Published: 14 April, 2023
Contents
Coming soon: Vulval and vaginal cancers – early detection and referral
Vulval and vaginal cancers are the least common types of gynaecological cancer in New Zealand. Most vulval cancers are squamous cell carcinoma and are usually related to high-risk HPV infection or vulval inflammatory disorders such as lichen sclerosus. The majority of primary vaginal cancers are also squamous cell carcinoma; however, these are rare. Instead, most cancers affecting the vagina are secondary, involving metastases from another site such as the cervix.
As part of the gynaecological cancer series, supported by Te Aho o Te Kahu - Cancer Control Agency, articles on the early detection and referral of patients with suspected vulval or vaginal cancer will be available soon on our website, with accompanying B-QuiCK summaries.
Read all the articles in the gynaecological cancer series, here.
The B-QuiCK summaries can also be read here.
Can you help? Atrial fibrillation audit
Can you help evaluate an electronic decision support tool designed to assist primary care clinicians with management of atrial fibrillation?
An electronic decision support tool has been developed to provide an individualised checklist for treatments known to reduce the risk of stroke, myocardial infarction, heart failure and bleeding in patients with atrial fibrillation who are managed in primary care.
The tool was created in collaboration with cardiologists and stroke physicians from the National Cardiac and Stroke Networks, and is based on recommendations from international clinical practice guidelines. It is designed to be quick and easy to use as part of routine care. This tool is now available to all practices that use MedTech-32 or Evolution.
To determine whether and how this atrial fibrillation clinical decision support tool influences treatment decisions, and to identify possible ways to improve it, an evaluation audit will be undertaken with anonymised outcomes data from national health databases.
If you choose to participate in this audit, you will be reimbursed $200 for each patient included in the audit (minimum of five patients) with funding from the Health Research Council (HRC) of New Zealand. This funding also acknowledges that additional time may be needed to adjust the patient’s treatment regimen. At the end of the audit there will be a short survey to complete within a three-month window to provide feedback on your impressions of the decision support tool. A register of your patients with atrial fibrillation can be provided if you choose to participate.
To sign up for the evaluation audit, please contact b-safe@bestpractice.org.nz or click here for further information.
Professor Ralph Stewart, Emeritus Professor Murray Tilyard, Professor Anna Ranta, Professor Richard Troughton
New digital Report to Coroner feature in Death Documents coming in April
The Ministry of Justice, in collaboration with Te Whatu Ora, Health New Zealand and the
Department of Internal Affairs, have developed a new Report to Coroner feature within the
secure digital tool, Death Documents. The aim is to improve the death reporting process and provide additional guidance for medical and nurse practitioners to increase confidence when deciding to report a death to the coroner. The Report to Coroner feature will be available from 20 April, 2023.
Features to make the death reporting process easier include:
- The addition of ‘smart logic’ questions which will determine whether a death must be reported to the coroner, or whether it is appropriate to issue a Medical Certificate Cause of Death (MCCD)
- Clear explanations of key terms and legislation that can be accessed while completing a report
- Improved questions which will allow the reporting practitioner to include greater detail early on, reducing the need for follow-up contact to be made and enable the coroner to make decisions earlier
- The ability to transfer information submitted in a Report to Coroner to a MCCD within Death Documents if the initial report is deemed unnecessary on advice from the coroner
Using Death Documents
Death Documents is a secure digital tool that allows medical and nurse practitioners to complete death-related forms online. To use Death Documents, a RealMe login (username and password) and Medical Council Number or Common Person Number (CPN) is required. For practitioners without a RealMe login, this can be created quickly when registering for Death Documents.
Practitioners with a verified RealMe (i.e. with photo identification) can also draw down patient information from the NHI database to pre-populate the forms which will make completing them faster.
Alert Communication: Increased risk of neurodevelopmental disorders with topiramate
Medsafe has issued an Alert Communication on the use of topiramate in pregnancy. As reported in Bulletin 62, there is evidence of an increased risk of neurodevelopmental disorders in children exposed in utero to topiramate.
Topiramate should only be prescribed to patients with epilepsy who are pregnant if the benefits of treatment outweigh the risks. Patients taking topiramate for epilepsy should be referred for specialist advice if they are considering becoming pregnant (or become pregnant while taking it). Prescribing topiramate for migraine prophylaxis in patients who are pregnant is contraindicated.
For further information on the use of topiramate in pregnancy for health professionals (and patients), read the full Medsafe communication here.
For further reading, also see: “Balancing the benefits and risks of prescribing antiepileptic medicines in women”
Permethrin supply issue
A supply issue affecting stock of permethrin products has been announced by Pharmac. Permethrin 5% cream (Lyderm) is no longer available due to the supplier, API Consumer Brands, leaving the New Zealand market.
Stock of permethrin 5% lotion (A-Scabies) is currently low due to increased demand. More stock is expected to arrive within two weeks, however, stock is expected to remain in short supply for the coming months. Pharmacists are recommended to contact the supplier (AFT Pharmaceuticals) to directly source supply.
Oral ivermectin (funded with Special Authority approval) may be a suitable alternative to permethrin if permethrin is unavailable, or when topical treatment is not effective or tolerated.
For further information on the treatment of scabies, see: https://bpac.org.nz/2022/scabies.aspx
Reminder about additional COVID-19 boosters
From 1 April, 2023, people aged 30 years and older and those at higher risk of severe illness from COVID-19 have been eligible for an additional COVID-19 booster (irrespective of the number of prior boosters received). The bivalent Comirnaty 15/15 mcg grey cap vaccine will be used for booster doses.
As reported in Bulletin 69, people can receive an additional booster if they have completed their primary course and it has been at least six months since their previous dose or positive COVID-19 test. Clinicians or vaccinators can, however, use their discretion with regard to the spacing of booster doses following informed consent from the recipient, but there should be a minimum of five months between the primary course and first booster, four months between booster doses and a minimum of three months after infection with COVID-19.
Check in with your patients who meet eligibility criteria to ensure that they are aware an additional booster dose is available. The influenza vaccine can also be given concomitantly.
Observation periods after influenza vaccination
The Immunisation Advisory Centre (IMAC) report in the 2023 Flu Kit that the observation period following influenza vaccination alone, or after concomitant influenza and COVID-19* vaccination is 20 minutes. The observation period after concomitant influenza and a non-COVID-19 vaccine is also 20 minutes.
The observation period can be reduced to five minutes after influenza vaccination alone, or 15 minutes after concomitant influenza and COVID-19 vaccination for people who meet all
the following criteria:
- Aged ≥ 13 years
- No history of severe allergic reactions
- Have been assessed for immediate adverse reactions to the vaccine(s) (i.e. for five minutes)
- Have another adult with them for 20 minutes after vaccination
- Have been advised not to drive, skate, scoot, bike or operate machinery until 20 minutes after vaccination
- Know when and how to seek advice after vaccination and can contact emergency services if required
*The observation period following COVID-19 vaccination alone is 15 minutes
Lamotrigine updates
Logem lamotrigine: change in packaging
Viatris has advised of a change in packaging of the Logem brand of lamotrigine 25 mg, 50 mg and 100 mg tablets. There is no change to the formulation, manufacturer or manufacturing method. This change in packaging is due to the rebranding from Mylan to Viatris. Logem is the currently funded generic brand of lamotrigine 25 mg, 50 mg and 100 mg tablets.
Short-dated stock of Arrow-Lamotrigine
Pharmac has advised of short-dated stock of Arrow-Lamotrigine 25 mg and 50 mg tablets (expiring 31 May, 2023) due to delays in manufacturing; 100 mg tablets are unaffected. This brand of lamotrigine is an exceptional circumstances product and is funded for people who were taking it prior to the brand change to Logem in 2019.
New stock is expected to arrive by mid-May. Pharmac do not anticipate existing short-dated supplies to be exhausted before this time.
To reduce the risk of patients taking expired lamotrigine tablets, pharmacists are encouraged to be aware of the short-dated stock when dispensing, and to consider limiting the number of affected tablets dispensed (if appropriate).
Consultation to seek information on the role of molnupiravir for the treatment of COVID-19
Pharmac has issued a consultation to seek wider feedback on the ongoing need for molnupiravir in New Zealand. Evidence is emerging that molnupiravir may no longer be effective for the treatment of COVID-19, particularly against current circulating strains of SARS-CoV-2, e.g. Omicron, and in highly vaccinated populations. In no longer recommended by the COVID-19 Therapeutics Technical Advisory Group for the treatment of COVID-19 in non-hospitalised patients due to a lack of evidence of benefit. However, there were concerns that the trial population did not consider older people in high-risk groups who may be unable to take Paxlovid. Feedback from primary care clinicians in New Zealand has been that removal of funded access may increase inequities and that remdesivir is impractical in a community setting (administered by daily IV infusion over three days).
Read more about the proposal here.
Information gathered from the consultation will be used to inform a proposal to either remove the funding of molnupiravir and delist it from the Pharmaceutical Schedule, or to restrict funding to certain groups who may still be expected to benefit from its use. Submissions are due by 2 May, 2023.
NZF updates for April
Significant changes to the NZF in the April, 2023, release include:
You can read about all the changes in the April release here. Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Revisiting the link between hormonal contraception and breast cancer risk
Previous studies have established that patients taking combined oral contraceptives are at slightly increased risk of breast cancer. Progestogen-only contraceptives have been considered an alternative option for patients where oestrogen is not recommended or contraindicated, however, the data regarding breast cancer risk and progestogen-only contraceptives has been inconsistent. A recently published study based in the United Kingdom (UK) now suggests that the risk of developing breast cancer in patients who take progestogen-only contraceptives is comparable to those taking combined hormonal contraceptives.
Should we be concerned about these findings? While it is recommended that the new information is included when discussing the risks and benefits of contraceptive options with patients, the UK-based Faculty of Sexual and Reproductive Healthcare (FSRH) have not currently recommended any major changes to clinical practice in response to the study.
Best practice tip: The absolute risk of breast cancer with progestogen-only contraceptive use is still very small, especially in younger patients with no familial breast cancer risk. The decision to prescribe any type of hormonal contraception should consider this low risk in the context of the possible benefits of use, e.g. reduced risk of an unplanned pregnancy and other non-contraceptive benefits such as reducing the risk of endometrial and ovarian cancers.
Read more
- A nested case-control study was undertaken, including 9,498 patients aged 20 to 49 years taken from UK Clinical Practice Research Datalink (CPRD) primary care database who were diagnosed with invasive breast cancer between 1996 and 2017. Over 18,000 matched controls were also identified.
- The observation period for each case was defined as starting from either 1 January, 1995 (to encompass the previous 12 months of medical records) or the date of entry into the CPRD database (whichever was later), and ended at date of diagnosis for invasive breast cancer
- Patients were considered to be “current users” of hormonal contraceptives if they had received any prescription within 12 months of their breast cancer diagnosis, e.g. combined oral contraceptive, progestogen-only oral contraceptive, progestogen intrauterine device (IUD), progestogen depot or progestogen injection throughout the observation period; those who did not were considered “non-users”
- The average age of patients in this study was 43 years and the average observation period was 7.3 years (range 1 to 22 years). Most patients (77%) were aged between 40 – 49 years. Only 2% of patients were aged under 30 years and 21% were aged between 30 – 39 years.
- A total of 4,195 patients (44%) and 7,092 controls (39%) received a prescription for any hormonal contraceptive over the observation period. Two-thirds of patients (7,511/11,287) received only one form of hormonal contraception during this period.
- Patients who received any form of hormonal contraception had an increased risk of invasive breast cancer (adjusted odds ratio [OR] 1.25) compared to patients who had never taken hormonal contraception. This increase was similar across all forms of hormonal contraception, and statistically significant for each except the progestogen implant (small sample size: 87 cases and 161 controls).
- For patients with invasive breast cancer, the average time between their last hormonal contraceptive prescription and diagnosis was three years
- There was no significant increase in breast cancer risk for patients who were prescribed a non-hormonal intrauterine device
- Patients who received their last prescription of hormonal contraception more than five years earlier had a lower risk of invasive breast cancer compared to those whose last prescription was within the last 12 months (adjusted OR 1.15 vs 1.33)
- In patients aged 16 to 20 years, the estimated 15-year absolute risk of breast cancer increased from 0.084% to 0.093% if they took an oral combined or progestogen-only contraceptive (an additional eight cases per 100,000 users). For patients aged 25 to 29 years the increase in 15-year absolute risk was from 0.50% to 0.57% (an additional 61 cases per 100,00 users) and for patients aged 35 to 39 years it increased from 2.0% to 2.2% (an additional 265 cases per 100,000 users).
- A meta-analysis was also conducted on published studies from January 1995 to November 2022 regarding progestogen-only contraceptives and breast cancer risk. When these findings were combined with the results of the nested case-control study, the authors confirmed an increased relative risk of breast cancer in patients who took any form of progestogen-only contraceptive.
- A possible limitation was an incomplete prescription history, e.g. patients prescribed a hormonal contraceptive before being enrolled in the database. The authors also acknowledged that patients who take regular hormonal contraceptives may be more likely visit their general practitioner and therefore increase the chances that breast cancer, if present, is detected.
Fitzpatrick D, Pirie K, Reeves G, et al. Combined and progestagen-only hormonal contraceptives and breast cancer risk: A UK nested case–control study and meta-analysis. PLoS Med 2023;20:e1004188. doi:10.1371/journal.pmed.1004188
For further information on the prescribing of hormonal contraceptives in primary care, see: https://bpac.org.nz/2021/contraception/oral-contraceptives.aspx
This Bulletin is supported by the South Link Education Trust
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