Published: 24 July, 2020
Contents
Return to stat dispensing from 1 August
Three-monthly dispensing will be reinstated for most medicines at 11.59 pm, Friday 31 July, 2020. Exceptions due
to supply issues include:
- Paracetamol, which will continue to be dispensed monthly (see: paracetamol supply issue ongoing)
- 12 additional medicines which will continue to be dispensed monthly (including amlodipine, clomipramine, oestradiol
patches, long-acting ibuprofen and ipratropium)
- Four oral contraceptives which will continue to be restricted to three-monthly dispensing, while other oral contraceptives
return to six-monthly dispensing
N.B. Medicines that were already on monthly dispensing before the temporary restrictions were applied (27 March),
will continue to be dispensed monthly.
These restrictions and affected medicines are subject to change, as supply continues to be disrupted
globally. Further information and a list of the medicines with dispensing restrictions in place
can be found here.
Paracetamol supply issue ongoing
PHARMAC reports that there is an ongoing supply issue with
500 mg paracetamol tablets. API Consumer Brands, who supply the sole-subsidised brand, Pharmacare,
have advised that due to COVID-19 there continues to be decreased manufacturing capacity at overseas plants and also difficulties getting stock into New Zealand due
to limited air travel. This means that restrictions placed on dispensing of paracetamol tablets on 9 March, 2020, will remain in place. PHARMAC is working to source
more paracetamol tablets as the current stock is likely to run out by the end of July.
Peer group discussions
Are you part of a peer group? Did you know that we have a catalogue of resources to assist groups or individuals in examining an aspect of primary care practice.
We collate articles within a theme, provide a short summary, and pose questions for consideration and discussion to get you started. These resources are
really useful for GP peer groups, or for any primary care clinician group – we hear that they are popular for medical student study groups too.
You can find all of our peer group discussion topics here: https://bpac.org.nz/peer-group-discussions
Upcoming MMR campaign
Regional DHB-led campaigns aimed at improving measles immunity in those aged 15-30 years are due to be launched soon.
Starting in late July, 2020 and extending until August, 2021, the aim is to increase awareness of the need for MMR
vaccination and DHBs will utilise approaches in the community as well as in general practices. Additional stocks of
MMR vaccine have been obtained. The campaign will focus on those aged 15-30 years, however, the Ministry of Health encourages
practices to continue working to ensure that those outside of this age range also receive two doses of MMR. Practices
have already been recalling people born in 1969 or after and this should continue. Many in this age group may have
been incompletely vaccinated or do not know their vaccination history. If the person’s immunisation record is incomplete,
the Ministry states that having a third dose of MMR is not associated with any additional safety issues.
Paper of the week: Safety and effectiveness of anticoagulants in general practice
The use of anticoagulants has changed since the introduction of direct oral anticoagulants (DOACs). Initial studies of safety and effectiveness were criticised as not being applicable
in the real-world, however, despite several studies aiming to address this, there has still been a lack of evidence on participants in a general practice setting.
Most studies have concluded that DOACs have similar efficacy as warfarin and are probably safer, but it is queried whether these results are directly relevant to
general practice due to the influence of practical issues such as individualisation for each patient, compliance, treatment changes and how to manage non-major bleeding.
Features of the study
A French multicentre prospective cohort study, the Comparison of Accidents and their Circumstances with Oral
Anticoagulants (CACAO) study was set up to assess the safety of over 7000 anticoagulated general practice patients.
Patients from phase one of the study were selected for follow-up in phase two.
The phase two study reported here
monitored over 3000 general practice patients who were taking an oral anticoagulant because
of non-valvular atrial fibrillation or for the secondary prevention of venous thromboembolism.
Every patient over age 18 years who was taking an oral anticoagulant was eligible for
the study. There were 1946 patients in the warfarin group and 1136 taking a DOAC and
the patient characteristics between the groups were felt to be similar, with further
matching performed using a propensity score (this included a wide range of clinical characteristics).
The aim was to compare the safety and effectiveness of warfarin (a vitamin K antagonist)
with that of DOACs.
Patients were followed as per their normal care (seen three-monthly) for one year by their general practitioners.
Data was collected on the treatment for each patient, any changes to this treatment, thromboembolic events, bleeding
and any deaths.
What did the results show?
The study included 3,082 patients cared for by 463 general practitioners. At 1 year:
- 42 patients (1.7%) had experienced an arterial or venous event (including ischaemic stroke – 14, myocardial
infarction – 11, DVT – 9, PE – 5)
- 151 (6.1%) had experienced bleeding, including 47 (1.9%) who experienced major bleeding
- 105 (4.1%) had died
No significant difference was found between the warfarin and DOAC patient groups regarding arterial or venous
events, or major bleeding. Those patients taking warfarin had a lower risk of overall bleeding (hazard ratio = 0.65;
95% CI, 0.43–0.98) but twice the risk of death from all causes (hazard ratio = 1.98; 95% CI, 1.15–3.42).
How do the results compare with existing studies?
The population studied was similar to other cohort studies with a mean age of 74 years in this study and 70 years in previous ones. More patients had renal impairment
than in other studies, most likely due to the small number of exclusions of participants from the study.
The overall incidence rate of any bleeding, major bleeding and mortality were similar to that shown in previous cohort studies.
A higher rate of death in patients taking warfarin has been a consistent finding in the phase III trials for DOACs and in previous real-world cohort studies.
However, the hazard ratio in this study was more than found in some others and it was statistically significant. The authors explained that this higher risk was
due to sudden deaths, deaths from other causes such as infection or malignancy and not to deaths from bleeding. They suggest that other factors unique to this
study are responsible, including that recruitment to the study was from primary care and that the results may lack statistical power. The authors suggest that
further research is needed to examine the reasons for the higher mortality rate in patients on warfarin.
Another difference from other studies (phase III trials and cohort) was a lower risk of any bleeding in the warfarin group compared with the DOAC group.
It was hypothesised that this may have been due to the recording of minor bleeding and to the prospective design of the study – clinicians being more watchful
in those patients receiving DOACs as they have been heavily marketed in France. It also seems likely that the patients on warfarin were monitored
more closely, simply due to being in the trial – so that “usual care” may not have actually been “usual care”.
Are these results applicable to a New Zealand general practice setting?
Yes, they probably are. Anticoagulation is managed in a very similar way in France to New Zealand and patients
are required to be registered with an individual general practitioner. There was good continuity of care – the investigator
was the patient’s usual doctor in 95% of cases. The cohort requiring anticoagulation appears to be clinically similar
to that experienced in a New Zealand setting.
The limitations of the study included:
- the prospective cohort design (which is likely to have had an impact on how the patients were monitored)
- that complete initial matching between the two groups was not possible
- and the low statistical power relating to the small numbers of bleeding and arteriovenous events.
This Bulletin is supported by the South Link Education Trust
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