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Clinical Snippets June 2022

1.  Proton Pump Inhibitors

A recent POEM of the Week podcast discusses the small risk of gastric cancer with long-term use of PPIs.  Numbers needed to harm were 2000 users after 5 years and 1200 users over 10 years to get gastric cancer. The risk was higher in patients on higher doses. The advice was to try short periods and lower doses of PPI.

A BPAC article notes additional adverse effects associated with long-term use of PPIs including:

• Bone fractures – absolute risk increase is estimated to be 0.1% to 0.5% per year for an individual patient.
• Malabsorption of nutrients including increased risk of B12 deficiency, hypomagnesaemia and iron deficiency  
• Clostridium difficile infection. The relative risk for community-acquired C. difficile infection is increased by 50% in people taking PPIs, however, the low incidence of this bacterial infection means the absolute risk increase is estimated to be 0.09% per year.
• Community-acquired pneumonia. The acid-lowering effects of PPIs is thought to allow proliferation of bacteria in the stomach, which may then move up into the oesophagus to be aspirated and cause lower respiratory tract infection, e.g. pneumonia.
• Chronic kidney disease. PPI use has been associated with chronic kidney disease and end-stage renal disease. The estimated absolute risk increase of chronic kidney disease for an individual patient per year is 0.1% to 0.3%.  There is also an association with acute interstitial nephritis – more common in patients aged over 60 and in the first thee months of use.

The BPAC article poses some questions to consider: 

• How often do you review patients on long-term PPI treatment?
• Do you have a system or plan for reviewing PPI use in patients? Do you discuss expected duration of treatment when you initiate PPIs?
• Have you ever had reason to suspect that PPI was associated with adverse effects, e.g. oesteoporosis or acute interstitial nephritis, in any patients?
• Were you aware of the issue of rebound acid secretion and do you/will you discuss this with patients?
• Do you encounter resistance from patients to withdraw from PPIs as they prefer PPIs to lifestyle adjustments for symptom control, and if so, how do you manage this?

2.  Patients who refuse to wear a mask

The RNZCGP has published advice on managing patients who refuse to wear a mask, initially in October 2021 with a more recent update. 

• Initial advice suggested that a patient presenting without a mask should be asked to wait outside where they could be assessed (subject to privacy considerations), or they need to be offered a telehealth consult to manage their medical problems remotely.
• However, if a face-to-face consultation is deemed necessary, or the patient refuses the telehealth consult, then the patient will need to be seen by a clinician, who may or may not be their usual GP. The patient should be treated as a ‘red’ stream patient according to practice procedures and appropriate precautions taken including:  separation in the waiting room, or waiting outside the practice (e.g., in the carpark) from other patients; the use of appropriate PPE by clinical staff interacting with the patient.
• The latest advice notes there is no legal requirement for a person to carry or show their exemption card when asked. The Ministry of Health warns that anyone questioning a non-mask wearer about their eligibility may be at risk of contravening the Human Rights Act. 
• Under these circumstances the College suggests   that practices might like to place a notice in their reception area stating:

This practice respects that some people are not able to routinely wear a mask and they have an exemption for this.  However, both our practice staff and other patients are in a particularly vulnerable situation with unmasked patients entering the building. 

For those who have an exemption, it would be appreciated if you would consider wearing a mask for the short duration that you are here.

If you are unable to wear a mask, we will insist that you remain separated from other patients by at least two metres.

3.  Scabies

Delayed diagnosis of scabies, particularly in aged care facilities, is a reasonably common source of complaint to HDC

• BPAC has recently released an updated article on diagnosis and management of scabies  noting aids to diagnosis include use of dermoscopy to visualise the mite or an ink test to highlight burrows.  Microscopy to confirm a diagnosis of scabies is rarely required except in crusted scabies when a skin scraping should be considered.

• Permethrin 5% cream (Lyderm) or lotion (A-Scabies) is the recommended first-line treatment for classic scabies.  Treatment is not effective against eggs so it should be repeated seven days after the initial application to cover any newly hatched larvae.  Hands will need to be treated with cream if washed with soap within 8 hours of application.

• The manufacturer recommends application to the body but to exclude head and neck. However, application should be extended to the scalp, neck, face, and ears according to NZF.  Larger patients may require up to 2 x 30 g packs for adequate treatment.

• Second line treatment for classic scabies (if permethrin ineffective) or first line if crusted scabies is oral ivermectin stat dose repeated after 7-10 days (not to be used in children weighing under 15kg). 

4.  Clinical Pearl – Suturing

When suturing a wound on the back of the hand and other areas in the elderly where the skin is like tissue paper first stick a piece of narrow Micropore tape or a wide steristrip along the wound edge and suture through it to close the wound.  The tape can be removed at the time of suture removal or left in place to separate over a longer period.  The technique is described in more detail with references and accompanying video on the laceration.com website.  

5.  Phentermine and serotonin syndrome risk

In the latest NZF update, serotonin syndrome has been added as a precaution to phentermine (Duromine) prescribing information when phentermine is prescribed with other serotonergic drugs. 

• Serotonin syndrome diagnosis is based on ingestion of a serotonergic agent(s), presence of a combination of different symptoms and exclusion of other causes.
• Symptoms may include alterations to mental status (eg, confusion, anxiety and agitation), autonomic changes (eg, hyperthermia, hypertension, tachypnoea, diaphoresis, diarrhoea and tachycardia) and neuromuscular effects (eg, clonus, tremors, hyperreflexia and hypertonia). The cardinal sign is clonus.
• Symptoms of serotonin syndrome usually occur within hours to days of taking the medicine.
• Treatment involves stopping the serotonergic agent and providing supportive care.

A non-exhaustive list of serotonergic agents is available in a 2015 Prescriber Update article with phentermine having been added since that time. 

An older BPAC article reviewed several cases of serotonin syndrome notified to CARM with clinical details:

• Fluoxetine added within the previous week to low dose amitriptyline taken for several months.
• Venlafaxine taken in increasing doses to 325 mg daily over five days.
• The patient was also taking nortriptyline.
• A single dose of citalopram added to tramadol which had been taken for three days.
• Paroxetine taken for less than one month, with a recent dose increase, in addition to long term clomipramine.
• Low dose phenelzine commenced. Citalopram had been discontinued five days previously with a dose reduction to 10 mg daily two weeks prior.

6.  Antivirals Access Criteria assessment tool

An electronic guide developed by Pharmac is intended to help clinicians assess whether their patient is eligible for funded COVID-19 antiviral treatments under section 4 of the access criteria.

7.  Post-Covid-19 Syndrome

There is evolving evidence regarding diagnosis and management of this condition summarised in a recent NZ Doctor article.   A similar guidance article from the UK reiterates some of the principles of management

• The illness is characterised by an unpredictable, relapsing–remitting pattern with fluctuating symptoms (dubbed the ‘corona coaster’). Significant associated conditions can often appear weeks to months into the disease course. Without effective treatment, recovery is typically very slow; in fact, many patients remain symptomatic up to 2 years after the initial infection.

• Barriers to recovery include stress, poor sleep, poor gut health, and menstrual hormone imbalance in women. Overexertion (both mental and physical) may cause an exacerbation of symptoms, termed the ‘boom-and-bust’ phenomenon.  Intercurrent infection can also trigger symptom flares.

• There is considerable overlap between some symptoms of long COVID and those of mast cell activation syndrome. A significant reduction in symptom burden was evident in up to 72% of patients with long COVID treated for up to 16 weeks with a combination of H1 and H2 antihistamines in an ongoing UK study.  Their standard antihistamine protocol is to recommend a therapeutic trial of the oral H1 antihistamine loratadine (10 mg twice daily), in combination with the H2 antihistamine famotidine (40 mg once daily), in all patients with long COVID. This treatment typically needs to be taken for a minimum of 3 months.

• Coding is important to monitor the burden of disease.