Published: 3 September, 2020
Something exciting is coming...
We are preparing to launch a new twist on an old favourite. Coming to your inbox very soon, watch this space.
Primary care update series: new topic now available
The first topic in our "Musculoskeletal theme" is now live – Gout: what's in and what's out. We are joined by Associate Professor Simon Stebbings,
Consultant Rheumatologist, to discuss the latest evidence for managing gout in primary care.
Here is a "sneak peek" audio snippet:
To access this topic and others in the Primary Care Update series, click here
Reminder: upcoming changes to National Immunisation Schedule
From 1 October, 2020, a new vaccination event for children aged 12 months will be added to the National Immunisation Schedule, to give the first dose of MMR and
booster (third) dose of PCV10. We covered all the changes to the Immunisation Schedule in a
bulletin. Printed resources, such as the National Immunisation
Schedule reference card, have been updated and are now available to order on the
website. The 2020 edition of the Immunisation Handbook will be available
online in mid-September.
For the Ministry of Health information about these changes,
Avoid prescribing allopurinol with azathioprine
In the latest edition of Prescriber Update
(September, 2020), Medsafe warns prescribers to avoid the combination of allopurinol with azathioprine or mercaptopurine
due to a risk of life-threatening bone marrow suppression. The Centre for Adverse Reactions Monitoring (CARM) has received 13 reports of bone marrow suppression occurring
with concomitant use of allopurinol and azathioprine.
Allopurinol is used in the management of gout and azathioprine is an immunosuppressant used for people with rheumatoid arthritis, Crohn's disease,
ulcerative colitis and other autoimmune conditions. Mercaptopurine is mainly used in the treatment of people with leukaemia but is also sometimes
used in people with Crohn's disease or ulcerative colitis.
- Although the alert does not mention febuxostat, this is also a xanthine oxidase inhibitor, and the same risk is likely to apply if used with azathioprine
- Probenecid may be an appropriate option for patients taking azathioprine who require urate-lowering treatment
- If it is necessary for a patient to be prescribed this combination of medicines, azathioprine should be used at 25% of the normal
recommended dose and the patient's blood count monitored.
Antihistamines should not be used for sedation in children
The Medicines Adverse Reaction Committee (MARC)
recommended that the indication of sedation be removed from
over-the-counter medicines containing sedating antihistamines. Promethazine (brand names Phenergan and Allersoothe)
is the only oral sedating antihistamine available for use in children aged two years and over. Sedation with an antihistamine
may be considered in some settings prior to a minor medical or surgical procedure in a child, and anecdotally some parents
may enquire about a sedating antihistamine for long-haul travel or troublesome sleeping in younger children. MARC considered
that there were other more appropriate methods if sedation was required in a child in a medical setting, and that the
over-the-counter sale of promethazine for sedation in children was inappropriate.
N.B. this advice does not apply to use of antihistamines for other indications.
Celiprolol to be discontinued
The supplier of the beta-blocker Celol (celiprolol) has advised PHARMAC
that this medicine will be discontinued. This brand is the only one currently
registered in New Zealand which means that celiprolol will be unavailable once the current stocks are depleted. Patients will need to be changed to another beta-blocker.
For further information on selecting a beta-blocker, see: https://bpac.org.nz/2017/beta-blockers.aspx
Supply issue with 25 microgram oestradiol patches
PHARMAC has advised
that supplies of the 25 microgram oestradiol transdermal patch are low and likely to have been depleted by the end of August.
No replacement brand has been able to be sourced, therefore patients will need an alternative treatment option until supplies are restored (e.g. switching
to oral tablets or using a higher strength patch). New stock is expected by mid-October, 2020. It is important to note that this only affects the 25 microgram
patch; supplies of the other sizes of oestradiol patch (50, 75 and 100 microgram) are not affected.
For further information on the role of oestradiol patches and other treatments for menopausal symptoms, see
Paper of the week: More than a (gut) feeling
A unique study has been published this week in the British Journal of General Practice, examining the utility of a general practitioner's "gut feeling" in
diagnosing cancer in primary care. The authors identified 16 studies or resources published on this topic and were able to perform a meta-analysis of outcomes.
They found that the pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded in the notes, and that the accuracy of gut feelings
in predicting cancer increased with the clinical experience of the general practitioner and their familiarity with the patient.
A gut feeling, also referred to as instinct, intuition or tacit knowledge, in the context of medicine is defined as: "an uneasy
feeling perceived by a GP as he/she is concerned about a possible adverse outcome, even though specific indications are lacking: There’s something wrong here."
The authors performed a systematic review of evidence and found that all data were from European studies and reports. They found that the general practitioner's gut
feeling arises from multiple verbal and non-verbal patient cues, in the context of their knowledge and experience. General practitioners described a feeling of alarm,
worry or suspicion, a "lurch of the stomach" or "hairs on the back of the neck", that the patient was seriously unwell, without being sure of a diagnosis at this
point. The positive predictive value of gut feelings for cancer increased with the general practitioners experience and age. Those who rated themselves highly
in terms of empathy were more likely to acknowledge gut feelings as part of their diagnostic process.
Non-verbal cues that contribute to a gut feeling mostly rely on a previous knowledge of the patient and continuity of care, and include:
- Inconsistencies with their normal physical appearance, grooming and standard of dress
- Perceived weight loss or loss of condition
- Change in complexion – some described this as a "magnolia" colour
- Posture, demeanour and way of talking
- Abnormal consulting frequency or behaviour
Verbal cues are mostly related to mention of symptoms, including:
- Unintentional weight loss
- Prolonged symptom duration
- Multiple symptoms
- Non-specific symptoms
A gut feeling should be considered as part of the analytical process for assessing the severity of a patient's condition and deciding on the appropriateness and
urgency of referral. Don't be hesitant to record a "gut feeling" in the patient's notes. If you think that an emotional response should not influence clinical practice,
it may be more acceptable to view it as a conscious and subconscious assessment based on pattern recognition that develops through repetition of clinical scenarios,
i.e. diagnostic memory. The ability to use "gut feeling" as a criterion for referral for further investigation in New Zealand would depend on the specific cancer
care pathway, but is it likely that the patient would still need to meet certain symptomatic requirements.
If you are a less experienced practitioner and want to strengthen your gut instinct skills, experts recommend that you reflect on your diagnostic reasoning and
pay attention to how patients present themselves and describe their illness, and what reaction this provokes in you – are you reassured because the last ten patients
you saw with these symptoms were fine, or are you starting to worry because it just doesn’t feel right to you? If you have this feeling, use it to guide your
examination, discuss it with a more experienced colleague and provide a safety net for the patient to come back if your instinct is right. Medicine has
always been both and art and a science.
Friedemann Smith C, Drew S, Ziebland S, Nicholson B. Understanding the role of GPs' gut feelings in diagnosing cancer in
primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Prac 2020;70(698): e612-e621. DOI:
This Bulletin is supported by the South Link Education Trust
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