Published: 14 May, 2021
Contents
eBPJ articles now online
All of the articles from our most recent edition of eBPJ are now loaded on our website as individual resources. You can read the articles on
your desktop or mobile device, make a new comment or join a discussion thread and download or save as a pdf version.
To check out all our new arrivals, click here.
Antidepressants article revised
We have completed a revision of our 2017 article on the role of
medicines in the management of depression in primary care. Non-pharmacological interventions
are the mainstay of treatment for patients with depression. The addition of pharmacological treatment is usually appropriate for patients with moderate to
severe depression or if other interventions have been inadequate. We offer guidance on how to select from the range of funded antidepressant medicines,
depending on the patient's specific needs.
As with all our revised articles, this article contains a box at the beginning to highlight key information that has been updated.
No new patients on cilazapril
A reminder that, as of 1 May, no new patients should be prescribed cilazapril and all existing patients who remain on cilazapril require their prescription
to be endorsed. If a clinician has not endorsed the prescription, pharmacists are able to annotate the prescription provided there is a record of a recent
prescription for that patient. See more information from
PHARMAC here.
We have revised our article "Prescribing ACE inhibitors: time to reconsider
old habits" to reflect these changes, and updated guidance on selecting an appropriate alternative. ARBs are now recommended as a first-line alternative to ACE
inhibitors for many indications and are significantly less likely to cause cough.
Latest medicine supply issues
The following medicine supply issues have been advised by PHARMAC:
- All formulations of cetomacrogol
with glycerol cream are out of stock due to shipping delays. An alternative product
(Pharmacy Health sorbolene with glycerin, 500 ml) is listed from 10 May, 2021
- From June, 2021 to mid-2022, flumetasone
pivalate
(Locorten-Vioform) ear drops will be out of stock due to problems
with the active ingredients. PHARMAC
advises that Triamcinolone acetonide with gramicidin, neomycin and nystatin (Kenacomb
brand) ear drops are a suitable alternative.
- Salbutamol with ipratropium
bromide (Duolin) inhalers remain out of stock. Although there have been batches of
Duolin recently manufactured, there are quality control issues at the point of manufacture in India. Patients have
been advised to use two inhalers (salbutamol and ipratropium) and the existing pharmacy co-payment charge for ipratropium
will continue to be waived until 30 June, 2021, i.e. patients are charged one co-payment only.
More than just a jab: findings from the Māori Influenza Vaccination Programme
In 2020, as part of the COVID-19 Māori health response, a programme was implemented that focused on addressing barriers and improving influenza
vaccination rates among Māori. The programme was successful in its objectives and provides a model for organisational change.
A
report outlining the programme and its findings is now available on the Ministry of Health website.
Read more
The programme identified three core strategies that made a difference:
- Mobilisation – providers visited communities to vaccinate, went where it was most convenient to gather, provided
transport and used local networks to identify whānau who were not vaccinated; each region customised their approach
depending on specific needs.
- Whanau-centred approach – utilised Māori leadership and providers, offered a holistic and adaptive range of services
- Focus on Māori workforce capability – increasing resources for workforce capability and capacity to widen
the available pool of Māori nurses and other healthcare providers who can vaccinate
Influenza vaccination rates for Māori aged over 65 years increased from 46% in 2019 to 59% in 2020; some of this change can be
explained by the increased interest in vaccination due to the COVID-19 pandemic, however, the overall equity gap improved
from -12.1% to -8.4%, therefore providing evidence of the programmes success.
"The programme displayed the effectiveness of mobilising primary care services, in combination with a whānau-centred
approach, alongside Māori workforce development, to reduce barriers and improve access to flu vaccinations for
Māori. A mobilised, whānau-centred approach offers a new lever in the health delivery system alongside GPs and
pharmacies. Over and above flu vaccinations, it has the potential to make a radical difference to Māori experiences
of primary health care, Māori health outcomes and equity".
Paper of the week: New NICE guideline on atrial fibrillation
The National Institute for Health and Care Excellence (NICE) has just published a new guideline
on the diagnosis and management of atrial fibrillation (AF). This is an update of the 2014 NICE guideline and addresses a number of areas
where new evidence had become available, such as a new tool for assessing bleeding risk.
It is uncertain at this stage how these recommendations might affect clinical practice guidelines in New Zealand.
We will assess any implications and provide further comment in our freely available
Primary
Care Update series topic on AF.
Read more
The latest update (April, 2021) of the NICE guideline on the diagnosis and management of atrial fibrillation (AF) includes the following key changes:
- The ORBIT bleeding risk score is now
recommended as the preferred tool for assessing the risk of bleeding.
This is based on evidence that ORBIT has a higher level of accuracy in predicting absolute bleeding risk than
other bleeding risk tools (HAS-BLED or ATRIA). However, NICE acknowledge that there may be some delay in implementing
this change as ORBIT is not currently embedded in clinical pathways or decision support software in the UK. The
ORBIT tool is yet to be widely validated; it has primarily been assessed in people already taking oral anticoagulants.
ORBIT does not include all risk factors that are included in the HAS-BLED tool, therefore clinicians are not prompted
to consider these factors, however, NICE believe that assessment of all modifiable risk factors for bleeding should
be “established clinical practice”.
- In New Zealand, HAS-BLED should continue to be used until local guidance
becomes available and, if recommended,
until ORBIT is embedded into decision support software.
- The results of assessments of stroke risk and bleeding risk should be interpreted in the context of the patient's
medical history, co-morbidities and preferences. Anticoagulation should usually still be considered in people
at risk of stroke, even if their bleeding risk is high (therefore no bleeding risk cut-off is suggested). Anticoagulation
should not be withheld solely on the basis of a person’s age or their risk of falls.
- If anticoagulation is indicated, a direct-acting oral anticoagulant (DOAC) should be prescribed first-line
in preference to warfarin (unless contraindicated or not tolerated) due to evidence showing better clinical effectiveness.
- NICE note that there are still no head-to-head comparisons, and recommend use of either apixaban, dabigatran,
edoxaban or rivaroxaban based on the patient’s clinical needs and preference
- In New Zealand, dabigatran and rivaroxaban are approved
and funded, apixaban is approved but not funded and
edoxaban is not an approved medicine
- Recommendations on pharmacological rate and rhythm control generally reflect current practice; however, NICE
recommend that digoxin monotherapy should be considered for people with non-paroxysmal atrial fibrillation who
are sedentary.
- In New Zealand, digoxin is used infrequently in clinical
practice due to its potential for medicine interactions,
lack of effect on heart rate during physical activity and narrow therapeutic index
- A risk of recurrent AF remains even after cardioversion or catheter ablation; NICE recommend that antiarrhythmic
medicine treatment should be considered for at least three months after left atrial ablation to prevent
recurrence
- There are no major changes to advice regarding stopping anticoagulation. NICE recommend that if the patient
appears to be in sinus rhythm, anticoagulation should not be stopped solely for that reason as paroxysmal AF is
not always detectable. The decision to stop anticoagulation should be made after a reassessment of stroke and
bleeding risk and a discussion with the patient about their preferences.
This Bulletin is supported by the South Link Education Trust
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