Published: 10th November, 2023
In case you missed it: new and updated resources from bpacnz
Cervical cancer – early detection and referral:
Cervical screening recommendations have been updated in this article to align with the HPV Primary Screening programme. HPV testing is now the primary cervical screening test in New Zealand, a move which is expected to improve cervical screening participation, promote equitable outcomes and further reduce the burden of cervical cancer over time.
Updated opioid report:
Last year we published a report on national opioid use between 2017 and 2021; we have now updated this with dispensing data from 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. Have you looked at your 2022 data yet? If you are having trouble logging in, email: firstname.lastname@example.org.
Cough medicines: do they make a difference:
Pharmacists and other staff working in community pharmacies are often tasked with guiding people who present with cough on appropriate management strategies. However, as there are a myriad of products available, with differing claims and extent of effectiveness, knowing which product(s) to recommend can sometimes be difficult.
#MedSafetyWeek 2023: 6th – 12th November
The eighth annual #MedSafetyWeek is being held this week. As reported in Bulletin 86, this initiative aims to raise awareness of adverse medicine reactions, with the theme this year being “Who can report?: How patients, doctors, pharmacists and other health professionals can contribute to pharmacovigilance”. In New Zealand, suspected adverse effects to medicines and vaccines can be reported to the Centre for Adverse Reactions Monitoring (CARM) or directly via your practice management software. How have you supported the initiative this #MedSafetyWeek?
World Antimicrobial Awareness Week: 18th – 24th November
World Antimicrobial Awareness Week is coming up, and like last year, the international theme is “Preventing antimicrobial resistance together”. Further information and resources for the global campaign from the World Health Organization are available here.
In New Zealand, along with raising awareness of antimicrobial resistance, prescribers are being encouraged to include a specific indication on their antibiotic prescriptions, e.g. flucloxacillin, 500 mg, four times daily, for five days, for cellulitis. Documenting the indication provides an opportunity for the prescriber, the pharmacist and other clinicians to consider the appropriateness of antibiotic use (including antibiotic selection, dose and duration of treatment), particularly if prescribing does not align with conventional guidance. It can also improve communication between healthcare professionals and reduce prescribing errors, with the overall goal of preventing inappropriate antimicrobial use.
Local resources for antibiotic awareness including posters and social media resources are available here.
bpacnz Primary Care Antibiotic Guide: choices for common infections
Since it was first published in 2011, the bpacnz Primary Care Antibiotic Guide has been the go-to resource for antimicrobial prescribing in primary care across New Zealand. We have recently updated several sections in the guide, and introduced some new topics, including chronic suppurative otitis media (CSOM), cryptosporidiosis, Helicobacter pylori eradication, Mycoplasma genitalium infection and prostatitis: check back regularly for further updates.
Deciding on the appropriate antibiotic, or whether to use an antibiotic at all, can sometimes be challenging. The antibiotic recommendations in our resource reflect the current evidence, balanced by expert opinion along with some necessary pragmatism to provide primary care prescribers with the most useful guide possible. But evidence and opinions change, and infectious diseases medicine is a dynamic discipline. To reflect this, our guide is a “living document” and any major changes in antibiotic choice, dose or management will be updated online as required. This allows us to make progressive and timely changes, so that meaningful differences to antibiotic prescribing can be promoted without delay. If you would like to suggest any changes to the guide or the addition of topics, email: email@example.com
It was recently announced that work is underway on a national antibiotic guideline that will encompass treatment of infections from community to hospital care. We await progress on these guidelines with interest, with the expectation that they will facilitate a consistent approach towards antibiotic choices and antimicrobial stewardship.
Antimicrobial stewardship should always be at the forefront of our clinical decisions
Antimicrobial stewardship is a collection of multidisciplinary strategies to promote the appropriate use of antimicrobials and minimise antimicrobial-related harms, including limiting antimicrobial resistance. It should always be at the forefront of our clinical decisions.
For further discussion on antimicrobial stewardship principles, see: https://bpac.org.nz/2018/antibiotics.aspx
November is Diabetes Action Month
This month is Diabetes Action Month, and the theme for 2023 is “Eyes on Diabetes”, which aims to raise patient awareness of eye health and how to protect their vision once a diagnosis of diabetes has been made. Diabetic retinopathy is a common microvascular complication of diabetes, and the risk of other eye conditions such as cataracts is also increased in people with diabetes.
Opportunistically ask patients with diabetes about any changes to their vision, and check as part of their annual diabetes review whether they are up to date with retinal photo-screening (occurs at least every two years). Also ensure that any pregnant women with pre-existing diabetes are scheduled to have, or have undergone, additional photo-screening in the first trimester.
bpacnz has published a suite of diabetes resources, including:
RNZCGP statement on medicinal cannabis prescribing
The Royal New Zealand College of General Practitioners (RNZCGP) has released a position statement on medicinal cannabis prescribing. In summary, the RNZCGP neither recommends nor encourages the use of medicinal cannabis products according to the current body of evidence. However, it is acknowledged that general practitioners may still choose to prescribe medicinal cannabis in certain situations after in-depth consultation with the patient and their wider care team about the risks and benefits of use. If such a decision is made, the RNZCGP states that medicinal cannabis products should only be considered when all first-line, conventional, evidence-based treatment options have been exhausted.
bpacnz, in conjunction with the Ministry of Health, has previously published an overview of medicinal cannabis for health practitioners - see: https://bpac.org.nz/2022/medicinal-cannabis.aspx. The RNZCGP position statement includes a quick reference summary of this resource. We have also published a medicinal cannabis guide for pharmacists, available at: https://bpac.org.nz/2022/medicinal-cannabis-guide.aspx
The Medicinal Cannabis Scheme came into effect on 1st April, 2020, with the aim of improving access to medicinal cannabis products by lifting regulatory barriers to prescribing. There are two main pathways for prescribing: (1) medicinal cannabis products approved for distribution under the Medicines Act 1981, and (2) those that are not approved, but that are verified by the Medicinal Cannabis Agency as meeting minimum quality standards. Products that do not meet either of these criteria can still be prescribed by a registered medical practitioner, however, they have no official New Zealand endorsement of efficacy, safety or quality.
Medicinal cannabis is not a conventional focus of medical training, meaning some clinicians may be uncertain about the risks and benefits of treatment, and when and how it should be prescribed. Medicinal cannabis is not a first-line treatment for any indication and currently available evidence is limited and inconclusive; the RNZCGP recommends that further high-quality research into the safety and effectiveness of medicinal cannabis products is required. If a decision is made to trial medicinal cannabis in patients with ongoing symptoms despite optimal use of conventional treatments, or if other medicine use is contraindicated or not tolerated, an initial 4 – 12-week trial can be undertaken based on a detailed treatment plan, including agreed upon objectives, and a plan for discontinuation if these are not achieved.
Given the lack of robust supporting data, the RNZCGP indicates that it is reasonable for general practitioners to decline initiating or issuing a repeat prescription for medicinal cannabis products.
Immunisation Register transition date announced
The Aotearoa Immunisation Register (AIR) is replacing the National Immunisation Register (NIR) and the COVID-19 Immunisation Register (CIR) on the 25th November, 2023. From this date, all vaccinations will be recorded in either your PMS or the AIR vaccinator portal. The NIR and CIR will no longer be used to record vaccinations or to view a patient’s immunisation status or history.
General practices using a PMS connected to the NIR will continue to record vaccinations in their PMS. The PMS will connect to the AIR instead of the NIR after the transition date. Pharmacies will record vaccinations in the AIR vaccinator portal.
For further information, including how to sign up to use the AIR vaccinator portal, see: https://www.tewhatuora.govt.nz/our-health-system/digital-health/the-aotearoa-immunisation-register-air/
MMR vaccination remains a priority
There have now been thirteen confirmed cases of measles in New Zealand in 2023. Healthcare professionals should remain alert for symptoms and signs of measles, particularly in patients who are not vaccinated or are immunocompromised, and especially if they have a recent history of overseas or domestic travel to locations of interest. Funding is available under certain circumstances, e.g. for close contacts who are requested by a Te Whatu Ora public health service to attend primary care for a measles test or consultation, check local HealthPathways or your PHO for details.
All suspected cases of measles must be notified to the local Medical Officer of Health.
MMR vaccination: Opportunistically check whether patients have received both doses of the MMR vaccine and offer vaccination where appropriate. Also ensure that patients with upcoming international travel are fully vaccinated with MMR.
MMR vaccination is funded for all children in New Zealand and anyone born from 1969 onwards who has not received two doses. Some people born overseas prior to 1969 are considered susceptible to MMR and so may be eligible for funded vaccination (click here for further information). N.B. MMR vaccination is contraindicated during pregnancy.
For further information on MMR, see: https://bpac.org.nz/2021/mmr.aspx
Further resources for healthcare professionals are available from: https://www.immune.org.nz/factsheets/measles-resources-quick-access
Medicine supply news: methylphenidate back in stock, metoprolol brand change
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.
Methylphenidate back in stock soon
Pharmac has advised that stock of the Teva brand of methylphenidate extended-release tablets will arrive during November. Wholesalers should now have supply of the 27 mg and 54 mg strength tablets and from Monday (13th November, 2023), supply of the 18 mg and 36 mg strengths should arrive. It may take some time for stock to reach all pharmacies.
The ongoing supply issue affecting the Teva brand of methylphenidate has meant that many patients will have been switched to the Concerta brand of methylphenidate, as reported in Bulletins 84 and 85. However, prescribers are being advised to switch patients back to Teva methylphenidate once stock becomes available to avoid an out-of-stock situation for Concerta.
Metoprolol brand change
The funded brand of metoprolol succinate modified release tablets is changing from Betaloc CR to Myloc CR. Patients will be switched to the new brand between now and 1st April, 2024, when Betaloc CR will be delisted from the Pharmaceutical Schedule (Betaloc CR will remain funded until this time). If metoprolol succinate is prescribed generically, prescribers will not need to change anything as pharmacists will dispense the newly funded brand when new prescriptions are presented (and stock is available).
Patients taking metoprolol tablets should be advised that their brand is changing, and that the tablet shape and packaging will look different, but be reassured that there has been no change to the active ingredient.
Proposal to fund testosterone gel
Pharmac has released a proposal to fund testosterone transdermal gel and to award Principal Supply Status to Testogel. Testosterone is currently approved for testosterone replacement in people with primary and secondary hypogonadism and for testosterone-based gender affirming hormone therapy, and is available in three formulations: injections, patches and capsules. The availability of testosterone gel will provide people who take testosterone with another option if other testosterone formulations are not suitable or appropriate. If the proposal is accepted, Testogel will be listed on the Pharmaceutical Schedule from 1st April, 2024 and funded without restriction. Submissions are due by 22nd November, 2023.
Read more about the proposal here
Pregnancy information updated in the NZF
In the November release of the NZF, pregnancy and breast-feeding advice sections in over 400 monographs have been reviewed and updated, where necessary, to align with updates to the Briggs Drugs in Pregnancy and Lactation summaries. Significant changes were made to the pregnancy advice in the clindamycin (systemic) monograph and to the breast-feeding advice in the misoprostol (gastrointestinal) monograph.
You can read about all the changes in the November release here. Also read about any significant changes to the NZF for Children (NZFC) here.
Annual report on abortion services published
Manatū Hauora, the Ministry of Health, has published Ratonga Whakatahe i Aotearoa | Abortion Services Aotearoa New Zealand: Annual Report 2023. In summary, access to abortion services increased overall in 2022, including for Māori and Pacific peoples, likely due to the establishment of the national telehealth early medical abortion (EMA) service (DECIDE), endorsement of EMA training for midwives and medicines for EMA now being available in the community. More EMAs were performed in 2022 than surgical abortions, which is the first year that this has been observed. Average gestation at the time of abortion also decreased across most ethnic groups compared to 2021. Read the full report here
The New Zealand College of Sexual and Reproductive Health (NZCSRH) has developed a series of four abortion theory training courses that are hosted on the bpacnz website. Click here to view the modules.
Paper of the Week: Colchicine for cardiovascular disease prevention
Colchicine has been a mainstay of treatment for joint pain since long before the modern era of medicine. It is most commonly used in the management of gout flares. However, as our understanding of disease pathophysiology has evolved, the potential applications for this medicine across a wider range of indications involving underlying inflammation has been considered, e.g. pericarditis.
There is growing evidence for clinical efficacy of colchicine in the prevention of cardiovascular disease (CVD). When balanced against the backdrop of increasing CVD deaths over the past few decades, this has led to some global regulatory agencies reconsidering its status. As outlined in a recent European Heart Journal review, the US Food and Drug Administration (FDA) has approved colchicine for reducing the risk of myocardial infarction, stroke, coronary revascularisation and cardiovascular death in adults with established atherosclerotic disease or who have multiple risk factors for CVD.
In New Zealand, the use of colchicine for the secondary prevention of CVD is not approved, nor is it common practice in primary care. As such, this announcement is likely to trigger some discussion and debate among clinicians. Do you think the current scope of evidence supports the use of colchicine for CVD prevention in specific patients, even if they don’t have gout? Would you be likely to alter your prescribing behaviour if similar changes in approval status and clinical guidelines were made here?
- Atherosclerosis is the main risk factor for CVD. While this condition was previously thought to involve simple lipid accumulation within large- and medium-sized arteries, it is now considered to involve a prominent and sustained inflammatory response
- Statins are integral to atherosclerosis management as they possess both cholesterol-lowering and anti-inflammatory effects. However, some patients who reach LDL cholesterol targets are still at risk of CVD due to a so-called “residual inflammatory risk”. As such, candidate medicines with anti-inflammatory properties are being considered in clinical trials to help bolster the treatment toolkit and improve patient outcomes, e.g. canakinumab (a biologic used for inflammatory conditions including juvenile idiopathic arthritis), anakinra (a biologic used for rheumatoid arthritis).
- Colchicine also possesses several anti-inflammatory actions relevant to atherosclerosis, including (1) interference with microtubule functions, (2) indirect blockade of NLRP3 inflammasome oligomerisation (through interference on microtubules), (3) impairment of neutrophil chemotaxis mobilisation and recruitment and (4) disruption neutrophil-platelet interactions
- Low-dose colchicine has been shown to reduce cardiovascular risk in three notable randomised clinical trials:
- LoDoCo (N = 532) – Colchicine 0.5 mg daily, in addition to statins and other standard secondary prevention treatments, reduced the risk of recurrent cardiovascular events in patients with stable coronary disease, compared to those taking standard treatments without colchicine. The primary outcome (cardiovascular event) occurred in 5.3% of patients who received colchicine versus 16% in those that did not (number needed to treat = 11); this was a 67% reduction in relative risk. Median follow-up was 36 months.
- COLCOT (N = 4,745) – Colchicine 0.5 mg daily reduced the absolute risk of recurrent cardiovascular events by 1.6% versus placebo (5.5% vs. 7.1%) in patients with myocardial infarction within 30 days of enrolment. Median follow-up was 22.6 months.
- LoDoCo2 (N = 5,522) – Colchicine 0.5 mg daily was associated with fewer cardiovascular events (cardiovascular death, myocardial infarction, ischaemic stroke or coronary revascularisation owing to ischaemia) compared with placebo (6.8% vs 9.6%) in patients with chronic coronary disease. Median follow-up was 28.6 months.
- In June, 2023, the FDA announced the approval of colchicine for reducing the risk of myocardial infarction, stroke, coronary revascularisation and cardiovascular death in adults with established atherosclerotic disease or who have multiple risk factors for CVD. Factors supporting this decision include that colchicine:
- Has demonstrated efficacy in alleviating residual inflammatory risk associated with standard treatments, e.g. statins, antiplatelets
- Is widely available and is relatively inexpensive
- Is administered orally (unlike biologic treatments, e.g. canakinumab, which are administered by injection)
- Possible disadvantages of using colchicine in this context include that:
- It has a narrow therapeutic index
- Is associated with adverse effects (e.g. gastrointestinal disturbances) which may be exacerbated by medicine interactions, e.g. inhibitors of CYP3A4 and/or P-glycoprotein
- There is currently a lack of evidence on accurate and measurable markers to identify which patients are suitable to treat with colchicine or how to assess treatment efficacy
- In July, 2023, American Heart Association and American College of Cardiology guidelines on the management of patients with chronic coronary disease recommended that colchicine can be considered for secondary prevention to reduce recurrent atherosclerotic CVD, but only in patients who remain at very high risk despite maximum tolerated, guideline-directed management
Bonaventura A, Abbate A. Colchicine for cardiovascular prevention: the dawn of a new era has finally come. European Heart Journal 2023;44:3303–4. https://doi.org/10.1093/eurheartj/ehad453
This Bulletin is supported by the South Link Education Trust
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