December 2023

Dr Joe Bourne ( revisited)

For December 2023 we are revisiting one of our most popular podcasts of all time, where Dr Joe Bourne, now Chief Medical Officer at Manatū Hauora / Ministry of Health shares his leadership story and what keeps him on track.

This is an opportunity to reflect on the Covid19 pandemic from the viewpoint of “the new normal” in which we live and to celebrate what we collectively acheived through that time.

Season 1 of the New Zealand General Practice Podcast is a collection of stories of what brings people joy in general practice, and what they do to increase job satisfaction and the culture of the teams they work in.

This episode is taken from Season 2 when we heard more in depth stories from doctors around New Zealand.

During the holiday season, take a little time to listen to some of these back issues and think about what you are going to do build the joy in your work.

Read more about Dr Joe Bourne in New Zealand Doctor:

https://www.nzdoctor.co.nz/article/news/cover-story/bourne-identity-gp-cmo-doctor-interrupted-lands-safely-community-care?check_logged_in=1

Shownotes

The Daily Show with Trevor Noah https://www.youtube.com/channel/UCwWhs_6x42TyRM4Wstoq8HA

Fighting Talk

https://www.bbc.co.uk/programmes/b0070hvs/episodes/downloads

Kermode and Mayo Film Review

https://www.bbc.co.uk/programmes/b00lvdrj

https://www.kermodeandmayo.com/

This too shall pass – Tom Hanks

Clinical Snippets August 2023

Clinical Snippets August 2023

1.  Varicella and pregnancy

• Every effort should be made to confirm the diagnosis in the suspected positive contact and assess significance of exposure. Exposure or symptoms in the final two weeks of pregnancy should always be discussed with a specialist.  Exposure to varicella or zoster for which ZIG is indicated for susceptible persons includes: living in the same household as a person with active chickenpox or herpes zoster; face-to-face contact with a case of chickenpox for at least 5 minutes; close contact (eg, touching, hugging) with a person with active zoster.

• If immune status of the pregnant patient is uncertain check serology urgently.  NB In people with no history or recall of the rash, 70 to 90% are still found to be immune.  Immunosuppressed patients are susceptible to chickenpox at all times.  For pregnant women who are immunosuppressed and those with negative varicella serology,   IMAC recommends discussing the clinical circumstances with an infectious diseases physician before deciding on which course of action is best.

• If seronegative and exposure is ≤ 10 days earlier give Zoster Immune Globulin (ZIG) as soon as possible and if 7-10 days post exposure, give oral acyclovir or valaciclovir if the mother is at risk of varicella pneumonitis (is in the second half of pregnancy; has underlying lung disease; is immunocompromised; or is a smoker).  ZIG requires NZ Blood Transfusion approval to be dispensed. 

• If exposure is >10 days previously, closely observe for symptoms of varicella infection and treat promptly with acyclovir or valaciclovir if symptoms develop.  However,  if the mother is at risk of varicella pneumonitis and exposure occurred less than 14 days ago, treat with acyclovir of valaciclovir rather than waiting. 

• If a pregnant woman develops symptoms of chickenpox, treat urgently with antivirals and seek acute obstetric advice. Reduce antiviral dose in renal impairment.  Counsel pregnant women exposed to varicella about the risks of congenital varicella syndrome. The risk is highest in the first 20 weeks of pregnancy (0.4% in first 12 weeks, up to 2% in weeks 13-20).

• For further details including a great algorithm see the IMAC website.  The NZ Blood Transfusion Centre Handbook has details on ZIG.    

2.  I take a green one at night

A handy website for identifying medications is MEDLOOK where you can search a medication and get a photo (for most commonly used drugs) and written description of the tablet, capsule or tube (including generic versions). 

3.  Implicit bias

Issue 104 of the Maori Health Research Review includes findings from the New Zealand Health Survey which show that more than one in three Māori (37.6%) experience racial discrimination over their lifetime. This includes ethnically motivated personal attacks, as well as unfair treatment in healthcare, employment or housing. The proportion of Māori experiencing racial discrimination in the past 12 months increased from 10.8% in the 2011/2012 survey to 13.8% in the 2020/2021 survey, and was increased further when Māori women were analysed separately (9.7% to 16.8%). Verbal abuse was the most common type of racial discrimination in the 12 months before the 2020/2021 survey. Racial discrimination was associated with higher rates of psychological distress, lower rates of good to excellent self-rated health, and higher rates of unmet need for primary healthcare. The authors noted that data was based on self-reported experience, and that individuals may under-report episodes of racial discrimination.

The Ministry of Health has developed a range of resources as part of the  Ao Mai te Rā anti-racism Kaupapa.   This includes a video and podcast series to build collective understanding of the impacts of racism on health, while also exploring key levers in the health system that could be used for change.

Out of interest, you might want to consider taking a Harvard University Implicit Association Test which assesses for unconscious or implicit preference on a number of issues including skin tone, race, age and weight.  

4.  Ocular NSAIDs and corneal melting

• The June edition of Prescriber Update noted that in NZ more than 11,000 people per year are dispensed an ocular NSAID. A rare but potentially devastating side effect of ocular NSAIDs is corneal melting which can lead to corneal perforation and vision loss.

• Various conditions can cause corneal melting, including eye infections, sterile inflammation, certain medical conditions (such as rheumatoid arthritis), and surgical or chemical injury to the cornea. Use of ocular NSAIDs has recently been linked to corneal melting. However, the mechanism behind this association is unknown.

• Consider the possibility of corneal melting in patients using ocular NSAIDs who complain of blurred/distorted vision, worsening eye pain, eye irritation and hypersensitivity and/or ocular discharge. Check these patients for corneal damage.

• Certain situations may increase the risk for NSAID-induced corneal melting, including (list not exhaustive):

• frequent application and/or prolonged treatment duration
• concomitant use of corticosteroids
• concomitant conditions such as acute eye infections, rheumatoid arthritis, diabetes mellitus, ocular surface disease
• recent complicated ocular surgery or patients with repeat ocular surgeries within a short period of time.

• Advise patients to seek urgent medical attention if they experience signs/symptoms suggestive of corneal melting. Early diagnosis and treatment are critical to prevent further corneal damage.  Patients with evidence of corneal epithelial breakdown should immediately discontinue ocular NSAID treatment and be closely monitored. Due to the risk of corneal perforation and vision loss, patients with corneal melting are usually managed in a specialist setting. Management of corneal melting may involve medical and/or surgical intervention.

5.   Nasopharyngeal cancer (NPC)

• NPC is a rare undifferentiated form of SCC with variable rate of occurrence ( 1 case per 100,000 in European populations and up to 25-50 cases per 100,000 in Southern China).  There is a male preponderance and risk factors are genetic susceptibility, previous EBV infection, and environmental factors such as smoking, alcohol and nitrosamine containing foods. 

• Presenting symptoms are variable but include:

• Nasal symptoms (around 80%):  including unilateral nasal obstruction, epistaxis, post-nasal drip, hyponasal speech, or cacosmia.
• Otological symptoms (around 50%): secondary to Eustachian tube obstruction by the tumour, such as conductive hearing loss, middle ear effusion, or aural fullness. An adult with unilateral middle ear effusion requires visualization of the nasopharynx to exclude neoplasm.
• Neurological symptoms:  Cranial nerve palsy is found in 20% of nasopharyngeal carcinoma patients and may be the presenting symptom. The most commonly involved nerve is the abducens (VI) nerve (lateral rectus palsy – horizontal diplopia when looking to affected side)
• Nodal involvement: One of the most common presenting features is an enlarged cervical lymph node. Lymph nodes of the apex of the posterior triangle and the upper jugular are initially most commonly involved.  Supraclavicular nodes are the last to be involved and are a sign of advanced disease. 
• More information is available in a StatPearls publication. 

6.  Funded meningococcal vaccine

The lates IMAC update notes  youth justice facilities have been added as a ‘specified close-living provider’ to the funded criteria for both Meningococcal B and ACWY vaccines.  People aged between 13 and 25, in their first year living in boarding school hostels, tertiary education halls of residence, military barracks, or correctional facilities are eligible for free meningococcal B immunisation.  

A free catch-up programme is available until 28 February 2024 for all people aged 13-25 currently living in boarding schools, university hostels, military barracks, or correctional facilities.  See the Te Whatu Ora website for more details. 

7.  Family history of colorectal cancer screening update

Te Whatu Ora have released updated guidance on surveillance recommendations for individuals with a family history of CRC.  The main changes relate to incorporation of the NBSP. 

(i)  Category 1: slightly above-average risk of CRC: one first-degree relative diagnosed with colorectal cancer at or over the age of 55 years.

• Strongly advise these individuals to participate in the NBSP when they become eligible.
• Individuals should make healthy lifestyle choices3 and report any bowel symptoms to their health care provider.

(ii)  Category 2: moderately increased risk of CRC:  one first degree relative diagnosed under 55yrs or 2 first-degree relatives on the same side of the family diagnosed with CRC at any age (and no high-risk features from category 3). 

• Individuals have a colonoscopy every five years from age 50, or from an age 10 years before the earliest age at which colorectal cancer was diagnosed in the family/whānau, whichever comes first. 
• Provided they have had a high-quality colonoscopy within the previous five years, individuals then participate in the NBSP from the age of 60 years.  This includes Maori who are eligible to join the NBSP at age 50 years but will maintain colonoscopic surveillance and join at 60 yrs.
• If aged over 60 years and the previous surveillance colonoscopy documented polyps that require further colonoscopy surveillance, continue with this surveillance in line with the Update on Polyp Surveillance Guidelines 2020. When colonoscopy surveillance is no longer indicated, return these individuals to the NBSP.

(iii) Category 3:  potentially high risk of CRC:- refer to publication

• Refer individuals either to the New Zealand Familial GI Cancer Service (NZFGCS) or to a genetic service for an accurate risk assessment.
• Follow the colonoscopy surveillance plan advised by the NZFGCS, genetic service or bowel cancer specialist.

8.  Child and adolescent forearm fractures

Issue 218 of GP Research Review references a randomised trial in Australia comparing  ultrasonography or radiography for suspected pediatric distal forearm fractures.   Children and adolescents aged 5-15 years (n = 270) with an isolated distal forearm injury without visible deformity underwent either ultrasonography or radiography.  No clinically significant fractures were missed on ultrasound and there was no difference between the two groups in functional outcome after 4 weeks.  The reviewer noted the potential for use of POCUS for this purpose in rural general practice. 

Clinical Snippets June 2023

1.  Stopping antidepressants

A recent BPAC bulletin reviewed a 2023 British Journal of General Practice article on appropriate withdrawal of SSRIs.  Key points included:

• A proportionate dose taper should be used where the dose is reduced by a proportion of the previous dose e.g. 50% of previous dose, depending on certain factors such as the patients symptoms and whether the available formulations of the SSRI allow the preferred reduction in dose.  Smaller dose reductions, e.g. 25% of previous dose, might be considered when low doses are reached and this might require alternate day dosing.

• Dose tapering should occur slowly over months to years depending on individual circumstances. Higher doses of SSRIs, longer durations of use and SSRIs with shorter half-lives, e.g. paroxetine, are generally associated with more severe symptoms of withdrawal and patients may require tapering of the dose at a slower rate.

• Monitor patients for symptoms of withdrawal and differentiate between withdrawal and relapse:  Symptoms of withdrawal include irritability, sleep disturbance, hallucination, suicidal ideation dizziness, headaches, sweating and are reported by more than half of patients when discontinuing SSRIs. Reinforce the use of coping strategies, e.g. exercise, mindfulness-based techniques, sleep hygiene and be prepared to slow the taper if withdrawal symptoms occur.  Symptoms of withdrawal are more likely to begin within days of discontinuation or reduction of the SSRI. In contrast, symptoms of relapse typically occur weeks to months after cessation of the SSRI.

• Discuss the possibility of withdrawal symptoms, including the importance of following the tapering protocol to minimise any symptoms. Advise that they should not abruptly stop taking the SSRI. A patient information sheet developed by Medsafe is available here.

Additional resources: 

• For further information on antidepressants, including switching or discontinuing, see: https://nzf.org.nz/nzf_2225
• A guide to what medications can be crushed or dissolved is available from SafeRx. 

2.   Miconazole gel and warfarin

• Miconazole oral gel inhibits the metabolism of warfarin via inhibition of CYP2C9.
• Healthcare professionals are advised to avoid miconazole oral gel in patients taking warfarin.
• If concomitant use of miconazole oral gel and warfarin is necessary, the patient’s INR should be carefully monitored.
• See the 2013 Prescriber Update on this topic. 
• The manufacturer data sheets for miconazole oral gel (and associated consumer information sheets) state it is contraindicated in children less than six months of age while NZFC  notes it is  not approved for use in children under 6 months of age (ie use in this age group is ‘off label’).  However, dosing instructions for neonates and infants under six months of age are provided in NZCF and:  For infants and young children, give oral gel in small amounts at the front of the mouth, or smear around the inside of the mouth. Do not place gel in the back of the mouth as this may cause choking. 

3.  Goodfellow Gem on lung cancer

A recent Goodfellow Gem refers to a Goodfellow Unit webinar on early detection and advances in management of lung cancer including a current study on low dose CT screening for lung cancer in high-risk Māori patients.  Lung cancer is the single biggest contributor to the difference in life expectancy between Māori and non-Māori, with lung cancer the leading cause of death for Māori women and the second leading cause of death for Māori men after cardiovascular disease. Māori women’s rates are more than four times higher and Māori men’s rates nearly three times higher than those of non-Māori.

The Gem looked at eight symptoms to consider for rapid diagnosis of lung cancer:

The persisting cough in the patient with COPD ± smoker is a common presenting symptom. The eight symptoms are:

•          Cough >3 weeks

•          Haemoptysis

•          Chest or shoulder pain

•          Dyspnoea

•          Hoarseness

•          Weight loss >10%

•          Unresolving chest infection

•          Symptoms suggestive of metastasis (liver, bone, brain, skin). In some parts of the country, if the CXR is suggestive of a curable lesion the chest CT can be bypassed but refer them to the respiratory team (refer local pathways). The e-referral should state “high suspicion of cancer”.  In those cases, the team may arrange a PET-CT scan. 

A 2021 systematic review and meta-analysis on performance of plain chest X-ray for diagnosing lung cancer in symptomatic primary care patients showed a sensitivity of around 80% with the comment: A negative chest radiograph does not exclude lung cancer, and physicians should maintain a low threshold to consider specialist referral or cross-sectional imaging.  BPAC has a comprehensive 2021 article on early detection of lung cancer in primary care. 

4.  Can PPIs help crying babies? 

A recent Tools for Practice looked at the clinical question:    In infants (≤1year) with crying/irritability attributed to feeds, do proton pump inhibitors (PPIs) improve symptoms over placebo without additional harms?  The context:

• Frequent effortless regurgitation of feeds is common in early infancy (affecting ≥40%).

• Regurgitation accompanied by distress symptoms (e.g., crying, back arching, irritability) have traditionally been attributed to gastroesophageal reflux disease. While PPIs improve oesophageal pH in infant RCTs, they do not improve symptoms.

• Guidelines recommend against empiric trials of acid-suppressing drugs for crying/distress or regurgitation.  Parents can be reassured that frequent regurgitation can be normal and frequently settles (90% have resolution at age ≤1 year).

The conclusion:  PPIs do not improve crying, fussiness, irritability, or regurgitation attributed to feeds. However, PPIs may increase the risk of serious adverse effects (e.g., respiratory tract infections) from 2.5% on placebo to 12% at 4 weeks.  Local HealthPathways state:  Use of omeprazole in infancy is not indicated in primary care as there is a lack of evidence for its effectiveness, and concerns about its safety. Evidence for the use and safety of alginates (e.g. Gaviscon Infant) is inconsistent. They may have a role in treating infants with GORD but only for an on-demand use rather than regular or long-term use.

5.  Aspirin and primary prevention of CVD

A recent issue of GP Research Review commented on a recently published literature review and meta-analysis on use of aspirin with or without statin across all risk groups in patients without confirmed atherosclerotic cardiovascular disease (ASCVD).  The investigators concluded that in patients without ASVCD the risk of major bleeding associated with aspirin is greater than the reduction in MI risk across all ASCVD risk levels. Concurrent use of a statin reduces the cardiovascular benefits of aspirin without influencing bleeding risk. Therefore, in patients without ASCVD who are already taking a statin, the addition of aspirin is unlikely to achieve a meaningful CV benefit but would increase the risk of major bleeding.

Current HealthPathways recommendations are, for primary cardiovascular disease (CVD) prevention: 

• Consider aspirin only for high-risk patients younger than 70 years, taking into account the benefits and harms.
• If not high risk, aspirin and other antiplatelet agents for primary prevention alone are generally not recommended.
• If older than 70 years, the balance of benefits and harms of aspirin is not clear, so is not recommended for primary prevention alone.

6.  Winter virus action plans

As part of its ongoing commitment to antibiotic stewardship, He Ako Hiringa has developed virus action plans for adults and children which cover rationale for avoiding antibiotics and extensive modifiable management and safety netting advice.  The plans can be edited on-line and then printed and/or downloaded for electronic transmission and retention.   

7.  Sodium valproate in males

A recent Medsafe Prescriber Alert comments on the risk of neurodevelopmental disorders in children fathered by patients using valproate at the time of conception.  Information for healthcare professionals includes: 

• The Epilim data sheet and CMI have been updated to include new safety information relating to use in males of reproductive potential.
• Use of sodium valproate at the time of conception by people who are able to father children has been linked to a potential increased risk of neurodevelopmental disorders in children compared to those who took lamotrigine/levetiracetam.
• Inform patients of this potential risk and consider alternative treatment options for those wishing to father a child.
• Discuss the need for effective contraception when starting sodium valproate and periodically throughout treatment.
• The company has produced a guide which should be provided to all male patients of reproductive potential using sodium valproate.

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-May-2023-e24n5fn

Clinical Snippets May 2023

1.  Pelvic Mesh Complications

• Te Whatu Ora female pelvic mesh complications service is a national service for people born with biologically female pelvic organs, who may have been harmed by mesh implanted for the treatment of urinary stress incontinence or pelvic organ prolapse.  The Te Whatu Ora website provides comprehensive information regarding the service including downloadable GP flyer and infographic of how the process works.

• Care and support options include continence care, chronic pain management, counselling, and surgery. Care is provided by a multidisciplinary team including physiotherapists, social workers, psychology services, surgeons, pharmacist, sexual health therapist, pain medicine specialists, nurses, health navigator, and dietitian.   Services are located in Auckland and Christchurch. Transportation and accommodation assistance may be available.

• Specific referral information is available via HealthPathways (New Zealand Female Pelvic Mesh Service Requests)with more information in a recent eReferrals newsletter. 

2.  PSA Testing

GP Research Review issue 2 2023  comments on the USANZ position statement on PSA testing.      This position statement serves as an interim document for the optimised use of PSA testing in Australia and New Zealand until current guidelines on PSA testing are updated. The USANZ New Zealand section is working on new PSA guidelines to be released later this year as the 2015 guidance is now outdated and inconsistent with contemporary clinical practice.

Recommendations include:

• Ensure prostate cancer awareness amongst men and counsel them on the potential risks and benefits of PSA testing.

• Offer an individualised risk-adapted strategy for early detection of prostate cancer in men aged >50 years of age with a life expectancy of at least 10 years.

• Offer early PSA testing to men at an increased risk of prostate cancer:
  • Men >45 years of age with a family history of prostate cancer
  • Men of high-risk ethnicities (including Indigenous men) >45 years of age
  • Men carrying BRCA2 mutations >40 years of age

• Stop early diagnosis of prostate cancer based on limited life expectancy and poor performance status; for example, men with a life expectancy of <10 years are unlikely to benefit.

• For men with an initial PSA test of >3 ng/mL, the use of risk stratification (considering factors such as age, family history, digital rectal examination and PSA density) can help guide the need for further testing, including MRI and biopsy.

3.  Polypharmacy

Issue 3 of GP Research Review looked at a recent article published in the Journal of Primary Health Care with a focus on polypharmacy.

• A total of 61 indicators for inappropriate medicines prescribing in polypharmacy that are relevant to people aged over 65 years in New Zealand were identified, and form the “New Zealand Criteria”. Indicators that were considered ‘very important’ or ‘important’ in New Zealand were similar to published international criteria.

• Medicines that were identified as being of particular concern included NSAIDs, benzodiazepines, anticholinergics, antipsychotics and first-generation antihistamines. There were two indicators that reached 100% consensus: a combination of three or more CNS active medicines (e.g., antidepressants, antipsychotics, antiepileptics, benzodiazepines, zopiclone, opioids); and the use of long-acting sulfonylureas (e.g., glibenclamide). Eight out of nine experts agreed that it was very important to correct the prescribing of alpha blockers in older patients with postural hypotension and NSAIDs in older patients with stage 4 chronic kidney disease or higher.

• A complete list of potentially inappropriate medicines indicators is available in the full article.  A 2018 BPAC article contains useful resources for de-prescribing including a discussion on pharmacist services (eg Medicines Therapy Assessment) available in some areas. 

4.  New COPD guidance

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published updated guidelines on chronic obstructive pulmonary disease (COPD).  The guidelines include several important changes, particularly concerning the use of long-acting bronchodilators in treatment.

• LABA/LAMA combination treatment is now recommended as first-line treatment in patients requiring a long-acting bronchodilator, including those who are more symptomatic or at high exacerbation risk. This supersedes previous guidance to use LAMA or LABA monotherapy first.

• Use of an ICS + LABA alone is now discouraged throughout COPD management unless prescribed for a concurrent diagnosis such as asthma, and a more targeted approach for ICS use is suggested.

• A revised “ABE” assessment tool for predicting patient outcomes and making treatment decisions. This recognises the clinical relevance of exacerbations, regardless of the patient’s symptom severity (i.e. categories “C” and “D” in the “ABCD” tool are now combined into a single “E” category).

• BPAC have previously provided useful COPD tools for assessment and management and note the following:  Given these significant changes, we plan to update our COPD tools. However, we will await any revision of New Zealand guidelines in accordance with the GOLD 2023 report. In addition, Special Authority approval criteria for LABA/LAMA combinations currently require patients to be stabilised on LAMA monotherapy first, making these recommendations difficult to apply equitably in practice.

5.  Type 2 diabetes

• A Dutch study reviewed in Issue 167 of the Diabetes and Obesity Research Review looked at use of SGLT-2 inhibitors in very-high cardiovascular risk patients with type 2 diabetes.  Only 10.3% of such patients were being prescribed SGLT-2 inhibitors despite being eligible under national guidelines.  Of those not prescribed the medication, there was no contraindication to prescribing in over 70% and none were on a GLP-1 agonist.  The reviewer notes SGLT-2 inhibitors have been available in the Netherlands for longer than they have here in NZ and wonders how well we are performing by comparison. 

• An excellent algorithm for management of patients with type 2 diabetes which incorporates prescribing of SGLT-2 inhibitors and GLP1 receptor agonists is available on the NZSSD website and can be downloaded as a PDF.  Further resources including interpretation and application of Special Authority criteria are available on the Pharmac website. 

• The EPIC dashboard on Te Ako Hiringa enables you to compare your prescribing for type 2 diabetes with those of your practice colleagues and national data and includes data on patient adherence to prescribed medication and tips for improving diabetes medicines equity. 

• The University of Waikato and New Zealand Society for the Study of Diabetes are running a free online diabetes management course starting 17 July 2023. The course is run over 20 weeks, made up of eight 30-minute webinars and eight 30-minute case discussion and mentoring sessions. The course is approved for 16 hours CME points.

6.  Vitamin D and diabetes

• A recent Goodfellow Gem commented on a study suggesting Vitamin D may reduce risk of diabetes in pre-diabetics.  The review and metanalysis of individual patient data from three trials reported a reduction of 3% in absolute risk of progression to diabetes. The comparable doses from two studies were 80,000 units 4 weekly and 120,000 units 4 weekly; the NZ option is 1.25 mg cholecalciferol tablet = 50,000 units once per month.

• There was an improvement with higher blood levels of Vitamin D, with the greatest reduction with a blood level of ≥ 125 nmol/l (18% absolute risk reduction). There appeared to be no adverse effects, but studies were not powered to detect these (but remember Vitamin D is fat soluble and can be toxic in overdose – usually serum levels >375 nmol/L).  The NNT to prevent diabetes is 30 (compared with 7 for intensive lifestyle and 14 with metformin). It was mainly effective in those with BMI < 31.3 Kg/m. The study ethnicities were European 50% and Asian 33%, so no Māori or Pacific patients.

• The same study was reviewed in Issue 212 of GP Research Review with the reviewer concluding:  Impressive, and I am going to be prescribing it for my prediabetics, can’t do any harm. 

7.  Topiramate in pregnancy

Medsafe have put out a further alert regarding use of topiramate in pregnancy and women of childbearing age.  Congenital malformations and neurodevelopmental disorders have been reported in children following in utero topiramate exposure.

Advice to health professionals includes: 

• Topiramate should only be used to treat epilepsy in pregnancy if the potential benefit justifies the potential risk to the mother and fetus.
• Refer epileptic women taking topiramate who become or plan to become pregnant for specialist advice.
• The use of topiramate for migraine prophylaxis is contraindicated in pregnancy.
• Perform pregnancy testing before starting treatment. Women of childbearing potential should use a highly effective contraceptive method during treatment.
• Inform women of childbearing potential about the risks of fetal harm if they become pregnant.

8.   Progestagen only contraception and risk of breast cancer

• A recent BPAC update bulletin notes previous studies have established that patients taking combined oral contraceptives are at slightly increased risk of breast cancer. Progestogen-only contraceptives have been considered an alternative option for patients where oestrogen is not recommended or contraindicated, however, the data regarding breast cancer risk and progestogen-only contraceptives has been inconsistent. A recently published study based in the United Kingdom (UK) now suggests that the risk of developing breast cancer in patients who take progestogen-only contraceptives is comparable to those taking combined hormonal contraceptives.

• While it is recommended that the new information is included when discussing the risks and benefits of contraceptive options with patients, the UK-based Faculty of Sexual and Reproductive Healthcare (FSRH) have not currently recommended any major changes to clinical practice in response to the study.

• Best practice tip: The absolute risk of breast cancer with progestogen-only contraceptive use is still very small, especially in younger patients with no familial breast cancer risk. The decision to prescribe any type of hormonal contraception should consider this low risk in the context of the possible benefits of use, e.g. reduced risk of an unplanned pregnancy and other non-contraceptive benefits such as reducing the risk of endometrial and ovarian cancers.

9.  Prescribing for ADHD

(i)  Pharmac has announced the General Rules of the Pharmaceutical Schedule will be amended from 1 June 2023 to allow three months of the stimulant/ADHD treatments, methylphenidate and dexamfetamine, to be funded when prescribed electronically.  While the Regulations allow electronic prescriptions for methylphenidate and dexamfetamine to be issued for three months at a time instead of one month, the frequency of dispensing for these medicines remains monthly. 

(ii)  The RANZCP has a statement on guidance for the use of stimulant medications in adults  (2015) which includes:  Specific caution, including appropriate monitoring, is required in the consideration of stimulant prescription to persons who have a history of substance abuse or dependence… Clinicians should assess and monitor the risk associated with stimulant prescription in adults with a history of hypertension, cardiovascular or cerebrovascular disorders. A baseline electrocardiogram (ECG) should be performed if there is a family history of serious cardiac disease or sudden death in young family members, or abnormal finding on cardiac examination. The patient’s blood pressure should be regularly monitored during the course of treatment with stimulant medication.

(iii)  New Zealand Formulary includes the following screening and monitoring advice for methylphenidate:

Pre-treatment screening 

• Obtain a detailed psychiatric history including family history of suicide, bipolar disorder, and depression
• Assess for risk of misuse (including family and caregivers)
• Assess for personal or family history of tics or Tourette’s syndrome
• Assess cardiovascular function including blood pressure and heart rate—seek specialist cardiac advice if history of, or current, cardiovascular disease
• Assess for family history of sudden cardiac or unexplained death or malignant arrhythmia
• Measure height and weight 

Monitoring requirements 

• Monitor for development or worsening of pre-existing psychiatric disorders, aggressive behaviour, anxiety or agitation at the start of treatment, at every dose adjustment, and at least every 6 months—consider discontinuing treatment if psychiatric disorders develop or worsen
• Monitor for emergence or worsening of tics or Tourette’s syndrome at every dose adjustment and at every clinic visit—consider discontinuing treatment if tics develop or worsen
• Monitor for misuse
• Monitor cardiovascular status including blood pressure and heart rate at least every 6 months and at every dose adjustment—seek prompt cardiac evaluation if palpitations, exertional chest pain, unexplained syncope, dyspnoea or other symptoms suggestive of cardiac disease occur
• Assess weight and appetite at least every 6 months
• Closely monitor patients at risk of acute angle-closure glaucoma
• Monitor full blood count, differential and platelet counts during prolonged therapy as clinically indicated.
• Consider de-challenge at least once yearly 

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-April-2023-e24n53a

Shownotes

Clinical Snippets April 2023

1.  Syphilis

(i)  A recent Te Whatu Ora Waikato newsletter notes here has been a sharp increase in infectious syphilis notifications during 2022. This is particularly in the upper half of the North Island including Waikato and largely due to a sharp rise in reported cases among men. Notifications among men who have sex with women (MSW) have more than doubled between 2022 Q1- 2022 Q3. Infectious syphilis notifications among Māori MSW more than tripled. Notifications among men who have sex with men (MSM) increased by 40%.

(ii) The number of infectious syphilis notifications among women of reproductive age (15-49) and pregnant women remain high. In Q3 about half of the women who have sex with men (WSM) notified were pregnant – we are not testing enough young women.  Congenital syphilis (CS) notifications remain high and individuals of Māori ethnicity continue to be overrepresented in maternal and CS cases.

(iii)  HealthPathways recommends testing for syphilis in the following situations:

• All patients having a routine sexual health check. Recommend a repeat test 3 months from the time of last sexual intercourse if particular concern.
• All pregnant women (first antenatal bloods). Offer re-screening between 28 to 38 weeks gestation for women at increased risk: who have had a new sexual partner during pregnancy; with more than one sexual partner during pregnancy; with an STI diagnosed during pregnancy; whose partner is diagnosed with an STI.
• All MSM, especially if HIV positive. Arrange serology at least annually.
• Any rash or genital symptoms in MSM
• HSV genital ulcer(s), atypical or non-healing genital ulcer(s)
• Unusual clinical presentations e.g., lymphadenopathy, unexplained abnormal liver function tests, alopecia, pyrexia of unknown origin
• Patients who have had sexual contact with a person diagnosed with syphilis (serology usually carried out by sexual health clinic)

(iv)  Syphilis can be asymptomatic. Consider syphilis testing in cases with unusual skin rashes, oral, genital or perianal ulcers, lymphadenopathy, hepatitis and/or neurological symptoms. Syphilis in its secondary stage can affect any body system and cause end organ damage, hence its reputation as the ‘Great Pretender’.   Management guidelines can be accessed through HealthPathways and the Aotearoa New Zealand STI Management Guidelines. 

2.  Verifying death

(i)  The Ministry of Health Guidelines for Verifying Death note that medical practitioners, nurse practitioners, registered nurses, enrolled nurses, midwives, emergency medical technicians, paramedics and intensive care paramedics are authorised by the Chief Coroner to verify death, including deaths which meet the criteria for reporting to the Coroner.  

(ii)  A health practitioner can verify death when:

• the body shows signs of rigor mortis incompatible with life, or
• the body has visible injuries incompatible with life, or
• the body shows signs of decomposition incompatible with life.

Alternatively, health practitioners can verify death once they have undertaken two assessments (a minimum of 10 minutes apart) to establish death. The health practitioner must confirm the following:

• no signs of breathing for one minute (requires exposure of entire chest and abdomen)
• no palpable central pulse (femoral, carotid or brachial). In most circumstances this will

require palpation for 5–10 seconds

• no audible heart sounds
• pupils dilated and unreactive to light (requires a focal light source eg a torch)
• where available, a cardiac monitor or defibrillator is used and shows asystole

The reason given for the second assessment is that the person may be in asystole for 5–10 minutes and then spontaneously develop return of a beating heart. This is sometimes called auto-resuscitation or the Lazarus reflex.

(iii)  Medical practitioners and nurse practitioners can now use Death Documents to report deaths to the coroner. This new function asks a series of screening questions to guide the practitioner through the reporting requirements then provides a firm recommendation to either complete and submit a Coroner Report or complete a medical certificate of cause of death (because the death does not need to be reported to the coroner).  GPs have previously phoned the coroner to report a death. They are now encouraged to report the death using Death Documents.  The coroner’s office (NIIO) is notified immediately, and the death is reported to Te Whatu Ora so that the NHI record can be updated with the date of death.  NIIO will register the report and contact the practitioner by phone within 2 hours to confirm whether they have taken the case.  If the coroner decides to investigate the death, you must notify the police of the death if they are not already involved.

3.  Opioid prescribing

A recent BPAC article on opioid prescribing (Quick reference here) includes some potentially useful resources related to the prescribing recommendations, and an oxycodone prescribing audit which can be used for Te Whanake CPD credits.  There is a link to the Live Well with Pain website which is an initiative developed by clinicians in the United Kingdom. It includes a comprehensive suite of freely available resources designed to inform and support health professionals working with patients who have persistent pain and to help guide the appropriate use of opioid medicines.  Free registration is required. 

Key recommendations in the BPAC article include:

• Establish a treatment plan when initiating an opioid, including measurable goals and the timeframes for achieving these, information about adverse effects and a plan to stop use. This jointly agreed plan can be verbal, but it should be documented in the patient notes. BPAC has provided an editable pain management plan template.

• In some cases, a formal written and signed opioid contract may be suitable to ensure safe and effective opioid use.  BPAC has provided an example opioid contract if you think it might be suitable for a specific patient.

• Ideally select an immediate release formulation due to the lower risk of sedation, respiratory depression and overdose (particularly during initiation). Modified-release opioids are a strong risk factor for opioid dependence. N.B. modified-release formulations may still be considered in certain scenarios depending on clinical judgement.

• Use the lowest potency and dose possible to effectively manage pain. Reassess the benefits and risks of treatment when considering each dose increase if pain is insufficiently controlled. Prescribe in combination with non-opioid analgesics and/or adjuvant medicines as this may reduce the dose of opioid required to achieve pain relief.  Be alert for potential signs of misuse and dependence, e.g. requests for early repeats or escalating doses

• If initiation of a strong opioid is being considered in primary care, ensure morphine is trialled first before prescribing oxycodone (unless the patient has a documented allergy or intolerance)

• Prescribe for the shortest possible duration (ideally three days or less). If this is not practical and longer-term use is required, advise intermittent dosing (i.e. as-needed within the daily dosing limits), rather than continuous use. Intermittent dosing reduces the risks of dependence without compromising potential benefits.

• Prescribe a laxative if use will exceed 2 – 3 days duration and advise patients to remain hydrated. 

• If longer-term use is required, check in with the patient at each new prescription to assess the need for continued use. The opioid dose or potency should be gradually titrated down as pain improves (as per treatment plan).  A link is provided to the Te Pou publication Substance withdrawal management: Guidelines for medical and nursing practitioners 

4.  Drug Driving

(i)  The Land Transport (Drug Driving) Amendment Act 2022 was introduced on 11 March, 2023.  The key changes, recommendations and resources are included in a recent Medsafe Alert.

(ii)  The key changes are the addition of Schedule 5 and new blood tests to measure the amount (concentration) of drugs in the blood.

• Schedule 5 contains 25 ‘listed qualifying drugs’ (4 illicit drugs and 21 prescription medicines). These drugs have been identified as having the highest risk to road safety.
• Police will continue to stop drivers at random to check for alcohol or drug driving. If a person fails a Compulsory Impairment Test (a behavioural test to check for impairment), they will be required to take a blood test to check for the presence of drugs. With the law change, blood concentration levels will also be measured for Schedule 5 drugs. The blood concentration determines the type of offence, which may be a fine, demerit points, licence disqualification, or a criminal conviction.

(iii)  If a qualifying drug is identified, a medical defence is available for the use of prescription medicines for drug driving offences:

• if the driver can demonstrate that they took the medicine according to a current and valid prescription from health practitioner, and
• they have followed any instructions from a health practitioner or manufacturer of the medicine.

(iv)  Advice for healthcare professionals

• Please discuss with your patients whether their medicines (both prescription and over the counter) could impair driving.
• Advise patients to check whether they have any side effects that could impair driving, and not to drive if these occur.
• Check section 4.7 of the medicine data sheet for the effects of a medicine on driving.
• Find the prescription medicines currently included in Schedule 5, for which blood concentration levels will be measured.

(v)  Points to consider

• MCNZ statement on good prescribing practice:  Ensure that the patient … is fully informed and consents to the proposed treatment and that he or she receives appropriate information, in a way they can understand, about the options available; including an assessment of the expected risks, adverse effects, benefits and costs of each option.

• Use of NZ Formulary Patient Information section and Patient Information Leaflets

• NZ Formulary Caution Advisory Labels (CALs) which are promoted by the NZ Pharmaceutical Society but do not appear to be a mandatory requirement

(vi) Additional resources

• Health Navigator Driving and medicines – contains both general and medicine-specific information for consumers including which medicines are most likely to affect driving, symptoms of impairment, when and how long to avoid driving  There is a special ‘Heavy transport and medication’ section included.
• NZ Police site explaining the new legislation from a consumer perspective
• Waka Kotahi information for consumers and  health professionals regarding substance impaired driving including a link to a substance impaired driving health professional CME online course

5. Phenobarbitone brand change

• Pharmac has notified the funded brand of phenobarbitone tablets (15 mg & 30 mg) is changing because a supplier is leaving the market.  Approximately 400 people in New Zealand take the drug.  Current stock is expected to run out in July.

• Patients taking phenobarbitone tablets for epilepsy require alerting to the impending brand change and required actions.  Two appointments with a healthcare provider are needed: at one month before (June 2023) and one month after the brand change.

• Serum phenobarbital testing is required to check that concentrations remain at the same level before and after the brand change. Testing is recommended:

• three weeks prior to the change
• within the week prior to the change
• within the first week of the change
• one month after the change

Laboratory reference ranges are for trough levels with test taken shortly before the scheduled dose.

• The brand change necessity may provide health professionals with an opportunity to review patient clinical management.  Funding is available from Pharmac to cover the patient co-payment for the two visits associated with this change.

• Waka Kotahi recommends that patients consider a voluntary driving stand-down period of eight weeks following an antiepileptic medication brand change.

• Detailed guidance on the brand change is available on the He Ako Hiringa website

6.   Take a breath

A recent Goodfellow Gem looked at two ways of breathing to improve mood/anxiety based on research from Stanford University which reported how the breathing exercises for 5 minutes per day were better for mood and anxiety than mindfulness meditation, where the breathing is just watched.   

• ‘Sighing’, characterized by deep breaths (a large breath and an extra inhalation) followed by extended, relatively longer exhales, has been associated with psychological relief, shifts in autonomic states, and a resetting of respiratory rate.
• ‘Box breathing’ or ‘tactical breathing’, which military members have used for stress regulation and performance improvement, is inhaling for a count of 4, holding for a count of 4, exhaling for a count of 4 and holding again for a count of 4. The researchers asked participants to breathe in through their noses and out through their mouths.

March 2023

Shownotes

Clinical Snippets March 2023  

1. Prescribing and equity resource – practice improvement 

• The He Ako Hiringa agency’s mission is to contribute to creating equitable access to funded medicines, by providing education and updates to primary care clinicians.  You can register with the agency and access a variety of educational resources related to equitable and best practice prescribing.   

• This includes your own EPiC dashboard which facilitates learning and reflective activities comparing your personal, practice and national prescribing data on an increasing number of themes such as equitable prescribing of cardiovascular medications for patients with CVD, antibiotic stewardship, asthma and diabetes prescribing.  Highly recommended!   

2.   Kiwifruit for constipation 

• Kiwifruit is a commonly suggested treatment for constipation in New Zealand and previous studies (here and here) examining the effects of kiwifruit on patients with constipation have demonstrated potential benefit. However, clinical guidelines favour the use of soluble fibre bulking agents as first line management options for patients with constipation.  

• With New Zealand currently experiencing ongoing supply issues with funded psyllium husk powder and other laxative products, patients need more options for symptom relief.  A 2023 paper published in the American Journal of Gastroenterology examined the effects of daily kiwifruit consumption on gastrointestinal function and comfort. This randomised controlled trial provides evidence that consumption of kiwifruit is beneficial for people with constipation and may have greater benefit than psyllium husk. 

• For further information on the management of constipation, see: https://bpac.org.nz/2019/constipation.aspx 
• For further information on the management of irritable bowel syndrome in adults, see: https://bpac.org.nz/BPJ/2014/February/ibs.aspx 

3.  New Zealand-based online CBT course for OCD released 

• Just a Thought is a New Zealand organisation that offers free online cognitive behavioural therapy (CBT) courses and hosts other resources for a range of mental health conditions. A new online CBT course has now been released for people with obsessive compulsive disorder (OCD). The course has been adapted for New Zealand from an Australian online CBT course for OCD. The Australian course by This Way Up has been evaluated in a randomised controlled trial showing good efficacy. 

• In many areas across New Zealand, there are significant wait times to access publicly funded psychological or psychiatric services, or even sometimes private services. Online therapy courses for OCD may have a role in supporting patients while they await access to secondary care services.  The course can either be completed by the patient in a self-guided manner or through prescription by a clinician. Adherence rates are higher when a clinician prescribes the course and incorporates it into their follow-up consultations. 

• For further information on the recognition and management of a patient with OCD, see: https://bpac.org.nz/2022/ocd.aspx 

4.  CRP and paediatric abdominal pain 

• A recent issue of NZ GP Research Review commented on a Dutch retrospective study looking at the added value of CRP to clinical features when assessing appendicitis in children with acute abdominal pain in primary care.  The study showed the sensitivity and specificity of a CRP cut-off ≥10 mg/L were 0.87 and 0.77 respectively. When symptoms lasted > 48 h, this sensitivity increased to 1.00. Positive predictive values for CRP alone were low (0.18–0.38) for all cut-off values.   

• The reviewer noted:  Point-of-care CRP testing is very common in the Netherlands. It is used in identifying viral versus bacterial infection especially for acute respiratory symptoms in children and this study demonstrates that it is valuable in diagnosing acute appendicitis versus mesenteric lymphadenitis, which can have very similar symptoms and signs.  If CRP is <10 mg/L along with non-progressive symptoms over a 48-hour time span, appendicitis is unlikely. 

5.  Croup and steroids 

• A recent PEARL in NZ Doctor  looked at the question:  Are glucocorticoids effective and safe for treating croup in children aged 18 years and under?  Citing a Cochrane systematic review, the bottom line is that compared with placebo, budesonide (2mg per nebuliser) and dexamethasone reduced the symptoms of croup within 2 hours of treatment, with the effect lasting at least 24 hours. One trial showed that prednisolone reduced the symptoms of croup within 6 hours, with the effect lasting at least 12 hours. One trial showed that fluticasone did not reduce the symptoms of croup after 2, 6 or 24 hours compared with placebo. 

• There was little to no difference between dexamethasone and prednisolone for reduction in croup symptoms 2 hours following treatment, and likely no difference after 6 hours. However, dexamethasone probably reduced the rate of return visits and/or (re)admissions for croup by almost half.   A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg but more studies are needed to confirm this.  

• Starship Hospital croup guidelines include the following recommendation:  Oral dexamethasone 0.15mg/kg/dose and oral prednisolone 1mg/kg/dose are both as effective as oral dexamethasone 0.6mg/kg/dose. In the community, where oral dexamethasone may not be available, community providers can prescribe oral prednisolone at 1mg/kg/dose once daily for 2 days. 

• It is important to differentiate the steroid advice for croup ad asthma from that for bronchiolitis where Starship Hospital and BPAC guidance advises:   

• Do not administer beta-agonists 
• Do not administer corticosteroids (systemic or nebulised) 
• Do not administer adrenaline (except in peri-arrest/arrest) 
• Do not administer hypertonic saline 

• Antibiotics and antivirals are not indicated in bronchiolitis 

6.  Prescriber Update 

The March 2023 Medsafe Prescriber Update included the following updates and reminders: 

(i)  Risk of neurotoxicity with cephalosporins 

• There have been reports of neurotoxicity with cephalosporins, including encephalopathy, seizures and/or myoclonus.  Risk factors include older age groups, renal impairment, underlying central nervous system disorders and intravenous administration.    
• Consider cephalosporins as a potential cause of neurotoxicity in patients with these risk factors and an unexplained, new onset neurological condition.  Symptoms of neurotoxicity have been reported to develop within several days after starting treatment and to resolve following discontinuation.  NB maximum doses dependent on eGFR are listed in NZF and drug data sheets. 

(ii)  Lithium and new diabetes agents 

• Sodium-glucose co-transporter 2 (SGLT2) inhibitors, such as empagliflozin and dapagliflozin, may increase the renal excretion of lithium and lead to decreased serum lithium levels. 

• Monitor the patient’s serum lithium levels more frequently when a SGLT2 inhibitor is initiated or following dose changes. Adjust the lithium dose if necessary. 

(iii)  Metoclopramide in children and young adults 

• Due to the risk of dystonic side effects, metoclopramide use in children and young adults (aged 1 to 19 years, inclusive) is limited   to certain conditions and for second-line therapy.  NZF states:  Patients under 20 years:  Use restricted to severe intractable vomiting of known cause, vomiting of radiotherapy and cytotoxics, aid to gastro-intestinal intubation, premedication; dose should be determined on the basis of body-weight. 
• Dystonia can occur after a single dose of metoclopramide and occurs more frequently in children and young adults, and in females. 
• Do not use in people under 20 years of age unless absolutely necessary, and then strictly follow the dose recommendations in the metoclopramide data sheets to reduce the risk of dystonic side effects.