipation. With New Zealand currently experiencing ongoing supply issues with funded psyllium husk powder and other laxative products, patients need more options for symptom relief.
A 2023 paper published in the American Journal of Gastroenterology examined the effects of daily kiwifruit consumption on gastrointestinal function and comfort. This randomised controlled trial provides evidence that consumption of kiwifruit is beneficial for people with constipation and may have greater benefit than psyllium husk.
Key findings
- A single blinded, crossover, randomised controlled trial was carried out over 16 weeks and involved participants from Italy, Japan and New Zealand. Participants were aged between 18 and 65 years and had been diagnosed with either functional constipation or irritable bowel syndrome (IBS) with predominant constipation, or were healthy controls.
- Participants with red flag gastrointestinal symptoms or an IBS-symptom severity index score > 300 were excluded
- Following a two-week lead in period participants were randomised to consume either two green kiwifruit* (without skin) or 7.5 g of psyllium husk per day, for four weeks, followed by a four-week washout period, and then crossover to the other intervention for a further four weeks.
- Both interventions equate to approximately 6 g of dietary fibre
- Participants completed Daily Bowel Health Diaries, describing frequency, completeness and spontaneity of evacuation, as well as stool form, laxative use and degree of straining. Food diaries, IBS-associated quality of life questionnaires, blood and stool samples were also assessed before and after both intervention periods.
- The primary outcome was an increase of ≥ 1.5 complete spontaneous bowel movements (CSBM) per week, measured before and after four weeks of each intervention (an increase of > 1 CSBM per week is recognised as a clinically relevant improvement). Secondary outcomes included gastrointestinal comfort, stool consistency and degree of straining.
- Of the 184 initial participants, 169 participants completed the study. Data from the healthy control group was compared against the functional constipation and IBS with predominant constipation groups, both separately and also with them combined into a single “constipation” group comparator.
- An increase of ≥ 1.5 CSBM was demonstrated for participants with functional constipation, IBS with predominant constipation and the combined group following the kiwifruit intervention. Following consumption of psyllium husk, this result was only demonstrated in participants with IBS with predominant constipation.
- Softening of stool consistency, reduction in straining and improvement in quality of life were associated with daily consumption of two kiwifruit in the combined group
- Stool consistency and straining were significantly improved following kiwifruit consumption, compared to psyllium husk
Clinicians could consider recommending fresh kiwifruit (or a frozen product, e.g. “Kiwi Crush” depending on seasonal availability) as an effective and accessible management option for patients with constipation, especially when other funded first line options, i.e. psyllium husk, are not available.
* The study was jointly funded by the New Zealand government and Zespri International Ltd
Gearry R, Fukudo S, Barbara G, et al. Consumption of 2 Green Kiwifruits Daily Improves Constipation and Abdominal Comfort—Results of an International Multicenter Randomized Controlled Trial. The American Journal of Gastroenterology, January 9, 2023. | DOI: 10.14309/ajg.0000000000002124
For further information on the management of constipation, see: https://bpac.org.nz/2019/constipation.aspx
For further information on the management of irritable bowel syndrome in adults, see: https://bpac.org.nz/BPJ/2014/February/ibs.aspx
This Bulletin is supported by the South Link Education Trust
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