Published: 18 November, 2022
New: Liver function tests in primary care
Liver function tests (LFTs) are among the most commonly requested laboratory investigations in primary care. However, as with all other laboratory tests, it is essential that clinicians consider whether LFTs are being requested for the right patient at the right time, and have a clear understanding of how results will be interpreted based on the specific clinical context.
This is a comprehensive resource on understanding and interpreting LFTs (and yes, we do discuss the use of this misnomer), along with a spotlight on the key causes of liver disease: metabolic-associated fatty liver disease, alcohol-related liver disease and hepatitis B- and C-related liver disease.
Need your answer now? B-QuiCK summary available here.
In case you missed it: Chronic kidney disease; the canary in the coal mine
Chronic kidney disease (CKD) is a growing issue in New Zealand. Māori and Pacific peoples are overrepresented in our CKD statistics which is concerning as it is a major driver of cardiovascular disease (CVD), and these groups are already disproportionately affected by risk factors such as diabetes, obesity and hypertension. Early detection of CKD can be achieved via regular testing of at-risk people; this permits timely interventions to lower CVD risk and slow or prevent the rate of kidney function decline.
This is an update of a previous bpacnz article that includes considerations when interpreting eGFR and ACR results and updated blood pressure targets, as well as discussing the place of SGLT-2 inhibitors in CKD patients and the usefulness, or not, of low protein diets.
World Antimicrobial Awareness Week (WAAW) – 18th – 24th November
The theme for this year’s WAAW is “Preventing antimicrobial resistance together”. Details of this global initiative from the World Health Organization are available here.
WAAW is a chance for healthcare professionals to reflect, and act, on the multidisciplinary responsibility for antimicrobial stewardship (AMS). The overarching goal of AMS is to improve the appropriate use of antimicrobials and minimise antimicrobial-related harms, including resistance and adverse effects.
General principles of antimicrobial stewardship include
- In most cases, only prescribe antibiotics if symptoms are likely to be due to a bacterial infection and:
- Are significant or severe; or
- Have a high risk of complications; or
- Are not resolving or are unlikely to resolve
- Follow local guidelines and select the recommended antibiotic, dose, route and duration
- Reserve broad spectrum antibiotics for when narrower spectrum options are not appropriate
- Talk with patients about responsible use of antibiotics, including the potential harms of using an antibiotic when it is not indicated
The Pharmaceutical Society of New Zealand (PSNZ) are taking part in an “Antibiotic Amnesty” as part of WAAW. People are invited to return any unused antibiotics to their community pharmacy for disposal.
For resources and further information on this initiative, click here
Local resources for antibiotic awareness including posters and patient education are available from the Ministry of Health website.
The bpacnz Antibiotics Guide
is a widely used resource among primary care clinicians to assist in making treatment choices for infections commonly managed in the community. The Guide is currently undergoing a full revision and we will let you know when the new version is available.
NZCSRH abortion training modules are now live
The New Zealand College of Sexual and Reproductive Health (NZCSRH) has developed a series of four abortion theory training modules with support from the Ministry of Health. This includes information for healthcare professionals on: (1) Consultation – communication and decision making, (2) early medical abortion using mifepristone and misoprostol, (3) early surgical abortion using vacuum aspiration and (4) point of care ultrasound. The development of these training modules was supported by bpacnz and they are hosted on our website. Any questions about the content of the modules should be directed to NZCSRH: email@example.com
Click here to access the training modules.
- The introduction section provides an overview of abortion in Aotearoa New Zealand and requirements for becoming an abortion service provider
- Information in the four training modules is presented across a variety of formats, including text, narrated videos and presentations and downloadable content
- Health practitioners who wish to provide abortion services can test their understanding and knowledge of the key points for each module by completing a quiz after reviewing the content; you must log-in to your Mybpac account to complete the quiz, or create a new account
- The Module 1 quiz (Consultation – communication and decision making) must be successfully completed before attempting quizzes for the other three modules.
- Once a quiz has been successfully completed (you may have unlimited attempts), a certificate can be downloaded
- To provide feedback for this training, complete the following form and send it to firstname.lastname@example.org
Changes to COVID-19 second booster vaccine eligibility
From today (18th November, 2022), Māori and Pacific peoples aged 40 – 49 years will be eligible to receive a second COVID-19 booster vaccine. People will still need to wait six months from their first booster dose. It is estimated more than 63,000 people will be eligible for the second booster vaccine. Read more about second boosters here.
As reported in Bulletin 53, the second COVID-19 booster vaccine is also available for all people aged over 50 years and for those aged over 30 years who work in health, aged and disability care.
Access to PCV13 pneumococcal vaccine to be widened
From 1 December, 2022, pneumococcal conjugate vaccine PCV13 (Prevenar 13) will be included as part of the childhood immunisation schedule, instead of the currently funded PCV10 (Synflorix). The timings of PCV13 dosing are identical to the PCV10 regimen. PCV13 is currently only funded for people who meet high-risk criteria.
Infants who have received one or more doses of PCV10 will be able to complete the course with PCV13. The Immunisation Handbook will be updated to reflect these changes.
Vaccinators should start administering PCV13 for childhood immunisations immediately from 1 December, 2022. Use of PCV10 after 1 December, 2022 is considered a medication error and if this occurs The Immunisation Advisory Centre (IMAC) should be contacted on 0800 IMMUNE for advice. However, PCV10 will continue to be listed in the Pharmaceutical Schedule and if administered, will be funded. Any unused PCV10 can be returned to ProPharma.
IMAC has produced both a written resource and a webinar explaining the change from Synflorix (PCV10) to Prevenar (PCV13) for health professionals.
Pneumococcal disease refers to illnesses caused by the bacterium Streptococcus pneumoniae, of which there are more than 90 different serotypes. Local pneumococcal disease is a frequent cause of respiratory illnesses such as otitis media, bronchitis and sinusitis. Invasive pneumococcal disease is a more serious illness that can occur when S. pneumoniae invades normally sterile tissue, e.g. pneumonia, meningitis or bacteraemia. Reports to the Medical Officer of Health showed that between January, 2022 and June, 2022, 19 people died with invasive pneumococcal disease. Six of these people tested positive for S. pneumoniae serotype 19A, which is linked to antibiotic resistance and associated with more severe illness.
Māori and Pacific peoples are disproportionately affected by invasive pneumococcal disease in New Zealand. Compared to New Zealand Europeans, rates of invasive pneumococcal disease are four times higher for Māori and five times higher for Pacific peoples.
Vaccination is the only method for preventing invasive pneumococcal disease. Children currently receive doses of the PCV10 vaccine at aged six weeks, five months and 12 months as part of immunisation schedule. Children at high risk of pneumococcal disease can receive an extra dose at three months. People at high risk of pneumococcal disease aged over five years can also receive up to four funded doses. The PCV13 vaccine covers the same S. pneumoniae serotypes* as the PCV10 vaccine, i.e. 1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F and 23F but provides additional protection against S. pneumoniae serotypes 3, 6A, and 19A.
*PCV10 vaccine provides some cross-reactive protection against S. pneumoniae serotype 19A in children aged under five years
Pamol brand of liquid paracetamol now available
As previously reported in Bulletin 58, changes are being made to liquid paracetamol as the supplier of the Paracare brand is leaving the market. On 1 November, 2022, the funded brand of paracetamol 250 mg/5 mL oral liquid changed to Pamol; remaining stock of Paracare may be used up first by some wholesalers or pharmacies.
A pamphlet for consumers detailing the change from Paracare to Pamol is available here
Key differences between Pamol and Paracare Double Strength:
- Pamol is a smaller bottle size (200 mL compared to 1000 mL for Paracare)
- Pamol is orange flavoured but colour-free (Paracare Double Strength is orange flavoured and orange coloured); N.B. this means that both strengths of liquid paracetamol (120 mg/5 mL and 250 mg/5 mL), as well as the currently funded brand of ibuprofen will now be colour-free, so this similarity should be highlighted to caregivers, along with a reminder to read labels carefully, to avoid dosing errors
To read more about upcoming changes to liquid paracetamol, click here.
Funding restrictions removed from Zoledronic acid
Pharmac is removing all Special Authority funding restrictions from zoledronic acid from 1 March, 2023, e.g. there will no longer be a requirement for bone mineral density scanning. The bisphosphonate zoledronic acid is indicated for people with osteoporosis and Paget disease, as well as some cancer-related indications. It is given as an intravenous infusion over 15 minutes and can be administered by health professionals as part of the community-based infusion service.
For further information about prescribing bisphosphonates, see: https://bpac.org.nz/2019/bisphosphonates.aspx
Effect of the COVID-19 pandemic on healthcare services: a HQSC report
The Health Quality & Safety Commission has released Part 2 of its investigation into the effect of the COVID-19 pandemic on healthcare services in New Zealand.
- Part 1, published in December 2021, focused on the effects of the COVID-19 pandemic on aspects of the functioning of the New Zealand health system, including the impact on primary care, immunisations and cancer screening and delays in elective procedures and cancer care. An executive summary can be read here.
- Part 2 expands on some of the aspects covered in part 1, and examines the impact that the pandemic had on mental health, healthcare workers and experience of care for people with a disability. An executive summary can be read here.
Paper of the Week: Before prescribing a PPI, ask yourself PPWhy?
Proton pump inhibitors (PPIs) are widely used in New Zealand and use is increasing over time. In 2020, omeprazole was the third most commonly dispensed medicine in New Zealand. A recent observational study published in the British Journal of General Practice, including nearly 150,000 patients across 27 general practices in the Netherlands from 2016 to 2018, found that more than half of patients prescribed a PPI had an inappropriate indication. The study also found a large number of patients continued to be prescribed PPIs beyond their recommended duration of use.
PPIs are generally safe and well tolerated, however, long-term use is associated with an increased risk of adverse outcomes, e.g. Clostridium difficile colitis, osteoporosis, kidney disease. Continuing PPI use without a current clinical indication exposes patients to these risks unnecessarily and may add to the complexity of their medicines regimen, increasing the risk of interactions and poor adherence.
- A total of 148,936 patients aged 18 years or older from 27 general practices across the Netherlands were included in this study (from 2016 to 2018)
- 16% (23,601) of patients started a PPI; mean age was 57 years, 59% were female
- At the time of the PPI prescription, 39% (9,281) of patients used non-selective NSAIDs, 13% (3,048) used low-dose aspirin. Antacids were prescribed before initiating a PPI in 4% (884) of patients and H2-receptor antagonists in 3% (801) of patients.
- 44% (10,466) of patients prescribed a PPI had a valid indication; 20% of patients were prescribed a PPI for upper gastrointestinal condition and 23% for ulcer prophylaxis
- PPI use was inappropriately continued (despite an initial valid indication) in 32% of patients who were prescribed a short-course treatment for dyspepsia, and in 11% of patients prescribed a PPI for ulcer prophylaxis
- Predictors of inappropriate prescribing were increasing age (odds ratio [OR], 1.03), use of non-selective NSAIDs (OR, 5.15), P2Y12 antagonists (OR, 5.07), COX-2 inhibitors (OR, 3.93) and low dose aspirin (OR, 3.83)
Consider the following points when prescribing PPIs:
- Discuss the expected duration of treatment with the patient so they are aware of whether the PPI is intended for short or long-term use. Instructions on stepping down treatment may be included as part of the initial prescription.
- Once there is no longer a clinical indication, trial stopping the PPI using a step-down protocol
- Remind patients about lifestyle changes to help manage symptoms
- If PPIs are prescribed prophylactically, ensure that the PPI is discontinued when the other medicine is stopped
- Review the dose periodically and step down to a lower maintenance dose if appropriate or assess whether treatment can be stopped completely. A reminder to review PPI use can be set in the PMS.
For further information on PPIs, see: https://bpac.org.nz/report/snippet/ppi.aspx and https://bpac.org.nz/2019/ppi.aspx
Koggel LM, Lantinga MA, Büchner FL, et al. Predictors for inappropriate proton pump inhibitor use: observational study in primary care. Br J Gen Pract 2022;:BJGP.2022.0178. doi:10.3399/BJGP.2022.0178
For further reading, also see: “Overprescribing, functional dyspepsia and PPWhy’s? A NB Medical Education blog.
This Bulletin is supported by the South Link Education Trust
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