Published: 26th July, 2024
Contents
Updated clinical audits: warfarin, sexual health checks in younger males
We regularly add new content to our website – check out the latest resources on our home page reel or search for something specific. Two updated clinical audits have recently been published:
Safe and effective use of warfarin
Direct oral anticoagulants, such as dabigatran or rivaroxaban, are often preferred to warfarin when anticoagulation is needed, there are, however, still some patients for whom warfarin is the most appropriate choice. Warfarin is associated with many adverse effects as well as numerous medicine and food interactions. This audit identifies patients who are prescribed warfarin and documents whether there is accurate and complete information recorded in their clinical notes to guide safe treatment.
Click here to view the audit
Sexual health checks in younger males
Males aged 16 – 30 years are less likely to present to primary care, therefore when they are seen, this is often an opportunity to assess a wider range of health parameters. The purpose of this audit is to identify whether people in this patient group have been offered a sexual health check within the past 12 months. This audit also provides an opportunity to check HPV vaccination status and offer vaccination where appropriate.
Click here to view the audit
World Hepatitis Day
World Hepatitis Day is being held on Sunday, 28th July, 2024. The theme for this year is “Take action" which focuses on improving rates of testing, treatment and vaccination of eligible people. Further information and resources for the global campaign from the World Hepatitis Alliance are available here.
Read more about hepatitis A, B and C
Hepatitis A infection in New Zealand is rare. Transmission occurs via the faecal-oral route and people are usually exposed overseas. Long-term complications following hepatitis A infection are unlikely, however, older age, immunocompromise and previous liver disease may increase this risk. Hepatitis A vaccination is recommended (not funded) for people travelling to high-risk countries and certain other people at risk (e.g. adults with chronic liver disease, men who have sex with men).
The incidence of hepatitis B infection has reduced since the introduction of hepatitis B vaccination to the National Immunisation Schedule in 1988. However, certain populations within New Zealand remain at risk, e.g. people who have migrated from or travelled to countries with a high prevalence of hepatitis B virus or those with limited access to vaccination. There are more than 100,000 people with chronic hepatitis B in New Zealand; many of these people are unaware they are infected and are at increased risk of cirrhosis and hepatocellular carcinoma. Serology to check for immunity is recommended in high-risk groups, i.e. those who may have been exposed during early childhood and now have chronic hepatitis B infection, and those with a potential exposure event as an adult (although this does not often progress to chronic infection). Treatment can take place in primary care, with support from specialist services.
In New Zealand, hepatitis C infection is a significant underlying cause for people requiring liver transplant and those with liver cancer, re-enforcing the importance of early identification and treatment; hepatitis C is now curable. Most newly acquired infections result from injectable drug use and these people may be asymptomatic in the acute stages. Opportunistic testing for hepatitis C infection is recommended in all patients with risk factors, such as injectable drug use or exposure to blood in a high-risk setting. There is no vaccine for hepatitis C available.
Further information on hepatitis is available from bpacnz:
Researching outcomes of cannabis exposure during pregnancy: Request for feedback
Researchers at the University of Canterbury are seeking to understand how the environment experienced during prenatal development, in particular, prenatal cannabis exposure, influences future health outcomes for children. Cannabis use during pregnancy is reportedly increasing in New Zealand, potentially due to recent legalisation of medicinal cannabis which may have decreased the public perception of risk.
Prenatal cannabis exposure is epidemiologically linked to impacts on child neuro- and behavioural development, learning disorders and autism, and it may increase the risk of psychiatric disorders in adulthood. However, these links are associative. The research project aims to understand the molecular mechanisms that link prenatal cannabis exposure to neurodevelopmental outcomes, and to provide more evidence about the short- and long-term impacts of exposure for children.
How can you help?
The research group is seeking feedback from healthcare professionals on what specific information about prenatal cannabis exposure would be useful to know, to ensure the research addresses real questions that are being asked around this topic in primary care and in the community. Questions for reflection are detailed below, but any feedback, comments, general questions or concerns would be gratefully received.
Questions for reflection
- Do you receive questions on the use and safety of cannabis and cannabis-containing products from people in the community? If so, how often?
- What specific questions have you been asked around prenatal cannabis exposure?
- Have you noticed an increase in frequency of enquiries around prenatal cannabis exposure?
- Do you find that people are concerned around the safety of prenatal cannabis exposure?
- Do you perceive that the community is, in general, supportive of the use of cannabis and cannabis-containing products during pregnancy?
- Do you receive questions around the use of specific cannabis forms, e.g. smoked cannabis, edibles, CBD-containing products?
- Do you receive questions on the use of medicinal cannabis products for pregnancy-related symptoms?
- Do you personally have any concerns around the use of cannabis or cannabis-containing products during pregnancy, and if so, what are they?
- What specific questions around prenatal cannabis exposure do you have that you would like to see answered by this research project, or by other research in this area?
- How much of a need do you think there is for community education around prenatal cannabis exposure?
- Are you and/or your patients aware of the links between prenatal cannabis exposure and adverse neurodevelopment? Do you think this knowledge would influence people’s choices?
- Have you observed any equity issues with prenatal cannabis exposure? Does it seem to involve any particular community demographic more frequently than others?
To provide feedback, or if you would like to discuss or learn more about the research project, contact: amy.osborne@canterbury.ac.nz
Dr Amy Osborne, Senior Lecturer Above the Bar in Genomics, School of Biological Sciences, University of Canterbury
Proposal to fund new medicines: oestradiol gel, recurrent UTIs, epilepsy
Oestradiol gel
Pharmac has released a proposal to fund oestradiol transdermal gel and to award Principal Supply Status to Estrogel. We previously reported that Pharmac was considering funding oestradiol gel in Bulletin 97. Oestradiol gel is indicated for use in menopausal hormone therapy and post-menopausal osteoporosis prophylaxis. The gel may also be used for oestradiol-based gender affirming hormone therapy and for premature ovarian insufficiency (unapproved indications). Oestradiol is also available in patches and tablets.
Given the ongoing supply issues affecting oestradiol patches, the availability of oestradiol gel will provide people who take oestradiol with another option. If the proposal is accepted, Estrogel will be listed on the Pharmaceutical Schedule and funded without restriction from 1st November, 2024. Submissions are due by 5 pm, Thursday, 15th August. Read more about the proposal here.
Fosfomycin for recurrent UTI and zonisamide for epilepsy
Pharmac has released a proposal to fund fosfomycin for the management of uncomplicated UTIs in the community and zonisamide for some types of epilepsy. Both these medicines would be funded subject to Special Authority approval (a date has yet to be announced); applications could be made by any relevant practitioner. Consultation closes 4 pm, Thursday, 1st August.
Read more
Fosfomycin is a broad spectrum antibiotic (currently funded for hospital use; IV administration) that is effective against a range of Gram-positive and Gram-negative bacteria. The recommended dose in the community setting is one 3 g sachet of powder (dissolved in half a glass of water). It is proposed that fosfomycin would be funded in the community for people with an acute, symptomatic bacteriologically-confirmed uncomplicated UTI if the bacteria is resistant to, or the patient has a contraindication or intolerance to, all of the following antibiotics: trimethoprim, nitrofurantoin, amoxicillin, cefalexin, amoxicillin with clavulanic acid and norfloxacin. Click here for further information.
It is proposed that zonisamide would be funded for people with developmental and epileptic encephalopathies (previously known as severe childhood epilepsy syndrome) and those with refractory focal epilepsies who have experienced an inadequate response or intolerance to certain antiepileptic medicines unless they are contraindicated. Click here for further information.
For further information on the management of UTIs, see: https://bpac.org.nz/2021/uti.aspx
Childhood asthma and acne management BPAC CS modules discontinued
BPAC Clinical Solutions offers a range of decision support modules available via practice management system software. Funding by Pharmac for modules on Childhood Asthma and Acne (isotretinoin) Management ended on 30th June, and access will be switched off on 31st July, 2024.
Healthcare professionals can refer to the following bpacnz articles for clinical guidance if required:
Abortion reversal position statement published by Ministry of Health
Some states in the United States of America have introduced legislation in recent years that requires people during pre-medical abortion counselling to be informed about the possibility of reversing the abortion should they change their mind; this is not evidence-based. There has been recent concern that abortion reversals may be offered in New Zealand. If patients enquire about this practice, they can be advised that it is neither safe nor effective, and they are strongly discouraged from seeking this clinically unsupported treatment from a provider.
The Ministry of Health, Manatū Hauora has released a position statement on abortion reversal. The statement does not support or recognise the use of progesterone to reverse the effects of early medical abortion medicines. Healthcare professionals are advised not to offer or provide this practice in New Zealand because safety and evidence for its use has not been established. The statement is endorsed by Sexual Wellbeing Aotearoa (formerly Family Planning), and is consistent with statements from other organisations that were published earlier this year, including the Royal New Zealand College of General Practitioners and the Royal Australia New Zealand College of Obstetricians and Gynaecologists.
Skin cancer primary prevention and early detection strategy consultation
The Melanoma Network of New Zealand (MelNet) has issued a consultation to get feedback on proposed updates to the New Zealand skin cancer primary prevention and early detection strategy. The strategy outlines recommendations to reduce the incidence of skin cancer in New Zealand; a summary of the key recommendations are available here. Submissions close soon on Wednesday, 31st July at 12 pm. N.B. This deadline has now been extended to 13th August.
Read more about the proposed recommendations, here. Read the current strategy document, published in 2017, here.
Further information on melanoma is available from bpacnz:
Upcoming webinars: immunisation catch-ups, recurrent staphylococcal infections
Immunisations. IMAC is hosting a webinar on planning immunisation catch-ups, including for people who have arrived in New Zealand from overseas. It is particularly aimed at new vaccinators (especially those who work alone or without experienced vaccinating colleagues). The webinar will be held on Tuesday, 6th August from 12.15 pm and a recording will be available at a later date.
Recurrent staphylococcal infections. HealthPathways is hosting a national webinar on managing recurrent staphylococcal infections. This free webinar coincides with the update of the recurrent staphylococcal infection pathway that was made across regional HealthPathways and is expected to cover topics including differential diagnoses, establishing a management plan and the place of suppressive antibiotics. The webinar will held on Tuesday, 27th August from 7 pm – 8 pm. Click here to register (a certificate of attendance and one CPD point is available).
Health Practitioners Disciplinary Tribunal vacancies
The Ministry of Health, Manatū Hauora, is seeking applications for health practitioners, including nurses and medical practitioners, to become a member of the New Zealand Health Practitioners Disciplinary Tribunal – Taraipuinara Whakatika Kaimahi Hauora (the Tribunal). The Tribunal makes decisions in response to allegations of professional misconduct made against health practitioners. Click here for further information, including how to apply.
In brief: NSU website now hosted on Health New Zealand
In a recent email to the sector, Health New Zealand, Te Whatu Ora, has advised that the National Screening Unit (NSU) website has been decommissioned, and its clinical/sector content has been moved to the Health New Zealand website. Consumer information, e.g. BreastScreen sign-up form, has been moved to the Health Information and Services website (click on Keeping healthy/Cancer screening).
Podcast of the Week: elbow tendinopathy, rotator cuff injuries and frozen shoulder
This week, we bring to you two podcast episodes from The Good GP, an Australian podcast series, discussing musculoskeletal ailments with an orthopaedic surgeon:
Managing elbow tendinopathies (10 minutes)
Elbow tendinopathies are estimated to affect around 5% of the population, however, there are limited effective treatment options. Rest and eccentric loading exercises (movements that lengthen the muscles) are an important part of management, in additional to topical NSAIDs (which are more effective than oral), physiotherapy and counterforce braces. Steroid injections should be avoided; platelet rich plasma (PRP) injections may be considered second-line (not funded).
Rotator cuff injuries and frozen shoulder (13 minutes)
Patients presenting with shoulder symptoms and signs is a regular occurrence in primary care. Rotator cuff injuries are the most common presentation and steroid injections are usually an effective first-line option for these (unless surgery is likely to be required within around six months). The management of frozen shoulder has evolved over time. Patients should be referred for physiotherapy early in the treatment course. Intra-articular steroid injections and hydrodilatation (injection containing a combination of saline, steroid and local anaesthetic; imaging is used to guide administration) are considered “excellent” management options.
Paper of the Week: The headache of migraine medicines
Migraine headaches are challenging to manage and can significantly reduce a person’s quality of life. More than 750,000 people in New Zealand are estimated to experience migraines. Initial treatment involves relieving acute symptoms with simple analgesia, antiemetics and triptans, e.g. sumatriptan, rizatriptan. In some cases, preventative medicines may be used to reduce the frequency of migraine headaches and can include antidepressants, antihypertensives, antiepileptics and melatonin. Patients whose symptoms are not adequately controlled are at increased risk of chronic migraines (≥ 15 days with headache symptoms per month, for at least three months) and medicine over-use headaches. Establishing current medicine use patterns may identify aspects of migraine treatment that could be optimised to improve patient outcomes.
The authors of an article published in the New Zealand Medical Journal surveyed more than 500 people who experience migraine headaches to understand their medicines use. Approximately one-quarter of those surveyed were at risk of medicine over-use headaches, while a substantial number of people were identified who were not currently taking preventative medicines but would likely benefit from them. Opioid use is also a concern in this population. Opioids are not recommended in the acute management of migraine symptoms, however, more than one-quarter of participants in this study were currently prescribed at least one opioid. These findings suggest there is room for improvement in the pharmacological management of migraine headaches in New Zealand.
Are there preventative medicines you consider more effective for migraines based on your experience? How do you manage patients who have trialled multiple medicines for migraine symptoms without clinical improvement? What non-pharmacological strategies do you recommend for these patients, e.g. avoiding triggers, dietary changes, mindfulness?
Read more
- An online survey was conducted between August and October, 2022. Responses were received from more than 500 people (82% female, 77% New Zealand European, 78% classified as episodic migraine).
- Respondents who had not received a diagnosis of migraine headache from a healthcare professional or did not have a positive ID-Migraine™ test were excluded
- The survey asked about acute and preventative medicines currently taken, medicines use in the previous month, previously trialled medicines and reasons for cessation
- Respondents who took paracetamol or NSAIDs on ≥ 15 days in the last month, or opioids and triptans (sumatriptan and rizatriptan) on ≥ 10 days, were considered at risk of medicine over-use headaches
- Those who experienced eight or more headache days per month or had a moderate-to-severe disability using the Migraine Disability Assessment (MIDAS) test were considered eligible for preventative medicines
- Triptans (65%) and NSAIDs (61%) were the most used management option for acute migraine symptoms, followed by caffeine (55%) and paracetamol (49%). More than one-quarter of respondents (27%) used opioids for acute migraine symptoms.
- Nearly half of respondents (46%) had previously taken paracetamol but stopped because they did not believe it helped their symptoms
- Preventative medicines were taken by 57% of respondents who were considered eligible for them. At least 70% of respondents with chronic migraine were taking preventative medicines, compared to 44% with episodic migraine.
- Commonly reported preventative medicines included amitriptyline, nortriptyline, venlafaxine, propranolol, topiramate and melatonin
- Medicines over-use was identified in 27% of respondents, of whom most experienced chronic migraine (70%). Triptans were the most commonly over-used medicine.
- In response to a direct question regarding calcitonin gene-related peptide (CGRP) monoclonal antibody treatments (erenumab and galcanezumab; not funded), respondents felt the cost (approximately $300 – $1400 per injection depending on the medicine and dose; usually administered monthly), lack of awareness from healthcare professionals and concerns over individual efficacy limited their use
- Pharmacological management could be optimised in a substantial number of people who experience migraine headaches in New Zealand. This includes increased use of preventative medicines, avoiding opioids for acute symptom management and education regarding medicine over-use headaches.
- The risk of medicines over-use may have been overestimated. Medicine over-use headache is diagnosed in patients who meet criteria each month for three months, however, one month was chosen to assess medicine use in this study for practicality and to reduce recall bias.
Imlach F, Garrett S. Use of medications for migraine in Aotearoa New Zealand. NZMJ 2024;137:65–87. https://doi.org/10.26635/6965.6586
For further information on the diagnosis and management of headache in primary care, see: https://bpac.org.nz/2017/headache.aspx
This Bulletin is supported by the South Link Education Trust
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