Published: 9th February, 2024
In case you missed it – Melatonin: is it worthwhile for sleep?
Melatonin is a naturally occurring hormone that regulates circadian rhythm and sleep. Given its important biological functions, there has been interest in melatonin as a medicine, and patients often enquire about whether supplementation can help manage sleep disturbances. Evidence suggests melatonin may provide some benefit for older adults with insomnia when dosed at the correct time, and it is generally well tolerated. However, melatonin is not a first-line treatment and use should not be prioritised over other forms of evidence-based care.
Read the full article here
Other recent resources from bpacnz
February is Ovarian Cancer Awareness Month
This month is Ovarian Cancer Awareness Month (following Cervical Cancer Awareness Month in January). Ovarian cancer is the second most common gynaecological cancer after endometrial and has a higher mortality than all other gynaecological cancers in New Zealand combined.
There is no effective screening test for ovarian cancer; diagnosis relies on the prompt recognition and investigation of suspicious symptoms. While ovarian cancer was historically considered to be a silent disease in its early stages, evidence suggests that 90 – 95% of people diagnosed with ovarian cancer are symptomatic. However, a key diagnostic challenge is that symptoms are often vague and non-specific. Clinicians should be alert for potential symptoms of ovarian cancer and have a low threshold for initiating further investigations (including CA-125) in people with suspicious symptoms.
Symptoms of ovarian cancer may include
- Abdominal bloating or distention
- Abdominal or pelvic pain
- Early satiety or loss of appetite
- Increased urinary frequency or urgency
- Changes in bowel habit
- Unexplained weight loss
- Post-menopausal bleeding
Symptoms are more likely to be associated with ovarian cancer if they are in a post-menopausal female and/or if they are new, severe, unusual, recurrent or persistent, e.g. occurring 12 or more days per month. New symptoms suggestive of irritable bowel syndrome, e.g. changes in bowel habit, in females aged > 50 years are unusual; consider the possibility of ovarian cancer in these patients (among other potential diagnoses such as bowel cancer).
For further information on ovarian cancer early detection and referral, see: https://bpac.org.nz/2023/ovarian-cancer.aspx
Updated national concussion guidelines for community sport
ACC, in partnership with seven national sporting organisations, has released updated guidelines on the recognition and treatment of concussion for people participating in community sport. This framework is intended to help foster a consistent standard of care, irrespective of the sporting discipline.
The guidelines include a six-stage graduated return to education/work and sport protocol, recommending that:
- Stage 1: players should initially undertake 24 – 48 hours of physical and mental rest
- Stages 2 – 4: during the 2 – 13 days post-injury, players can progressively re-engage in normal daily activities, increase their tolerance for physical and mental activities, before returning to work/study and types of sport-specific training that do not risk head impact. The progression through these stages and the intensity of re-engagement should be guided by symptoms.
- Stage 5: after at least 14 days, players can re-engage in full contact-based sport specific training if they are asymptomatic. Players must have fully returned to school or work before returning to contact-based training.
- Stage 6: a minimum of 21 days should have elapsed before players can return to full competition, they should be symptom free during sports training and they should have received medical clearance from a qualified medical practitioner (strongly recommended)
View the full guidelines here. An accompanying press release about the guidelines is available here.
ACC has also released a position statement about no longer accepting “post-concussion syndrome” as a covered injury. Click here to view the statement. This decision, and the evidence behind it, was also discussed in the bpacnz article on concussion.
For further information on the management of concussion in primary care, including for patients who sustain non-sports-related concussion, see: https://bpac.org.nz/2022/concussion.aspx
Spike in lead notifications from suspected Kamini use raises concerns
The National Public Health Service (NPHS), Te Whatu Ora, has received notification of a cluster of cases of lead poisoning with exposure suspected to be from an Ayurvedic product known as Kamini (also referred to as Kamini Vidrawan Ras, KVR). The NPHS is urging clinicians to be alert for further potential cases of lead poisoning associated with this product.
Kamini comes in the form of small pellets, swallowed like tablets.
Kamini is an opioid-containing herbal medicine that may contain high levels of hazardous substances, including lead and mercury. Despite being illegal to import, supply or possess without a prescription, Kamini is increasingly seen in New Zealand within specific groups, mostly within the Indian community and followers of Ayurvedic or Unani medicine. It is claimed to have wide ranging benefits for men’s health, including improved sexual function and overall vitality.
With the recent cluster of lead notifications suspected to be due to Kamini consumption, this is a timely reminder that use of traditional herbal medicines is not without potential harm and that people can be exposed to a range of contaminants. If patients are using herbal medicines/remedies such as Kamini, assess whether they have any abnormal symptoms or signs. Ask them if they experience any problems when they miss a dose or try to stop. Local Community Alcohol and Drug Services can provide assistance with patients experiencing difficulties.
Reminder. A blood lead level ≥ 0.24 micromol/L is notifiable to the local Medical Officer of Health within the NPHS who will investigate the exposure further. This includes suspected occupational exposure which is assessed by the NPHS before being notified to WorkSafe for further investigation. Lead-based paint is the most common source of blood lead notifications in New Zealand, but traditional medicines and cosmetics have also been reported as sources.
For further information on Kamini, see: https://bpac.org.nz/2020/kamini.aspx
For further information on lead poisoning, including notifying the local Medical Officer of Health, see: https://bpac.org.nz/2021/lead.aspx and https://www.tewhatuora.govt.nz/our-health-system/environmental-health/hazardous-substances/lead/lead-poisoning/
Medicine supply news: molnupiravir, ciprofloxacin, testosterone gel
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.
Molnupiravir no longer available
Molnupiravir (Lagevrio), a COVID-19 antiviral, is no longer available in New Zealand. Supplies of molnupiravir expired on 31st January, 2024, and based on clinical advice, Pharmac is not planning to source additional stock. Pharmacies should return any remaining molnupiravir stock to the wholesaler.
In the first half of 2023, the COVID-19 Therapeutics Technical Advisory Group recommended that funding of molnupiravir be removed based on evidence that it had not shown benefit in preventing hospitalisation or death in people at higher risk of severe symptoms with COVID-19 (see Bulletin 70). In July, 2023, following a consultation process (as reported in Bulletin 72), Pharmac revised the access criteria for funded treatment with molnupiravir to certain groups who were unable to take other funded antivirals (see Bulletin 80 for further details).
Nirmatrelvir with ritonavir (Paxlovid) and remdesivir (Veklury) are still available for people with COVID-19 who are at higher risk of severe disease and meet eligibility criteria. A COVID-19 antiviral access criteria assessment tool is available here.
Ciprofloxacin stock update
The currently funded brand of ciprofloxacin (Cipflox) is being discontinued by the supplier; all strengths, i.e. 250 mg, 500 mg and 750 mg, are now out of stock. A replacement brand for the 500 mg tablets is available (Ciprofloxacin – Torrent; as reported in Bulletin 89) and Pharmac has announced that an alternative brand of the 250 mg ciprofloxacin tablets has now been listed on the Pharmaceutical Schedule (stock is expected to become available over the next few weeks). The Ciprofloxacin – Torrent brand of 250 mg and 500 mg ciprofloxacin tablets does not have Medsafe approval, so will need to be prescribed for supply under Section 29 of the Medicines Act 1981. Currently, there is no alternative brand to replace the 750 mg ciprofloxacin tablets.
Testosterone gel to be funded
Pharmac has announced that testosterone transdermal gel (Testogel) will be funded from 1st April, 2024. As mentioned in Bulletin 87, Testogel will be fully funded without restriction. 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.
Rapid antigen test for COVID funding extended
Te Whatu Ora, Health New Zealand, has announced an extension to the funding of rapid antigen tests (RATs) for COVID-19 testing. RATs will now be funded up until 30th June, 2024 (replacing the previous date of the end of February). Pharmacies and practices can continue to order RATs as usual (e.g. via the online portal process).
A list of available RAT collection sites is available here.
Which medicines are most likely to cause hyperglycaemia?
Managing a glucose-control regimen in a patient with diabetes, or those at risk of diabetes, can often be a delicate balancing act, made more difficult when medicines for other conditions need to be added, either acutely or long-term. Being aware of the medicines that are most likely to increase glycaemic levels can make treatment decisions a little easier. Medicine-induced hyperglycaemia is usually mild and reversible upon discontinuation of the medicine, and in many cases, may be temporarily accommodated during short-term treatment. However, for some people, alteration of their existing glucose-lowering regimen, or initiating a glucose-lowering treatment, will be required, particularly if the causative medicine is needed long-term.
A recent Medscape commentary identifies the top five medicines that can increase glucose levels (in patients both with and without diabetes), along with some “honourable mentions”, and offers practical management tips for patients taking these medicines:
- Antipsychotics, particularly clozapine, olanzapine and haloperidol
- Thiazide diuretics
- Statins, particularly higher potency statins such as rosuvastatin
- Beta blockers, particularly metoprolol and atenolol
Also: androgen therapy, antiretroviral therapy, immunosuppressants
When prescribing any of these medicines to a patient with diabetes (or at increased risk of diabetes) in primary care, consider the potential impact that it may have on glucose levels and how this risk can be mitigated. For example, does the risk of hyperglycaemia outweigh the benefit of treatment? Can another medicine be prescribed instead? Is a low dose sufficient? Does a glucose-lowering medicine need to be added to the treatment regimen?
Corticosteroids. The association between high-dose glucocorticoids (corticosteroids) and new-onset diabetes (or worsening of existing diabetes) is well established. The extent of hyperglycaemia depends on multiple factors, including baseline HbA1c level, the dose and duration of treatment and the presence of co-morbidities. If a patient experiences hyperglycaemia with a corticosteroid, and the dose cannot be reduced or withdrawn, it may be appropriate to add metformin (if not already prescribed) with or without a sulfonylurea (e.g. gliclazide, glipizide) to their regimen. In some cases, escalation to other glucose-lowering treatments, including insulin (short-acting) may be required. People with type 1 diabetes may require an increase in their insulin dose. When corticosteroid treatment ceases (with dose tapering), re-assess the need for the sulfonylurea or insulin, if added (or dose increased), as ongoing use may result in hypoglycaemia.
Antipsychotics. The use of antipsychotic medicines can directly influence pancreatic beta cell activity, impairing insulin sensitivity and secretion, and in some cases resulting in apoptosis (cell death). Antipsychotics are also associated with weight gain which, in turn, increases the risk of type 2 diabetes; this is most apparent in antipsychotics which strongly block muscarinic M3 and histamine H1 receptors, e.g. olanzapine, clozapine and chlorpromazine. Haloperidol and quetiapine are also reported to be associated with hyperglycaemia. Ziprasidone, aripiprazole and amisulpride are associated with the least amount of hyperglycaemia and weight gain and may be the most appropriate choices for patients at higher risk. Read more about antipsychotics here.
Thiazide diuretics. Hypokalaemia, dyslipidaemia and increased blood glucose levels are associated with the use of thiazide diuretics, e.g. bendroflumethiazide, chlorthalidone, indapamide. Thiazide diuretic-induced diabetes is possibly due to hypokalaemia, which can in turn decrease insulin secretion and sensitivity in a dose-dependent manner. High doses of thiazides should be avoided in people with diabetes. Regular electrolyte monitoring is recommended for patients taking thiazide diuretics. If hypokalaemia is detected, advise the patient to increase dietary intake of potassium or consider potassium supplementation. Other antihypertensive options may be more appropriate, read more here.
Statins. New-onset diabetes occurs in approximately one in ten patients taking a statin. Statins may contribute to diabetes by decreasing insulin sensitivity and impairing insulin secretion. However, the benefits of statin treatment for cardiovascular disease likely outweighs the potential risk of hyperglycaemia in many cases. People most at risk of developing diabetes while taking a statin are those who already have risk factors such as impaired fasting glucose, elevated HbA1c, or increased BMI. Higher potency statins such as rosuvastatin are associated with a greater risk than lower potency statins such as pravastatin. Read more here.
Beta blockers. Non-vasodilating beta blockers, e.g. atenolol, metoprolol, are more likely to be associated with diabetes (and weight gain and dyslipidaemia) compared with vasodilating beta blockers, e.g. carvedilol. Carvedilol is therefore usually the preferred beta blocker for people with cardiovascular disease, e.g. heart failure, and co-morbid insulin resistance or type 2 diabetes, as there is some evidence that it improves insulin sensitivity and does not adversely affect glycaemic control. Read more about beta blockers here: and look out for an update of this article coming soon.
For further information on the management of diabetes in primary care, see: https://bpac.org.nz/category.aspx?CategoryId=2
Updated MCNZ statement on disclosure of harm
The Medical Council of New Zealand has released updated guidance for doctors on disclosure of harm following an adverse event. This follows a consultation process in the latter half of 2023 to seek feedback on proposed changes (as reported in Bulletin 82). The statement is intended to help clinicians understand the purpose of open disclosure of harm and what is expected of them if patient harm occurs.
Key points include
- Inform the patient (and/or family/whānau) when harm or a near-miss occurs as a direct result of medical care. Information should be delivered as soon as practical in an honest and transparent manner.
- Harm is defined as: “An outcome that negatively affects a patient’s health or quality of life. Sometimes, it could result in death. Harm may or may not relate to the risks discussed during the informed consent process.”
- Near-miss is defined as: “A situation where something occurred during the patient’s treatment that could have, but did not, result in harm to the patient. A near-miss can be the result of an error or a deviation from normal practice.”
- Where possible, review what led to the harm and implement measures to prevent a similar incident from occurring
- When disclosing harm:
- Ensure that a senior clinician is present (ideally this should be the doctor who has lead responsibility for the patient’s care). If the relevant clinician is not available, consider the impact of delaying disclosure against the benefits of timely communication.
- Consider the patient’s and family/whānau’s needs for information and further support, e.g. interpreter, social worker, Māori health provider
- Document details of the harm in the patient records and any disclosures that have been made. This includes the nature of harm, contributing factors, subsequent action(s) taken, details of the disclosure (what was discussed, who was present and what was the patient’s reaction) and any follow-up or ongoing care required.
- Consider whether any third parties should also be informed of the harm and complete relevant documentation
- Ensure the patient and/or family/whānau are aware of available complaints processes
Read the full statement here
NZF updates for February
Significant changes to the NZF in the February, 2024, release include:
- Therapeutic notes have been updated for Angiotensin-II receptor blockers (pregnancy and breast-feeding advice updated), Cough suppressants (Medsafe Alert Communication added about pholcodine – for further information see Bulletin 84) and Hypertension in pregnancy (section updated)
- Updated dosing regimen added to the tranexamic acid monograph for menorrhagia
- Updated contraindications, cautions, hepatic impairment and dosing regimen in the paracetamol monograph
- New caution added to the phenobarbital monograph (caution when switching between brands in epilepsy)
- Pregnancy advice section updated in the mebendazole monograph (anthelmintic for threadworms and other gastrointestinal parasites)
- Medsafe Monitoring Communication link added to the vildagliptin and vildagliptin + metformin monographs on the possible risk of ileus with DPP-4 inhibitors (see Bulletin 91 for further information)
- New monograph added for zonisamide (Section 29, not funded; generally initiated in secondary care), indicated for focal seizures in people with epilepsy
- Pholcodine monograph has been archived, as this medicine is no longer available in New Zealand (see Bulletin 84)
You can read about all the changes in the February release here.
Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Managing dysmenorrhoea in primary care
Dysmenorrhoea, or painful menstruation, affects a significant proportion of menstruating females and is a common cause of absenteeism from education and employment. Given the physical, psychosocial and economic impacts of dysmenorrhoea, it would be expected that managing patients with this condition is a regular occurrence in primary care. However, that is often not the case. A 2016 Australian study found that while most females aged 16 – 29 years experienced dysmenorrhoea at some point, two-thirds did not seek help from health care professionals. Almost 90% reported that they consulted family/friends, social media and the internet for information and advice regarding dysmenorrhoea management, which may expose them to an increased risk of harm and ineffective treatment. Primary health care professionals can ensure that patients know that treatment for dysmenorrhoea is available and encourage those affected to seek help for their symptoms.
A recent article published in the Australian Journal of General Practice reviews the management of dysmenorrhoea in primary care. It is recommended that patients with symptoms of dysmenorrhoea are initiated on regular NSAIDs and/or a combined oral contraceptive, even while possible secondary causes are being investigated. Non-pharmacological strategies such as regular exercise and heat packs may be useful adjuncts to pharmacological treatment.
Do you believe dysmenorrhoea is under-reported among your patients? How do you evaluate and manage a patient presenting with painful menstruation? What non-pharmacological interventions do you suggest to patients with dysmenorrhoea?
- Dysmenorrhoea generally involves pelvic or lower abdomen pain (cramping) that occurs before or during menstruation. It typically lasts 8 to 72 hours and may be associated with other symptoms such as bloating, nausea, vomiting, diarrhoea, fatigue and insomnia.
- Dysmenorrhoea can be described as primary (idiopathic) or secondary (resulting from the presence of pelvic pathology, e.g. endometriosis). Primary dysmenorrhoea typically develops within 6 – 12 months of menarche, while secondary dysmenorrhoea can develop at any time, in relation to the causative condition.
- Risk factors for primary dysmenorrhoea include younger age (< 30 years), menarche occurring before age 12 years, longer or heavier menstrual bleeding, low or high body mass index (< 20 or > 30 kg/m2), nulliparity, smoking, premenstrual symptoms, previous pelvic inflammatory disease, psychological disorders or previous sexual assault. Pain sensitisation (due to the presence of other chronic pain conditions) may also be contributory. Protective factors for primary dysmenorrhoea include use of an oral contraceptive pill, increasing age, increasing parity and exercise.
- Symptoms suggestive of secondary dysmenorrhoea include worsening pelvic pain, painful intercourse, vaginal discharge, abnormal bleeding or insufficient response to first-line treatment options, i.e. NSAIDs, combined oral contraceptives (see below)
- Dysmenorrhoea is a clinical diagnosis based on symptoms and medical history. Consider the possibility of pregnancy or infection in patients who are sexually active.
- N.B. A pelvic examination and referral for an ultrasound may be required in patients who present with symptoms and signs suggestive of secondary dysmenorrhoea
- Do not delay initiating treatment when distinguishing between primary or secondary dysmenorrhoea, or investigating potential secondary causes, as standard treatment is often effective for both conditions
- A NSAID (e.g. ibuprofen, naproxen) is usually first-line for managing patients with dysmenorrhoea. Patients should begin use one to two days before menses and continue treatment until two to three days after menstruation has started. A loading dose on the first day of treatment is associated with lower reported pain scores compared to conventional NSAID dosing (see NZF for specific NSAID dosing regimens). Patients who experience adverse gastrointestinal effects should be advised to take the NSAID with food, or consider adding a proton pump inhibitor (e.g. omeprazole). A COX-2 inhibitor, e.g. celecoxib, may be better tolerated.
- Continuous use of a combined oral contraceptive is also an effective treatment option for patients with dysmenorrhoea who are not planning pregnancy. Combined oral contraceptives inhibit ovulation and endometrial thickening; this reduces prostaglandin, progesterone and vasopressin production, which in turn limits uterine motility and cramping.
- Progesterone-only contraceptives that inhibit ovulation (e.g. oral desogestrel; not funded, depot medroxyprogesterone acetate; Depo-Provera, levonorgestrel intrauterine system; Mirena) have also been used for dysmenorrhoea
- In New Zealand, tranexamic acid can be considered in patients who experience menorrhagia (heavy menstrual bleeding) associated with dysmenorrhoea
- Regular exercise (e.g. 45 – 60 minutes at least three times per week) is associated with a clinically significant decrease in dysmenorrhoea symptoms. This effect is likely due to increased local blood flow, a release of endorphins and a general decrease in the patient’s stress and anxiety levels.
- There is some evidence suggesting the application of heat packs is comparable to ibuprofen in the management of dysmenorrhoea and may be more effective than paracetamol. This effect is also likely due to increases local blood flow and tissue oxygenation.
- High frequency transcutaneous electrical nerve stimulation (TENS) and physiotherapy may also provide symptom relief for some patients with dysmenorrhoea
- Patients with suspected primary dysmenorrhoea who do not have adequate symptom control after three to six months of pharmacological treatment should be referred to a gynaecologist for further investigations and treatment, e.g. surgical intervention
Christensen K. Dysmenorrhea: An update on primary healthcare management. Aust J Gen Pract 2024;53:19-22. doi:10.31128/AJGP/04-23-6815
For further information on the diagnosis and management of endometriosis in primary care, see: https://bpac.org.nz/2021/endometriosis.aspx
For further information on managing heavy menstrual bleeding, see: https://bpac.org.nz/2019/bleeding.aspx
This Bulletin is supported by the South Link Education Trust
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