Published: 24th November, 2023
New article: Oral anticoagulant selection in primary care
Direct oral anticoagulants (DOACs) such as dabigatran and rivaroxaban are now established as the “go to” choice in primary care for prevention of thromboembolic events in patients at increased risk. In addition to their superior clinical efficacy, DOACs also have a number of practical advantages compared with the conventional option, warfarin, including more predictable pharmacokinetic and pharmacodynamic properties, no INR monitoring requirements, significantly fewer medicine and food interactions and more rapid onset of action.
Oral anticoagulant selection should, however, always be individualised, and warfarin is still sometimes required on a case-by-case basis in patients with specific co-morbidities or characteristics that make DOACs unsuitable. For example, warfarin should be used in patients with mechanical heart valves, moderate-to-severe mitral stenosis or severe liver disease. Regardless of the option selected, ongoing management involves consideration of modifiable risk factors for bleeding, treatment adherence and monitoring for adverse effects.
The full article can be accessed here. A B-QuiCK summary is also available here.
World Antimicrobial Awareness Week: 18th – 24th November
Antimicrobial Awareness Week ends today, but our collective dedication to antimicrobial stewardship does not. As reported in Bulletin 87, the international theme this year is “Preventing antimicrobial resistance together”.
Make it meaningful: A New Zealand initiative encourages prescribers to include a specific indication on their antibiotic prescriptions, e.g. flucloxacillin, 500 mg, four times daily, for five days, for cellulitis. This allows reflection on medicine choice, to help promote a consistent and safe approach to the use of antibiotics.
The bpacnz antibiotic guide has been used by prescribers in primary care for over ten years. Keep checking regularly to ensure you are up to date with the latest recommendations.
Medicine supply issues: morphine oral liquid, olanzapine depot injections, prochlorperazine tablets
The following issues relating to medicine supply, of particular interest to primary care, have recently been announced. This information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Morphine oral liquid supply issue
There will be interruptions to the supply of morphine hydrochloride liquid (RA-Morph) over the next few months, due to a change in manufacturer. Current stock will either be exhausted or expire before new stock is scheduled to arrive in April, 2024, but an alternative product will be available.
The present situation is that stock of morphine hydrochloride liquid (RA-Morph) 10 mg/mL expires this month (November, 2023), and supplies of the most commonly prescribed strength, 1 mg/mL, will likely run out before the end of the year. Pharmac reports that there is enough stock of morphine hydrochloride liquid (RA-Morph) 2 mg/mL and 5 mg/mL to last until April 2024, however, this stock will expire at the end of March, 2024. An alternative brand of morphine liquid will be temporarily listed on the Pharmaceutical Schedule from 1st December, 2023, to ensure there is sufficient low-strength morphine liquid to cover any deficits during this period.
The alternative product is morphine sulphate liquid (Wockhardt) 10 mg/5 mL (2 mg/mL), i.e. a different salt and strength. This product will be supplied in 100 mL glass bottles (as opposed to the 200 mL plastic bottles of RA-Morph). It is not approved by Medsafe and will need to be prescribed for supply under Section 29 of the Medicines Act 1981. This means patients with repeats of morphine hydrochloride liquid (RA-Morph) 1 mg/mL will need a new prescription for the alternative product, including a new calculated dose volume. While the different morphine salts are considered interchangeable, care needs to be taken when prescribing, dispensing and administering this medicine due to the difference in strength. A brand switch fee can be claimed by pharmacists from 1st December, 2023, to 29th February, 2024, which acknowledges the additional patient counselling that is required.
A printable patient information resource will be available soon (check here)
Have you seen the bpacnz opioid report? We recently published an updated report on national opioid use between 2017 and 2022. A new-look interactive graph format allows comparison between New Zealand regions in 2020 and 2022, and the personalised data section has been updated to also include 2022 statistics.
No new patients to be initiated on olanzapine depot injections
Pharmac has announced that from 1st December, 2023, funding of olanzapine depot injections (indicated for people with schizophrenia who cannot tolerate oral olanzapine) will be temporarily restricted to existing patients only. This is in response to a global supply issue affecting stock of olanzapine depot injections. Supply is expected to be restricted for the next six to nine months. New patients will be able to be initiated on olanzapine depot injections once the supply issue has been resolved. However, an exceptional circumstances framework will be available for assessing cases in the meantime, where there is a need; further details on this process are expected to be released soon.
See the full medicine notice here for further information, including current stock levels and alternative treatment options.
Prochlorperazine supply issue
There is a supply issue affecting stock of the Nausafix brand of prochlorperazine 5 mg tablets. An alternative brand, Prochlorperazine-AA, has already been listed on the Pharmaceutical Schedule and is currently funded. Prochlorperazine-AA is not approved by Medsafe and will need to be prescribed for supply under Section 29 of the Medicines Act 1981.
The Nausafix tablet contains 5 mg of prochlorperazine maleate (equivalent to 3 mg of prochlorperazine) whereas the Prochlorperazine-AA contains 8.1 mg prochlorperazine maleate (equivalent to 5 mg of prochlorperazine). Pharmac advises that this difference in strength is not of significant concern, however, people taking Prochlorperazine-AA should be asked to report any adverse effects.
From 1st December, 2023, Nausafix will be available again. This will be a new formulation not approved by Medsafe and needs to be prescribed for supply under Section 29 of the Medicines Act 1981 (until it is approved).
Pertussis immunisation reminder
The Immunisation Advisory Centre (IMAC) has reminded healthcare professionals about the importance of maternal pertussis vaccination, in a recent email to the sector. Maternal immunity may be lower than pre-COVID-19 levels due to a combination of factors, including lower vaccination rates and a period of low pertussis circulation. Cases of pertussis are now on the increase, including three infant deaths this year, and IMAC notes that a predicted pertussis outbreak is now overdue.
Tdap (Boostrix) immunisation is recommended and funded for pregnant women during every pregnancy and for all children. As outlined in Bulletin 70, it is also recommended but not funded for close family contacts of young infants and in some cases for those at higher risk of complications, e.g. patients with COPD. The exact duration of protection is unknown, but many groups (e.g. lead maternity carers, primary care clinicians, early childhood workers) are recommended to have a booster dose at least every ten years; see the Immunisation Handbook for further information.
A factsheet for healthcare professionals on recommended and funded vaccines during pregnancy is available from IMAC, here
All suspected cases of pertussis must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before isolating, treating and notifying.
Immunisation Register transition delayed
The transition to the Aotearoa Immunisation Register (AIR) will now occur on 2nd December, 2023, instead of the previously announced date of 25th November, 2023 (as reported in Bulletin 87). From 2nd December, all vaccinations will be recorded in either your PMS or the AIR vaccinator portal. The National Immunisation Register (NIR) and COVID-19 Immunisation Register (CIR) will no longer be used to record vaccinations or to view a patient’s immunisation status or history.
For further information, see: https://www.tewhatuora.govt.nz/our-health-system/digital-health/the-aotearoa-immunisation-register-air/
Clinical workforce for HPV testing expanded
Since 12th September, 2023, HPV testing, which detects the presence of high-risk HPV types known to cause cervical cancer, has been the primary cervical screening test in New Zealand. HPV testing can be performed from a vaginal swab sample (with the option of self-testing) or liquid-based cytology sample. Early feedback suggests that the option of self-testing has already increased participation among people who have previously been reluctant to receive screening.
Initially, only doctors and midwives, or other healthcare professionals (e.g. nurses, nurse practitioners) who had completed NZQA training in cervical screening were able to facilitate HPV self-testing. This has now been extended as part of a phased workforce expansion programme to include enrolled nurses, registered nurses and nurse practitioners who have not completed NZQA training in cervical screening if they meet certain criteria (see below). This group will be referred to as HPV screen-takers and will be eligible to facilitate HPV self-testing upon completion of the “HPV Screen-taker Learning Pathway”. A summary of the new Learning Pathway can be found here.
Read more about the HPV Screen-taker Learning Pathway
N.B. HPV screen-takers cannot take a cervical LBC sample; if a LBC sample is required or preferred by the patient, referral to an accredited cervical sample taker is needed, click here for a HPV screen-taker decision flowchart.
For information on cervical cancer, including new cervical screening recommendations, see: https://bpac.org.nz/2022/cervical-cancer.aspx. A brief HPV testing summary guide for general practice is also available here.
Rural telehealth service launched
An after-hours telehealth service (by Ka Ora Telecare Limited) is now available for people in rural communities across New Zealand. The service, which operates from 5 pm to 8 am during weekdays, and 24 hours during weekends and on public holidays, can be accessed by patients by calling 0800 2KA ORA (0800 252 672) or via referral from the patients rural general practice. The service is available to all people who live rurally (or who are currently visiting a rural area), regardless of whether they are enrolled with a rural practice.
Patients will be initially triaged by a kaiāwhina or nurse and if needed, referred through to a clinician. There is no charge for a nurse consultation, however, a patient co-payment is required if a telehealth consultation with a clinician is needed. If a patient has a Community Services Card or is aged ≥ 65 years, they will be charged a lower fee ($19.50); there is no charge for children aged under 14 years. Click here for further information.
RNZCGP statement on smoking and vaping
The Royal New Zealand College of General Practitioners (RNZCGP) has released a position statement on smoking and vaping. Views have been developed and grouped into three sections: (1) Protecting rangatahi (young people); (2) Supporting people who smoke or used to smoke; and (3) Protecting all people from the potential harm of vaping. In summary, the RNZCGP believes that vaping can have a role in aiding smoking cessation, however, the availability of vapes is currently too wide; restrictions and regulatory changes are required to reduce potential harms and prevent younger people from starting vaping. Read the full statement and specific recommendations here.
The Asthma and Respiratory Foundation NZ has recently published guidelines for healthcare professionals on supporting young people and adolescents to quit vaping, covering screening and assessment, behavioural support, pharmacotherapy and follow-up. Read the full guideline here.
Upcoming ACC webinars
ACC is hosting two upcoming webinars that may be of particular interest to primary care:
In case you missed it. ACC recently hosted webinars on how to invoice under the Rural General Practice Services contract and on how to complete an ACC45 Injury Claim Form. If you missed it, recordings of the webinars can be viewed here and here.
Pancreatic Cancer Awareness Month
November is Pancreatic Cancer Awareness Month. Pancreatic cancer can be particularly aggressive and has a high mortality rate; in 2018, it was the fourth most common cancer-related death in both males and females in New Zealand. Primary care clinicians can facilitate the early detection of pancreatic cancer; however, this can be challenging as symptoms and signs are often absent in the early stages or are non-specific.
Early detection of pancreatic cancer is difficult as symptoms and signs may not be initially apparent. Indicative features typically only appear once the cancer is at an advanced stage and has spread to nearby organs, or is large enough to block the bile duct.
When present, symptoms and signs are generally non-specific and may include abdominal pain (pain can also radiate to the back), loss of appetite, unintended weight loss, jaundice, changes in bowel habit. New-onset diabetes or existing diabetes that has become difficult to control can also be a sign of pancreatic cancer. Risk factors include increasing age, history of smoking, diabetes, obesity, chronic pancreatitis, excessive alcohol consumption and a family history of pancreatic, ovarian or bowel cancer.
If pancreatic cancer is suspected, initiate further investigations early, e.g. laboratory testing (including tumour marker CA 19-9 which is elevated in approximately 80% of people with pancreatic cancer), referral for imaging (usually ultrasound).
For further information on pancreatic cancer, see: https://teaho.govt.nz/cancer/types/pancreatic and https://www.cancer.org.au/cancer-information/types-of-cancer/pancreatic-cancer
Paper of the Week: Running away from depression
The annual Movember campaign for men’s health is currently in full swing. This movement raises awareness for men’s mental health and suicide prevention as well as prostate and testicular cancer. While growing a moustache is synonymous with Movember, another way to show support for men’s health, particularly mental health, is by running (click here for details). During the COVID-19 lockdown, many people turned to running as a way of coping with the increase in stress and isolation. Maintaining the momentum now that life is slowly returning to “normal” can be a challenge.
It is well established that regular exercise can help to prevent or treat various conditions, e.g. hypertension, diabetes. There is also mounting evidence that exercise may be at least as effective as standard treatment strategies for mild to moderate depression. A recent study published in the Journal of Affective Disorders compared the effects of running and antidepressant medicines on the mental and physical health of people diagnosed with either depression or anxiety disorder. The authors found that remission rates were comparable between those running and those taking antidepressant medicines, however, unsurprisingly, people in the running intervention group showed significant improvements in physical health outcomes, e.g. body weight, waist circumference, systolic and diastolic blood pressure.
Given that not everyone who is prescribed an antidepressant experiences meaningful symptom improvement, and they are associated with adverse effects (e.g. gastrointestinal or anticholinergic adverse effects, sexual dysfunction), it seems reasonable that exercise should be strongly emphasised to all patients as part of their treatment strategy for depression or anxiety. If they are physically capable and motivated to take up running, this would be a preferable activity.
How likely are you to recommend running to patients with depression or anxiety? Is there something specific about running that makes it an effective treatment for depression, e.g. endorphin release? Are there other types of exercise that you think would achieve the same results that you could recommend to patients who are not able to run? Have you given a written prescription for exercise before (see below)?
- This 16-week intervention study included 141 people in the Netherlands with a current diagnosis of major depressive disorder or anxiety disorder (generalised anxiety disorder, panic disorder, social phobia or agoraphobia)
- Participants had not taken antidepressant medicines in the previous two weeks, did not engage in regular exercise (more than once per week), did not have a clinical diagnosis of (another) severe psychological condition, and had no contraindications that would prevent them taking antidepressant medicines or running
- Over the 16 weeks, participants were allocated (partially randomised) to receive either:
- 10 mg escitalopram, daily, with follow-up by a psychiatrist (assessing treatment efficacy and adverse effects) at weeks 0, 2, 6, 10 and 16. If required, the escitalopram dose was increased to 20 mg, daily. If there was an inadequate clinical response to the maximum escitalopram dose, or adverse effects were intolerable, participants were instead prescribed 50 mg sertraline (up to a maximum of 150 mg per day).
- Supervised outdoor running for 45 minutes with the goal of attending two to three sessions per week
- The composite international diagnostic interview (CIDI) was used to establish the presence of depression or anxiety disorders at weeks 0 and 16. Severity of depression and anxiety were measured using the Inventory of Depressive Symptomatology – Self Report (IDS-SR) and the Beck Anxiety Inventory (BAI), respectively. Severity was assessed at weeks 0, 6, 10 and 16.
- The measured mental health outcomes were remission (no longer meeting the criteria for depression and/or anxiety as per the CIDI) and response (achieving a ≥ 50% reduction in symptoms severity as per the IDS-SR or BAI)
- Physical health outcomes were also measured at weeks 0 and 16, and included height, weight, blood pressure, waist circumference, triglycerides, hand-grip strength and peak expiratory flow
- Significantly higher treatment adherence was observed for the antidepressant group compared to the running intervention. After 16 weeks, 82% of participants in the antidepressant group were still taking their prescribed medicines, whereas only 52% of participants in the running intervention completed the targeted two sessions per week. Statistical analysis did not show any differences in treatment adherence between participants who were randomly allocated and those who chose their preferred treatment.
- The differences in treatment adherence between the two interventions reinforce the difficulty experienced by people trying to establish and maintain healthy lifestyle changes. Identifying and removing any barriers to initiating or maintaining lifestyle changes may increase the likelihood of positive/desired outcomes.
- Mental health outcomes were similar for both antidepressant and running intervention groups. The rate of remission was 45% for the antidepressant group and 43% for the running group. Self-reported symptom severity was similar for depression between treatment groups, but a larger reduction in anxiety-related symptoms was seen in the antidepressant group compared to the running group.
- Participants in the running intervention group reported significant improvements in waist circumference, heart rate and peak expiratory flow, whereas participants in the antidepressant group showed significant increases in weight and CRP, along with border-line significant increases in diastolic blood pressure and triglycerides
- The authors acknowledge that the low rate of randomisation potentially exposes their results to selection bias. However, they also point out that this study design increases the generalisation and ecological validity of their results as the participants who were allowed to choose their intervention would not have taken part in the study if their intervention was randomly selected.
Verhoeven JE, Han LKM, Lever-van Milligen BA, et al. Antidepressants or running therapy: Comparing effects on mental and physical health in patients with depression and anxiety disorders. Journal of Affective Disorders 2023;329:19–29. doi:10.1016/j.jad.2023.02.064
Consider giving patients a written prescription to take away with them after recommending regular exercise, e.g. 30 minutes of walking, daily and 30 minutes of resistance training, twice weekly. The act of filling out and giving the patient the prescription may help to reinforce that the exercise component of management is just as important as medicines.
This Bulletin is supported by the South Link Education Trust
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