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Published: 5 June, 2020


Updated information about prescribing tramadol

Some important tramadol prescribing changes have recently been announced by Medsafe, based on information from clinical trials and data from the Centre for Adverse Reactions Monitoring (CARM):

  • Tramadol is now contraindicated in all children aged under 12 years (previously the limit was age two years)
  • Tramadol is contraindicated in children aged under 18 years for post-operative pain management following tonsillectomy and/or adenoidectomy
  • Tramadol should be used with care in patients aged 75 years and older due to the prolonged elimination half-life; a lower maximum daily dose of 300 mg should also be used in this group
  • Response to tramadol is variable depending on whether people are fast or slow metabolisers of the CYP2D6 enzyme; this can explain why some people are more sensitive to the adverse effects of tramadol and why others have reduced benefit

For more information on prescribing tramadol, see:

A reminder about the safe prescribing of clozapine

Clozapine is an effective treatment for some patients with schizophrenia, however, it is associated with a number of significant adverse effects that necessitate close monitoring and co-ordinated care between the patient, caregivers, mental health and primary care teams. A recent coroners case has again highlighted the potentially fatal outcomes when this medicine is not managed optimally.

Key practice points for prescribing clozapine:

  • Clozapine-induced constipation is highly prevalent, often difficult to detect and potentially fatal; prophylactic laxatives are recommended when clozapine is initiated, and constipation should be assessed for at every consultation
  • Monitor for symptoms and signs of cardiac toxicity and neutropenia; regular blood tests are mandatory to detect blood dyscrasias and for continued supply of the medicine (white blood cell count and absolute neutrophil counts weekly for first 18 weeks, then four-weekly)
  • When prescribing other medicines, consider whether they may interact with or exacerbate the adverse effects of clozapine
  • Substantial changes in cigarette or caffeine consumption may necessitate a dose adjustment of clozapine

To refresh your knowledge on the safe prescribing of clozapine, see:

Ambulance care summaries to be sent electronically to GPs for patients treated in the community

Approximately one in six people who receive ambulance care are managed in the community without requiring transfer to a medical facility. In these cases, the patient receives a handwritten Ambulance Care Summary (ACS) Advice Sheet, with a code which they, or their general practitioner, can use to access their full ACS report online*. However, in many cases this information "slips through the cracks"

The RNZCGP reports that from 19th June, 2020 St John and Wellington Free Ambulance services will send an electronic ACS to a patient's general practitioner, even when the patient is not transported to a medical facility (including patients who are deceased). The ACS includes the history, details of the clinical problem, treatment and recommendations provided to the patient. It will be transferred directly into the practice's patient management system via Healthlink.

N.B. An ACS is not intended as a transfer of care document; if urgent action is required ambulance personnel will contact the GP directly.

* The ACS can be downloaded within 7 days of the event using the patient’s ACS access code and date of birth at (St John) or (Wellington Free Ambulance). Reports can be accessed after this date by requesting directly from the ambulance service.

A trial will commence from 5th June, 2020 in Bay of Plenty, Wairarapa and Southern DHB areas

For further information about electronic patient records, see St John or Wellington Free Ambulance

Reconsider the use of ondansetron in pregnant women during the first trimester

Ondansetron is indicated for the management of nausea and vomiting induced by cytotoxic chemotherapy and radiotherapy, and for preventing post-operative nausea and vomiting. However, it is also prescribed off-label for nausea and vomiting due to other causes, including for women in the early stages of pregnancy.

Two large epidemiological studies* have now been published demonstrating an approximate 25% increase in the relative risk of oral cleft defects, e.g. cleft lip or cleft palate, when ondansetron is used during the first trimester; amounting to approximately three additional cases per 10,000 exposed pregnancies.

For further information on managing nausea and vomiting during pregnancy, see:

* Huybrechts KF, Hernández-Díaz S, Straub L, et al. 2018. Association of maternal first-trimester ondansetron use with cardiac malformations and oral clefts in offspring. JAMA 320(23): 2429–37. DOI: 10.1001/jama.2018.18307; Zambelli-Weiner A, Via C, Yuen M, et al. 2019. First trimester ondansetron exposure and risk of structural birth defects. Reproductive Toxicology 83(Jan): 14–20. DOI: 10.1016/j.reprotox.2018.10.010

Paper of the week: Is there a gene for thinness?

A paper published this month in Cell by Orthofer et al, may provide some important clues in unravelling the mystery of how genes influence our weight. But, unlike the usual studies of obesity, these researchers identified a genetic determination for thinness.

This Bulletin is supported by the South Link Education Trust

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