Published: 3rd May, 2024
Contents
Reflections on the last days of life: what does this mean for you?
Since publishing the first resources in our Last Days of Life series in September, 2023, there have been over 20,000 views. This is clearly a topic that generates much interest and signifies that there has been a need for resources in this clinical area. We have now released a podcast episode, which is a conversation with three outstanding clinicians who champion efforts to improve the standard of end of life care within New Zealand, compered by the team at bpacnz. If you haven’t listened already, we urge you to engage in this important conversation.
As a result of the feedback we have received, we have now published a Reflections page as a space for our readers to share their experiences and thoughts about the role of primary care clinicians in caring for patients in the last days of life. We would like to hear from a wide range of people, including our colleagues with many years of experience, those who may have recently cared for their first patient who died, and those with experiences from other cultures or perspectives. You can remain anonymous if you wish, and if writing isn’t your forte, we are here to help with crafting your thoughts into words. Email: editor@bpac.org.nz
A brief excerpt from Reflections:
“I firmly believe that honesty about a realistic future is the keystone for palliative care, and it needs to be done with skill, empathy and have a definite plan for further events rather than face chaos in times of a sudden medical event. As physicians, we have this responsibility - we know what they do not know. We have a responsibility to be honest, talk about treatment options, and prepare a plan of appropriate palliative care for the future.”
Read the full letter and other reflections here
New CKD guidelines now available: KDIGO 2024
New guidelines are available from the Kidney Disease: Improving Global Outcomes (KDIGO) group, providing clinicians with further direction when caring for patients with chronic kidney disease (CKD). This updates the previous 2012 KDIGO guidelines and includes supplementary resources on the “Top 10 Takeaways” for primary healthcare clinicians regarding evaluation and management.
Key highlights of most relevance to primary care include
- Guidance on measuring estimated glomerular filtration rate and albuminuria. Creatinine-based estimation of glomerular filtration rate (eGFRcr) should generally be prioritised when investigating most adults. However, the KDIGO group recommends that estimating GFR from a combination of creatinine and cystatin C (eGFRcr-cys) “enhances accuracy and strengthens risk relationships”. The advantage of cystatin C testing is that its production rate is constant, and not substantially affected by factors such as age, sex, ethnicity or muscle mass.
- Cystatin C testing is available and funded in New Zealand but is not recommended for routine use. Expert opinion is that it may be considered in select cases where there is uncertainty around the accuracy of GFR estimates, such as in patients with abnormally low or high muscle mass, those who are obese or malnourished (e.g. BMI < 20) and children.
- Utilisation of CKD risk prediction equations is recommended in patients with eGFR grade G3 – G5 to more accurately assess the absolute risk of kidney failure. International examples in the guidelines include www.kidneyfailurerisk.com or https://www.ckdpc.org/risk-models.html. A five-year risk of kidney failure ≥ 3 – 5% indicates a need for secondary care referral.
- Treatment should be individualised for optimal kidney and cardiovascular risk reduction. However, a healthy diet (including higher consumption of plant-based foods compared to animal-based foods and reduced sodium intake) and encouraging physical activity, weight management and smoking cessation should underpin management in all cases. Statins also continue to be recommended in most patients with CKD.
- ACE inhibitor or ARB treatment should be first line for blood pressure control in most patients with CKD, particularly when albuminuria is present. Doses should be titrated to the maximum tolerated level for the most significant reduction in CVD/CKD risk. Further antihypertensive treatment can then be added, as needed, to achieve blood pressure targets.
- The KDIGO guidelines suggest the addition of a non-steroidal mineralocorticoid receptor antagonist (MRA) such as finerenone in patients with CKD and diabetes who exhibit persistent albuminuria despite a maximally tolerated ACE inhibitor/ARB dose. However, these medicines are not routinely available in New Zealand; the only funded options available are steroidal MRAs (e.g. spironolactone, eplerenone) which are not specifically recommended for this patient group. The guidelines note that steroidal MRAs may still be used in patients with CKD for the treatment of co-morbid heart failure, hyperaldosteronism or refractory hypertension (but caution is required due to risk of hyperkalaemia or a reversible decline in glomerular filtration).
- An intensive systolic blood pressure (SBP) target of < 120 mmHg is recommended unless patients are frail, have a high risk of falls and fractures, limited life expectancy or symptomatic postural hypotension. This differs from the < 130 mmHg SBP threshold recommended in most general hypertension guidelines for high-risk patients. The KDIGO work group’s justification is that “by aiming for an SBP < 120 mmHg, more adults with CKD will achieve an SBP < 130 mmHg, even if they do not meet the < 120 mmHg target”.
- SGLT-2 inhibitor treatment is now recommended in most patients with CKD, even in those without diabetes, e.g. if their urine ACR is moderately increased (≥ 20 mg/mmol) or if they have heart failure.
- SGLT-2 inhibitors are currently only funded with Special Authority approval in New Zealand for patients with diabetes; this may present a barrier to equitable access as non-diabetic patients with CKD will need to self-fund treatment.
To access the 2024 KDIGO CKD guidelines, click here. An executive summary is also available here.
For further information on identifying and managing CKD in primary care, see: https://bpac.org.nz/2022/ckd.aspx (this article will be updated as required after full review of the new guidelines and expert advice)
bpacnz hypertension article update: consider kidney dysfunction early
Hypertension is a particularly common clinical finding in primary care, so it should come as no surprise that the article “Hypertension in adults: the silent killer” is consistently among our most highly viewed resources. As with all our online content, we aim to progressively revise information over time to reflect changes in the evidence base and expert perspectives.
In a recent update to this resource, we emphasise the significant interconnectedness between the cardiovascular system and the kidneys, and consider the implications this has on evaluation and management. Albuminuria (or proteinuria) is often the first sign of vascular endothelial dysfunction in patients with hypertension, and is strongly associated with an elevated risk of CVD and death. However, unless patients have diabetes, urine ACR testing is often underutilised in New Zealand primary care during initial evaluation patients with hypertension.
What are the key practice points from this update?
- Assess kidney function, including both eGFR and ACR, as part of baseline CVD risk evaluation in all patients with newly identified hypertension. Many standard CVD risk calculators do not include these parameters (unless they are specifically for patients with diabetes), and therefore potentially underestimate CVD risk.
- If significant proteinuria or CKD is identified, initial antihypertensive treatment should ideally include either an ACE inhibitor or ARB at the maximum tolerated dose; this optimises their antiproteinuric effect and delivers the most substantial reduction in CVD/CKD risk
Immunisation news: World Immunisation Week, influenza vaccine, RSV vaccine
World Immunisation Week
World Immunisation Week was held on 24th – 30th April. The theme for this year was “Humanly Possible: Immunization for All”. This is a timely reminder to opportunistically check that patients are up to date with their immunisations as part of routine appointments, and to offer vaccination where appropriate. A list of available vaccinations for adults, including for special circumstances, e.g. overseas travel, can be found here.
Anyone for flu vaccine?
The Influenza Immunisation Programme for 2024 started at the beginning of April. The national target is for at least 75% of all adults aged 65 years and over to be vaccinated this influenza season. As of 28th April, the overall vaccination rate in this group is 39%, so good progress is being made towards this target. Health New Zealand, Te Whatu Ora, publishes data on uptake of vaccinations by district, updated weekly; check out how your area is doing here. Ensure patients who meet eligibility criteria for funded vaccination are aware that they can receive a flu vaccine for free.
New article on influenza and COVID-19 vaccinations
We recently published an article outlining the latest information about seasonal influenza and COVID-19 vaccinations; click here to view. The Nuvaxovid® COVID-19 vaccine (Novavax) is no longer available in New Zealand as stock has now expired. Comirnaty™ vaccines remain available. Medsafe is currently evaluating an application for the Nuvaxovid® Omicron XBB.1.5 vaccine; an approval decision is yet to be made.
Patient sheets on managing at home with Cold & Flu and COVID-19
A reminder that you can download and print, send a link or direct patients to information sheets on managing at home with seasonal viral illness or COVID-19.
RSV vaccine for older adults now available
A new vaccine (Arexvy) for the prevention of lower respiratory tract disease caused by respiratory syncytial virus (RSV; covering RSV-A and RSV-B subtypes) is available from 1st May for adults aged 60 years and over. The vaccine is a one dose course administered via intramuscular injection in general practice. It is not currently known whether re-vaccination is required, but evidence suggests that it will provide protection for at least two RSV seasons. The vaccine is not funded; it can be ordered via Healthcare Logistics (HCL). Pharmac has received an application for funding, however, a decision is yet to be made.
N.B. In some countries, the Abrysvo RSV vaccine is recommended for people who are pregnant, however, this vaccine is not currently approved for use in New Zealand. Arexvy is not recommended during pregnancy.
Information for healthcare professionals about the vaccine, including safety and effectiveness, is available from IMAC, here. A Goodfellow Unit webinar hosted by IMAC on RSV is available here.
Patient information from GSK about RSV and Arexvy is available here
Medicine news: dulaglutide/liraglutide, levothyroxine, omeprazole
The following news relating to medicine supply, of particular interest to primary care, has recently been announced. Medicine supply information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
No new patients can start on dulaglutide or liraglutide
The Special Authority criteria for dulaglutide and liraglutide have been amended due to ongoing supply shortages to ensure that people currently taking either of these medicines can continue to do so. No new patients can receive Special Authority approval for either medicine until further notice.
Eltroxin (levothyroxine): new look and formulation
The supplier of the Eltroxin brand of levothyroxine has advised of changes to the 50 microgram and 100 microgram tablets:
- 50 microgram tablets will have a different tablet shape and imprint. Patients taking these tablets should be advised that their tablets will look slightly different but be reassured that there has been no change to the formulation, manufacturer or manufacturing method.
- As there will be no change to the formulation, no additional thyroid function testing is recommended unless clinically indicated
- 100 microgram tablets will be reformulated with reduced quantities of excipients (but the same excipients). The tablet size will be smaller, and the shape and imprint will also have changed. Patients taking these tablets should be advised that their tablets will be reformulated and look slightly different, but be reassured that there has been no change to the active ingredients, manufacturer or manufacturing method.
- A thyroid function test six weeks after the transition is recommended for patients currently taking 100 microgram tablets. A thyroid function test is also recommended after six to eight weeks for patients who require adjustments to their dose.
These changes will occur once current stock is exhausted; this is expected from June, 2024. A brand switch fee will be available for pharmacies in late 2024. An information sheet is available to give to patients here. An information sheet for healthcare professionals is also available here.
Omeprazole back in stock
20 mg and 40 mg omeprazole capsules are currently back in stock after ongoing supply issues (as reported in Bulletins 93 and 96). Stat dispensing is expected to be reinstated soon once there is sufficient levels of reserve stock.
Upcoming webinar on HIV PrEP and PEP prescribing
HealthPathways, in conjunction with The Royal New Zealand College of General Practitioners and the Burnett Foundation Aotearoa, are hosting a webinar on prescribing HIV pre- and post-exposure prophylaxis (PrEP and PEP). This free webinar is aimed at primary care prescribers and will cover:
- Background on the goals and barriers to eliminating HIV transmission in New Zealand
- Practical information regarding prescribing of PrEP and PEP in primary care
- Burnett Foundation Aotearoa resources
- How to navigate HealthPathways
The webinar will be held at 7 pm on Tuesday, 14th May. Click here to register.
Burnett Foundation Aotearoa and the New Zealand Sexual Health Society are also running a series of free HIV PrEP and PEP education sessions for non-specialist prescribers around the country and online. These CME-accredited sessions will focus on the practical aspects of prescribing HIV PrEP and PEP, e.g. clinical training, time management, prescription repeats. Click here for dates and locations.
Watch this space for an upcoming bpacnz article update on prescribing HIV PrEP and PEP in primary care.
Updated Australian cardiovascular disease risk guidelines
New guidelines are available in Australia on the assessment and management of cardiovascular disease (CVD) risk. This updates the previous 2012 guidelines and includes a new CVD risk calculator, which uses the New Zealand PREDICT risk equations. The guidelines are endorsed by the Royal Australasian College of General Practitioners. A summary of the changes can be found here.
New Zealand cardiovascular risk assessment and management guidelines were published in 2018. Guidance is largely similar, however there are some differences, including younger age groups for risk assessment and definitions of CVD risk categories (over five years) as well as the consideration of insulin use when calculating CVD risk in people with diabetes. We are not aware of any planned updates to New Zealand guidance at this stage.
Read more
In Australia, CVD risk assessment is recommended from age 45 years (up to age 79 years). Risk assessment is recommended from age 30 years in First Nations people. People with diabetes (without known CVD) should have their CVD risk calculated from age 35 years. In New Zealand, the starting age for CVD risk assessment is from 45 years for males and age 55 years for females (up to age 74 years). CVD risk assessment is recommended 15 years earlier for people of Māori, Pacific or South Asian ethnicity, i.e. from age 30 years in males and 40 years in females.
The five year CVD risk categories are also grouped differently. In Australia: high = ≥ 10% CVD risk, intermediate = 5 - < 10% CVD risk, low = < 5% CVD risk. Whereas, in New Zealand, high = > 15% CVD risk, intermediate = 5 - 15% CVD risk, low = < 5% CVD risk. As a result, the recommendations on when to prescribe blood pressure lowering and lipid lowering medicines slightly differ.
Read the full guideline here. A summary of recommendations and a factsheet for healthcare professionals is also available.
Australian Prescriber has published a practical summary of the guidelines, available from: https://australianprescriber.tg.org.au/articles/assessing-communicating-and-managing-cardiovascular-disease-risk-a-practical-summary-of-the-2023-guideline.html
Finasteride associated with psychiatric effects and sexual dysfunction: report from the UK
In April, 2024, the United Kingdom Medicines and Healthcare products Regulatory Agency (MHRA) published a new Drug Safety Update on finasteride (used in the treatment of male pattern hair loss and benign prostatic hyperplasia), reminding healthcare professionals and patients about the potential risk of psychiatric adverse effects and sexual dysfunction associated with its use. In some cases, sexual dysfunction persists after finasteride has been discontinued.
Read more
Healthcare professionals in the UK are being encouraged to ask patients whether they have a history of depression or suicidal ideation prior to prescribing finasteride, and advise them to seek health care advice (and stop the medicine if they are taking it for hair loss) if they experience depression or suicidal ideation. Patients taking finasteride should also be monitored throughout the treatment course for any psychiatric adverse effects or sexual dysfunction (e.g. decreased libido, erectile dysfunction). Further information from the MHRA, including an evidence review, can be found here. An associated news release is also available here.
Finasteride is a prescription-only oral medicine in New Zealand. There have been no recent medicine communications from Medsafe regarding finasteride, however, in 2016, a Prescriber Update article was published highlighting post-finasteride syndrome. Any suspected adverse effects thought to be related to finasteride use can be reported to the Centre for Adverse Reactions Monitoring (CARM).
Free cultural competency courses for healthcare professionals
A range of New Zealand based cultural competency courses are available for healthcare professionals through eCALD. These free resources aim to help clinicians strengthen relationships with culturally and linguistically diverse (CALD) patients, and patients from Asian, Middle Eastern, Latin America and African backgrounds. Courses can be completed online in a self-guided manner or via Zoom with an educator, or in-person. Click here for further information, including available courses.
New registered ACC treatment providers proposed
A consultation has been released on “Changes to ACC regulations for Chinese medicine, paramedics and audiometrists”. It is proposed that from late 2024, practitioners of Chinese medicine, paramedics and audiometrists would be able to provide treatment to patients through the ACC Cost of Treatment Regulations. Healthcare professionals and organisations are encouraged to comment on the proposal. The consultation closes Thursday 16th May, 2024 (submissions are made via the Ministry of Business, Innovation and Employment, here).
Read more about the proposal here
World Hand Hygiene Day – 5th May
World Hand Hygiene Day is coming up on Sunday (5th May); a day to remind healthcare professionals of the important role that good hand hygiene practices have in the healthcare setting. The theme for this year is about sharing knowledge and promoting training and education about infection prevention and control. Further information and resources for the global campaign from the World Health Organization are available here.
To support World Hand Hygiene Day in New Zealand, the Health Quality & Safety Commission has produced information and resources for healthcare professionals, including an online quiz and other activities. Click here to access them. Resources are also available from the Australasian College for Infection Prevention and Control.
NZF updates for May
Significant changes to the NZF in the May, 2024, release include:
- New monograph added on fluticasone furoate + umeclidinium + vilanterol (indicated for maintenance treatment of moderate to severe COPD and asthma in those not adequately controlled with an inhaled corticosteroid and long-acting beta2-adrenergic agonist)
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Updated dosing recommendations for the following ACE inhibitors:
- Captopril: new starting dose for patients with hypertension who are elderly, taking concomitant diuretics, at risk of ACE inhibitor-induced hypotension or have severe refractory hypertension. New starting dose and frequency for patients with heart failure. (N.B. only available funded formulation now is an oral liquid)
- Enalapril: new starting dose for patients with hypertension who are elderly, taking concomitant diuretics or at risk of ACE inhibitor-induced hypotension
- Lisinopril: new starting dose for patients with hypertension who are elderly, taking concomitant diuretics or at risk of ACE inhibitor-induced hypotension. New dose range for patients with heart failure or asymptomatic left ventricular systolic dysfunction (unapproved indication).
- Quinapril: new starting dose for patients with hypertension who are elderly, taking concomitant diuretics or at risk of ACE inhibitor-induced hypotension. Dose has been added for patients with diabetic nephropathy (unapproved indication).
- Medsafe Monitoring Communication link added to each of the individual calcium channel blocker monographs on the possible risk of new-onset eczema (see Bulletin 97 for further information)
- Cautions, adverse effects and patient advice updated in the individual quinolone monographs. The therapeutic notes have also been updated.
- Contraindications updated in the iron monographs
- New formulations, dosing and advice added to the testosterone and esters monograph (for testosterone replacement in primary and secondary male hypogonadism and hypoactive sexual desire dysfunction in post-menopausal females [unapproved indication])
- New section added on testosterone and management of menopausal symptoms (N.B. Testosterone cream [AndroFeme] used for these symptoms is an unapproved medicine [Section 29] and is not funded.)
You can read about all the changes in the May release here. Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Antipsychotic medicines associated with negative outcomes in people with dementia
The prevalence of dementia is rising both here and globally. Approximately 4% of adults aged over 60 years in New Zealand have dementia, and this rises to 14% in those aged over 80 years. Māori and Pacific peoples also have higher rates of dementia in these age groups, compared to people of European and Asian ethnicities (data available here).
People diagnosed with dementia require significant family/carer support and often pharmacological management. In some cases, antipsychotic medicines may be prescribed to manage target behavioural and psychological symptoms (BPSD), e.g. aggression, agitation and hallucinations. Antipsychotic medicines have limited evidence of benefit for BPSD and are associated with significant risk. “Off-label” use for patients with dementia to increase sedation or manage sleep or anxiety disorders is discouraged.
A study published in the British Medical Journal analysed the link between antipsychotic medicine use in patients with dementia and the incidence of adverse outcomes. The results suggest that patients with dementia who are prescribed antipsychotic medicines may be at higher risk of acute kidney injury, fracture, heart failure, myocardial infarction, pneumonia, stroke and venous thromboembolism, compared to patients with dementia who have never taken antipsychotic medicines. Interestingly, the highest risk of negative outcomes occurs soon after initiating treatment, i.e. within the first week. Given the already increased vulnerability of this patient group, the authors question whether more needs to be done to ensure these medicines are only used when clearly indicated and necessary.
What criteria do you employ when assessing whether antipsychotic medicines are appropriate for a patient with dementia in your care? Do you provide specific information for family/carers about the need for increased monitoring, and potentially the lower threshold for seeking urgent medical attention following initiation of an antipsychotic medicine? Do you assess effectiveness against the target behaviour and have a plan for stopping if risks outweigh the benefits?
Read more
- This population-based cohort study used electronic primary care health records to identify people aged 50 years and over living in England who were diagnosed with dementia between January, 1998, and May, 2018
- Of the approximately 370,000 people included in this study, 24,696 were prescribed antipsychotic medicines on or after the date of their dementia diagnosis. They were then matched with up to 15 other comparators who were diagnosed with dementia at a similar time (same date of diagnosis or in the 56 days following) but had not been prescribed antipsychotic medicines at any point.
- Antipsychotic medicine use was defined as:
- Current – evidence of a prescription for an antipsychotic medicine within the previous 90 days
- Recent – a period of 180 days following the end of the current use period
- Past – any time after the end of the recent use period
- Potential adverse outcomes investigated in this study included acute kidney injury, fracture, heart failure, myocardial infarction, pneumonia, stroke, venous thromboembolism (including pulmonary embolism and deep vein thromboembolism) and ventricular arrhythmia
- Both appendicitis and cholecystitis were also investigated as negative controls (i.e. unrelated conditions), in case of unmeasured confounding
- Risperidone, quetiapine, haloperidol and olanzapine accounted for almost 80% of antipsychotic medicines prescribed to patients included in this study
- Any use of antipsychotic medicines was associated with an increased incidence of all adverse outcomes (except for ventricular arrhythmia) at both 180 days and two years after the start of the follow-up period, compared with people who had never taken antipsychotic medicines. There was no increased risk of the negative control outcomes.
- The hazard ratio (HR) for all adverse outcomes (except for ventricular arrhythmia) was higher for current use of antipsychotics, compared to recent or past use. For example, there was an increased risk of myocardial infarction (HR: 1.28, confidence interval [CI] = 1.15 – 1.42) and heart failure (HR: 1.27, CI = 1.18 – 1.37) in the first 90 days of treatment with an antipsychotic (current use), however, these associations were not observed when considering the “recent use” and “past use” time periods.
- The effect of current typical antipsychotic use was larger than current atypical antipsychotic use for acute kidney injury (HR: 1.22, CI = 1.05 – 1.42), fracture (HR: 1.22, CI = 1.08 – 1.38), heart failure (HR: 1.18, CI = 1.01 – 1.39), pneumonia (HR: 1.92, CI = 1.77 – 2.08) and stroke (HR: 1.23, CI = 1.09 – 1.40)
- A strong association between use of antipsychotic medicines and pneumonia was found in this study, especially in the first week following initiation (HR: 9.99, CI = 8.78 – 11.40). The mechanism behind this relationship is unclear and the authors hypothesise reverse causality may have contributed to this result, i.e. older people with pneumonia may present with delirium instead of respiratory symptoms and receive initial antipsychotic treatment prior to pneumonia diagnosis.
- As dementia is often diagnosed later in life, confounders specific to older adults may have influenced these results. Older people are more likely to be prescribed multiple medicines and are therefore at higher risk of medicine interactions which could increase rates of some negative outcomes, e.g. acute kidney injury.
- Standard limitations associated with electronic health records include coding input errors, differences in data quality between different healthcare clinics, missing information relating to dosing and inability to judge medicines adherence. In addition, the specific datasets used in this study do not provide information on any medicines prescribed outside of primary care, e.g. hospital.
Mok PLH, Carr MJ, Guthrie B, et al. Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study. BMJ 2024;:e076268. doi:10.1136/bmj-2023-076268.
For further information on managing behavioural and psychological symptoms in people with dementia, see: https://bpac.org.nz/2020/bpsd.aspx
This Bulletin is supported by the South Link Education Trust
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