Published: 20 August, 2020
COVID-19 "Auckland August" cluster
We are aware of the increase in workload and stress for primary care with the recent new outbreak of COVID-19 in Auckland. This has obviously had a significant
impact on practices in Auckland who are now operating under Level 3, but also affects all primary care practices around the country who are managing unprecedented
levels of demand for COVID-19 testing. This occurs along with other patient behaviours we have previously experienced with COVID-19 restrictions such as early
requests for repeat prescriptions and an increase in health-related anxiety. This is simply an acknowledgement of the pressure that primary care is currently
under, and a message of support from the bpacnz Publications Team, three of whom are GPs.
Additional brand of paracetamol listed
There are ongoing supply issues with the funded brand of paracetamol tablets (Pharmacare) due to the COVID-19 pandemic. A number of alternative brands of
paracetamol were listed on the Pharmaceutical Schedule on 22 July, 2020, but stocks of these are now also depleted. An additional brand (Panadol Mini Caps) was
listed on 12 August, 2020, however, stock may not yet be available for supply; this will be updated on the
PHARMAC website. It is understood that stock levels
of paracetamol around the country are variable and some pharmacies may not currently be able to fill paracetamol prescriptions. Note that the current restriction
of paracetamol to one-month supply also applies to the alternative brands.
Update on Norimin supply issues and replacement options
Norimin, a combined oral contraceptive, is currently out of stock, but supply is expected to be restored by mid-October.
PHARMAC initially listed an alternative product, Necon, to cover the out-of-stock period. However, stock of Necon is expected to run out by late-August.
Brevinor 28 day, which contains the same active ingredients as Norimin and Necon, will be listed from 1 September, 2020, as an alternative, however,
stock of Brevinor 28 is anticipated to run out at the end of October.
Information for community pharmacists: Brevinor 28 can be substituted for Norimin or Necon if patients have any repeat prescriptions owing.
All of these brands are restricted to three-month dispensing.
A note on Brevinor products:
Brevinor 28 is different from Brevinor-1 28; Brevinor 28 contains a lower strength of norethisterone. Both products are every day formulations,
i.e. contain placebo pills, and are fully funded. Brevinor-1 28 is currently subject to
stock supply issues. Brevinor 21 and Brevinor-1 21 contain
the same active ingredients as Brevinor 28 and Brevinor-1 28, respectively, however, they are 21-day formulations, i.e. do not contain placebo pills.
Brevinor 21 and Brevinor-1 21 have been delisted from the pharmaceutical schedule, i.e. they are no longer funded.
For further information, see:
For further information on selecting a contraceptive, see:
Discontinuation of oxazepam
PHARMAC has announced that the supplier of oxazepam,
Douglas Pharmaceuticals, is to discontinue this medicine
in New Zealand and an alternative supplier has not been identified. The current brand of oxazepam is the only one approved
by Medsafe. This decision will affect approximately 4,600 people who are currently prescribed oxazepam. Supplies of
the 10 mg tablet will run out in mid-October, 2020 and the 15 mg tablets in mid-November, 2020. Once the stock is depleted,
PHARMAC will delist the medicine from the Pharmaceutical Schedule. Prescribers should:
- Consider whether a benzodiazepine is still clinically indicated
- Provide advice to patients currently taking oxazepam so that they can change to an alternative medicine or slowly
discontinue the oxazepam as it should not be stopped abruptly
- Not start oxazepam as a new treatment option for any patients
Discontinuation of Pulmocare
The suppliers of Pulmocare, an oral feed indicated for patients with COPD, have discontinued this product and it will be delisted from the Pharmaceutical
Schedule on 1 October, 2020.
PHARMAC state that Ensure Plus or Fortisip may be acceptable alternatives for patients affected by this change. Ensure Plus and
Fortisip are funded with Special Authority approval, and earlier this year the restrictions were changed to include additional funding by endorsement for patients
with COPD and hypercapnia (defined as a CO2 value > 55 mmHg); refer to the
Schedule for further information.
Reminder to avoid fluconazole in pregnant women
Topical intravaginal antifungal treatment is the first-line treatment for vulvovaginal candidiasis in pregnant women. Although oral antifungal medicines such as fluconazole
should be avoided in pregnancy, previous data on pregnancy outcomes in women exposed to short courses and low doses was reassuring, therefore some clinicians may have considered
fluconazole as a "last resort" in pregnant women if intravaginal treatment had not resolved symptoms. However,
a recent study has concluded that any dose of fluconazole during
pregnancy is associated with risk and it should not be used in pregnant women. As fluconazole is available as a Pharmacist only medicine, it is also imperative for pharmacists
to be aware of the importance of ruling out pregnancy before providing fluconazole.
At its most recent meeting in June, 2020, the Medicines Adverse Reaction Committee (MARC) considered this new evidence showing an increased risk of adverse
fetal outcomes with any maternal exposure to fluconazole during pregnancy, including low dose. Specifically, the risk of spontaneous abortion is increased with
any dose of fluconazole, and the risk of cardiac septal closure anomalies is increased with doses greater than 150 mg in the first trimester.
MARC has recommended
that medicine datasheets should be updated to state that fluconazole is only indicated for vaginal candidiasis "when topical therapy has failed" and include a
warning about adverse pregnancy outcomes with maternal exposure of ≥ 150 mg.
For further information on managing vaginal candidiasis, see: "Vulvovaginal health in premenopausal women",
available from: https://bpac.org.nz/BPJ/2011/december/vaginal.aspx
Paper of the week: NICE draft guideline on chronic primary pain
In this section, rather than our usual focus on a research paper we draw your attention to a
released draft guideline from the National Institute for Health and
Care Excellence (NICE), United Kingdom, on managing chronic pain in people aged over 16 years. The guideline is now open to review and comment from
clinicians in the UK and it has already generated some heated debate.
The first thing that should be noted is that the guideline applies to people with chronic primary pain -
defined as pain that is recognised as a condition in itself, rather than pain that is a symptom of an underlying
condition (referred to as chronic secondary pain). Chronic primary pain is multifactorial and characterised by functional
disability and significant emotional distress. The definition of chronic primary pain includes complex regional
pain syndrome, chronic primary headache and chronic primary musculoskeletal or visceral pain.
The release of this draft guideline in the UK has created much interest because one of the key recommendations is that most
commonly used analgesic medicines should not be prescribed…not at all. This includes paracetamol, non-steroidal anti-inflammatories,
opioids (both weak and strong) and gabapentinoids. The guideline recommends that non-pharmacological approaches should be
considered instead and if medicines are required, off-label use of antidepressants is recommended in preference to analgesics.
Good communication is highlighted as being of great importance so that prescribers gain an understanding of how a patient
is affected by pain, so an individualised care plan can be put in place.
The news has been met with both praise and criticism in the UK. NICE has been commended for taking a bold and honest approach
based on the lack of evidence of benefit for these medicines and the potential for many of them to cause harm. However, it
has also been criticised that its advice takes an “ivory tower” approach and does not recognise the difficulties that clinicians
face when trying to manage these patients and the lack of access to non-pharmacological treatments.
Click here for a link to a blog written by a UK GP that outlines the differing perspectives. In whatever form the final
version of the guideline ends up, there will likely to be an impact on how we practice in New Zealand.
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