Published: 7 October, 2022
No new patients should be started on dulaglutide: global supply issue
A global supply issue is affecting stock of dulaglutide (Trulicity), an injected GLP-1 receptor antagonist for people with type 2 diabetes, and supply pressures are likely to continue through to early next year. Pharmac has asked health professionals to “strongly consider” not starting new patients on dulaglutide so that existing stock can be prioritised for those who are already taking the medicine.
Empagliflozin (with or without metformin), an oral SGLT-2 inhibitor, is the primary funded alternative treatment for patients who meet the Special Authority criteria. 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, e.g. empagliflozin, vildagliptin, initiating insulin and monitoring for complications. Individual articles can be found here.
Consultation to fund adrenaline auto-injectors
Pharmac is seeking feedback on a proposal to fund adrenaline auto-injectors (e.g. EpiPen) for people at risk of anaphylaxis. Submissions are due by 11 October.
Currently, people at risk of anaphylaxis can purchase adrenaline auto-injectors at a pharmacy without a prescription. However, the cost, alongside a short expiration date (efficacy may be compromised in expired products), can be significant barriers to access.
Adrenaline is an endogenous hormone administered in the emergency treatment of people experiencing anaphylaxis. Pre-dosed auto-injectors can be used by non-medically trained people. Administration of adrenaline causes stimulation of adrenergic alpha and beta receptors, resulting in vasoconstriction and a reduction in tissue oedema. In some cases, bronchodilation and increases in systolic blood pressure and cardiac output can also occur. If the response is not sufficient after an initial dose, or the patient has high risk features, subsequent doses can be given at 5 – 15 minute intervals from a new device: see NZF for dosing details.
It is proposed that adrenaline auto-injectors are funded with Special Authority approval for patients who have previously experienced an anaphylactic reaction that resulted in presentation to the emergency department or who have been assessed to be at significant risk of anaphylaxis by, or on the recommendation of, a relevant specialist.
The proposal will allow for two adrenaline auto-injectors to be prescribed in the initial prescription and additional prescriptions of up to two devices following administration or before expiry. The start date for funding and the brand of adrenaline auto-injector that will be funded would be released once a tender decision has been made.
N.B. This consultation also includes a proposal to fund nusinersen (Spinraza) for the treatment of people with spinal muscular atrophy.
COVID-19 mortality in New Zealand: analysis released
Manatū Hauora, The Ministry of Health, has published a report on COVID-19 mortality in New Zealand. The analysis was undertaken by the Public Health Agency to identify and quantify inequities in COVID-19 mortality in New Zealand, particularly for Māori and Pacific peoples, and to examine factors that may influence this risk.
The analysis included 1,797 people whose death had been attributed to COVID-19 between 1 January and 26 August, 2022. Age was found to be the most significant predictor of mortality from COVID-19. Other risk factors included:
- Māori and Pacific ethnicity. Māori and Pacific peoples had 2.0 and 2.5 times greater risk of COVID-19 mortality, respectively, compared to European/Other.
- Low socioeconomic status. The most deprived 20% of people in New Zealand had 3.0 times the risk of COVID-19 mortality compared to the least deprived 20%.
- Pre-existing health conditions. People with one or more co-morbidities (particularly those aged under 60 years) had a 6.3 times greater risk of COVID-19 mortality compared to people without co-morbidities.
Being vaccinated provided significant protection for all ethnicities; two or more doses of a COVID-19 vaccine reduced the risk of death by 62% compared to fewer than two doses.
Read the full report here. There is also an associated press release detailing some of the key findings.
Shingrix to be the new funded brand of shingles vaccine
As reported in Bulletin 56, the funded shingles vaccine is changing from Zostavax to Shingrix as the supplier is discontinuing supply of the current vaccine. Shingrix will be funded for people aged 65 years once stock of Zostavax is exhausted. Shingrix is given as two doses, two to six months apart (the second dose will be funded as long as the patient was aged 65 when they received their first dose).
Boostrix is now available in community pharmacies
The funded brand of the diphtheria, tetanus and pertussis vaccine (Boostrix) is now able to be offered in community pharmacies for eligible people at no cost. The eligibility criteria for funded vaccination can be found here . See Bulletin 59 for further details.
Novavax primary doses are now available for everyone aged 12 years and older
People aged 12 years and older can now receive a primary course of the Novavax COVID-19 vaccine. The Pfizer vaccine remains the preferred vaccine in New Zealand. The interval between doses of the primary course of Novavax is the same as for the Pfizer COVID-19 vaccine (i.e. minimum of at least three weeks with eight weeks being optimal). Novavax is only available as a booster for those aged 18 years and older.
The 2022 flu season may be over, but influenza vaccination is still encouraged
This year’s flu season officially ended on the 30th of September and coverage reached some of the highest levels in recent years. More than 70% of people aged 65 years and older received an influenza vaccination this year; click here to view the latest vaccination coverage data. Despite flu season officially ending, stocks of the vaccine will still be available until December. Influenza vaccination should still be encouraged over the next couple of months, particularly in vulnerable populations, e.g. pregnant females.
ACC to cover injuries during labour or childbirth
From 1 October, 2022, birthing parents who are injured during labour or childbirth are eligible for support from ACC. Data show that up to 80% of birthing parents experience an injury during labour or childbirth. Previously, the definition of injury in the Accident Compensation Act 2001, specified the application of force or resistance that was external to the body; obstetric injuries were judged to be due to an internal force and therefore did not meet the requirements for cover. This has meant that only injuries that occurred as a result of treatment during childbirth were covered by ACC. It is estimated up to 28,000 birthing parents will benefit from this change, each year.
A defined list of birth injuries that are covered has been developed by ACC, including uterine prolapse, obstetric fistula and genital tears. People who experience significant morbidity or long-term complications following an injury during labour or childbirth, will be able to access compensation, support and rehabilitation services.
NZF updates for October
Significant changes to the NZF in the October, 2022, release include:
You can also read about any significant changes to the NZFC, here.
In brief: Medicine updates
Citalopram brand change
A new brand of citalopram, Celepram, has been listed to replace the current brand PMS citalopram that is being discontinued due to the supplier leaving the market. It is expected that patients will have to be changed to the new brand by December. Read more about this decision here.
New strength of perindopril available
Following Medsafe approval, an 8 mg tablet of perindopril is now available, fully funded. Perindopril is also available and funded in 2 mg and 4 mg tablet strengths. Read more about prescribing ACE inhibitors here.
Paper of the Week: How general practitioners in New Zealand treat patients with a first or new episode of depression
A recent qualitative study published in the Journal of Family Medicine and Primary Care has examined how general practitioners in the Auckland region treat patients presenting with a first or new episode of depression.
General practitioners were interviewed about their approach and a wide variety of management options were reported; physical activity and antidepressants were the most common. Despite evidence suggesting behaviour activation (re-engaging with activities) is an effective treatment for depression, it was recommended by less than half of all clinicians interviewed.
The initial consultation when a patient presents with depression is important as treatment decisions at this time can have long-term consequences. The first consultation may also be the only opportunity to discuss appropriate treatments with a patient, as the follow-up rate after a diagnosis of depression is often low. Consider how you approach the first consultation with a patient with depression, and what determines your decisions for recommending different management options.
- A random sample of 45 general practitioners in the Auckland region were invited to participate in the study. In total, 21 clinicians were interviewed; the average number of years since graduation was 27 years and 43% were female
- Responses were grouped into three main themes: characteristics of general practitioners (confidence using talking therapy, limitations, e.g. time constraints, relationship with the patient), characteristics of patients (severity of depression, ethnicity, patient preferences) and characteristics of treatment options (effectiveness, ease of delivery, accessibility)
- Just over 70% of the clinicians felt “very” or “somewhat’ confident in their own ability to use talking therapy with their patients, however, when asked about the confidence of the profession as a whole, more than half believed that general practitioners were not confident using talking therapy
- Time constraints and a lack of appropriate skills and training were suggested as reasons for the use of antidepressants over non-pharmacological treatments; clinicians who reported good rapport with a patient were more confident in recommending non-pharmacological treatment options
- Patients who met criteria for major depressive disorder were more likely to be prescribed an antidepressant than patients assessed as less severe. Clinicians in this study felt that efficacy of an antidepressant is associated with the severity of the patient’s depression symptoms.
- Clinicians were divided over whether a patient’s ethnicity would influence treatment preference, however, some general practitioners highlighted that Māori patients prefer psychological treatments such as talking therapies over pharmacological treatment. Clinicians agreed that patient preference should be considered before making treatment decisions.
- There is limited access to psychologists or counsellors in New Zealand; wait times for publicly funded services and financial barriers to private specialists may result in antidepressants being preferred by patients who want or need treatment immediately, or who cannot access therapy
- The treatment of depression at the first consultation varies widely between clinicians. Time off work, the use of antidepressants, physical activity and sleep advice were most commonly recommended; behaviour activation (e.g. re-engaging with social activities, friends/family/ whānau, hobbies, volunteering) and problem-solving were the least common.
Moir F, Roskvist R, Arroll B, et al. Treatment of depression in the first primary care consultation: A qualitative study. J Family Med Prim Care (2022). https://doi.org/10.4103/jfmpc.jfmpc_1904_21
For further reading, also see: “Depression or distress? Examining SSRI prescribing in primary care.” Bpacnz. https://bpac.org.nz/2019/ssri.aspx
This Bulletin is supported by the South Link Education Trust
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