Published: 8 July, 2020
What’s happening with monthly dispensing?
In March, 2020, PHARMAC announced
that medicines should be dispensed monthly (or three-monthly for oral contraceptives) due to
concerns about the supply chain during the COVID-19 pandemic.
Currently, no date has been set for a return to three monthly stat dispensing, however, work is progressing towards
this goal and PHARMAC will give at least three weeks’ notice of any change*. Due to ongoing global issues affecting
manufacturing and supply it is likely that some medicines will need to continue to be dispensed monthly; it is anticipated
that these supply issues may continue for the rest of 2020 and even beyond.
If necessary, pharmacists may still make exceptions to the current monthly dispensing requirements, based on rule 4.4.2 of the Pharmaceutical
Schedule, e.g. for people who have mobility issues, live in rural areas, are older or are immunocompromised.
*On 9/7/20 it was announced that there would be a return to stat dispensing on 1 August, 2020 (with some restrictions).
Gemfibrozil tablets discontinued
PHARMAC has announced that the fibrate gemfibrozil
is to be discontinued and stocks will likely be exhausted during early July, 2020. This is because the
supplier (Douglas) is unable to obtain the raw material for manufacture. No other manufacturer of gemfibrozil has been able to be found to supply the New Zealand market.
Approximately 800 patients taking gemfibrozil will be affected by this discontinuation.
Patients taking gemfibrozil will need to be changed to another lipid-lowering treatment. PHARMAC will reimburse general practices for
the cost of this consultation – the co-payment waiver reimbursement form is
What should I prescribe instead?
Atorvastatin is the usual preferred first-line treatment for hyperlipidaemia and CVD risk reduction. Fibrates are no longer routinely recommended
for reducing cardiovascular risk for either primary or secondary prevention. They are also not the first-line medicine for people with
familial hypercholesterolaemia; a high-intensity dose statin should be prescribed. One exception where a fibrate may be indicated is in
a patient with marked hypertriglyceridaemia to reduce the risk of pancreatitis. Bezafibrate will be the only fibrate available and fully funded in New Zealand.
For more information on lipid-lowering treatments, see
“Prescribing statins to reduce cardiovascular risk”
New guidelines for young people with type 2 diabetes
Australasian guidelines for the screening, assessment and management of type 2 diabetes in children and adolescents have just been released and
here. This guidance has been developed to provide consensus on how to detect young people at risk of type 2 diabetes and how to
manage them once diagnosed. A key aim of the guidelines is to address the challenges and specifics of care for children from Indigenous
populations in both Australia and New Zealand who are at higher risk.
For more information on diabetes in younger people,
see “A rising tide of type 2 diabetes in younger people: what can primary care do?”
Cilazapril + hydrochlorothiazide discontinuation
As previously reported, the combination tablet cilazapril with
hydrochlorothiazide is no longer being supplied, due to withdrawal of the manufacturer,
Apotex, from the New Zealand market. There are no other brands of this medicine available. From 1 March, 2020, cilazapril + hydrochlorothiazide was not funded
for new patients. Patients already receiving this medicine could continue to do so with an endorsed prescription. However, patients should now be in the
process of changing to an alternative medicine regimen (or already changed). It is now expected that stocks of cilazapril + hydrochlorothiazide will run out in September, 2020.
What should I prescribe instead?
- Change to another fixed-dose combination, i.e. quinapril with hydrochlorothiazide or losartan with hydrochlorothiazide
- Change to two separate antihypertensives; ACE inhibitors/ARBs, calcium channel blockers and thiazide (and
thiazide-like) diuretics are all first line antihypertensives with a comparable blood pressure lowering effect
- De-escalate treatment to use of a single antihypertensive in rare cases where long-term users of cilazapril
with hydrochlorothiazide have applied major lifestyle changes and are consistently achieving blood pressure targets
More about Apotex withdrawal from the New Zealand market
It has been recently reported in the media that Apotex is withdrawing from the New Zealand market; this may cause concern for patients taking one of
the 41 medicines that Apotex supplies. PHARMAC has been aware of this news for some time and invited alternative suppliers for these medicines to
their interest by 7 July, 2020. Replacement brands will be finalised before the end of 2021, when Apotex will cease to supply medicines in New Zealand.
Patients currently taking an Apotex-branded medicine can be informed that a brand change will occur at some point before the end of next year,
and reassured that their treatment will be able to continue. The only discontinuation announced to date is cilazapril + hydrochlorothiazide tablets.
A new topic on managing hypertension is available in the bpacnz Primary Care Update Series
Paper of the week: Māori are more likely to experience NSAID-related harm
In our feature paper this week, we review a New Zealand retrospective cohort study conducted by researchers at bpacnz
and Waitemata/Auckland DHBs. Although widely used in New Zealand, non‐steroidal anti‐inflammatory drugs (NSAIDs) are
associated with a number of serious adverse effects, including upper gastrointestinal bleeding, acute kidney failure
and heart failure. A retrospective cohort study using national pharmaceutical dispensing and hospital admissions data
from 2007 – 2015 was used to assess ethnic disparities in the risk of hospitalisation for NSAID-related adverse effects in New Zealand.
- The risk of upper gastrointestinal bleeding, heart failure and acute kidney failure associated with NSAID use in
New Zealand varies according to patient ethnicity
- Māori and Pacific patients were more likely to be hospitalised for upper gastrointestinal bleeding (rate ratios
[RRs], 2.54 and 3.17, respectively) and heart failure (RRs, 2.48 and 1.97, respectively), and Māori were more likely
to be hospitalised for acute kidney failure (RR, 1.46), during NSAID treatment than Europeans
- The relative risk of upper gastrointestinal bleeding and heart failure associated with NSAIDs was greatest in Māori
and Pacific patients aged under 60 years
This study reinforces the potential risk of serious harm associated with NSAID use and shows that the risk of harm varies according to the ethnicity of
the population exposed. The increased prevalence of co-morbidities such as gout in Māori and Pacific patients may partly explain the increased risk but it
is also likely that inequities in patient care are a significant factor. For example, use of gastroprotection such as omeprazole was lower in Māori and
Pacific patients compared to Europeans. It is also possible that there may be differences in the availability of information and the extent and method
of communicating the risks of NSAIDs when prescribed to Māori and Pacific people compared to Europeans.
This is one of very few studies investigating variability in medicine-related harm by ethnicity; it indicates the need for further research
into the reasons for such disparities. This research can readily be performed in New Zealand using the national data collections.
Irrespective of the reasons for the disparities the study highlights the need to manage the risks associated with NSAIDs especially in high risk groups
such as Māori and Pacific patients. This should include review and confirmation of a current indication for NSAIDs, consideration of the increased risk
due to co-morbidities, minimising use of NSAIDs by better pain control and optimum control of gout and the provision and effective
communication of appropriate patient information.
Tomlin A, Woods D, Lambie A, et al. Ethnic inequality in non‐steroidal anti‐inflammatory drug‐associated
harm in New Zealand: A national population‐based cohort study. Pharmacoepidemiol Drug Saf. 2020;1–9.
Abstract available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/pds.5028
N.B. We prefer to review open-access papers, however, made an exception in this case due to the subject interest and relevance to the New Zealand population.
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