June 2024

CLINICAL SNIPPETS JUNE 2024

1.  Child Disability Allowance

• MSD wishes to remind primary care providers of the Child Disability Allowance (CDA).  CDA is paid in recognition of the extra care and attention a caregiver needs to provide for a child or young person with a serious ongoing health condition or disability. The eligibility criteria include the applicant being the main carer of the child and a NZ citizen or permanent resident with both carer and child living and intending to stay in NZ.  The child must be under 18 years and assessed by you as needing constant care and attention for 12 months or more because of a serious disability.

• The child or young person must need constant care and attention, over and above the ordinary care and attention required by a child or young person of the same age.  This might include frequent attention from another person in connection with their bodily functions or daily living activities, substantially more attention and supervision than is normally required by a child of the same age and gender, or regular supervision from another person to avoid substantial danger to themselves or others.  Examples of situations where the CDA might or might not be considered, and review times, are available on the MSD website. 

• The CDA is currently $59.23 per week.  It is not taxable or means tested and is provided in recognition of the extra care and attention the child requires.   It isn’t paid to cover costs associated with the child or young person’s disability as these costs aren’t in themselves a qualification for the Child Disability Allowance. However, if the child’s condition does result in significant costs, they may be eligible (in addition) for the Disability Allowance which is means tested. 

2.  Isotretinoin and suicide risk

• A paper reviewed in issue 56 of Dermatology Research Review looked at risk of suicide and psychiatric disorders among isotretinoin users via a meta-analysis of studies involving  over one and a half million patients.  The findings included the 1-year absolute risk of completed suicide, suicide attempt, suicide ideation, and self-harm among isotretinoin users was less than 0.5% each, while that of depression was 3.83%. Isotretinoin was not associated with the relative risk of all psychiatric disorders, and isotretinoin users were less likely than nonusers to attempt suicide at 2 to 4 years following treatment.  These findings indicate that there is no epidemiological evidence to suggest an increased relative risk of suicide or psychiatric conditions among isotretinoin users at a population level.

• The authors note that relationship among acne, isotretinoin, and psychiatric disorders is a complex one. Some studies have provided strong evidence for a direct causal relationship between isotretinoin use and mood changes in rare individuals, via biological effects on the central nervous system. This may be an idiosyncratic reaction that is difficult to predict. However, there may be a second indirect effect of isotretinoin on improved mood, mediated by improved acne and self-image which is consistent with the meta-analysis findings.  Hence, while clinicians should remain vigilant and continue to practice holistic psychodermatologic care and monitor patients for signs of mental distress during isotretinoin treatment, they should be aware that isotretinoin appears to be safe at a population level.

3.  Scabies

• Another paper reviewed in Dermatology Research Review compared the efficacy of topical permethrin (the only topical scabies treatment available in NZ) with benzyl benzoate (BB) for treatment of scabies.  They found a dermoscopy-verified cure rate of 27% in the permethrin group and 87% in the BB group, although the permethrin was far better tolerated than the BB (43% experienced burning sensation).

• The reviewer (dermatologist Dr L Reiche) noted there are concerns regarding resistance to permethrin.  The current regimen is to apply permethrin from head to toe and wash off after 8–12 hours and then repeat after 1 week.  She suggests with more severe infections permethrin can be applied either daily for 1 week or for 3 days in a row followed by a repeat course after 1 week. It is important to treat contacts. Make sure the hands, face, scalp and under the nails are treated.

• Health Pathways has a section on scabies treatment that includes considering oral ivermectin (requires Special Authority) for certain situations where oral treatment will be easier to implement, or if topical treatment fails and to repeat the dose after 7 days.  For more comprehensive discussion and advice, there is an excellent 2022 BPAC article available.

• NZF notes that ivermectin is not approved for more than 2 doses in a course of treatment for scabies and to round the dose to the nearest 3 mg for adults. There is a rare risk of serious or fatal encephalopathy if the patient is co-infected with Loa-loa (African eye worm – endemic to Central and West Africa, where it is transmitted by deerflies). 

4.  ED in a young gym-goer

• A recent NZ Doctor article presented the case of a younger male requesting sildenafil for ED.  It transpired this apparently fit gym goer was using self-obtained anabolic-androgenic steroids for muscle bulking and had developed secondary hypogonadism.  The author notes that anabolic-androgenic steroids (AASs) are one of the major concerns in professional and amateur athletes, particularly young men in their 20s and 30s who practise weightlifting to increase their muscle mass and improve their physical appearance. The prevalence of AAS use/abuse in this population is estimated to be approximately 5 per cent among all gym-goers (in a single study in Germany, it reached 13.5 per cent of gym clients) and 25–50 per cent among competitive bodybuilders.

• The article discusses the multi-disciplinary approach (GP/endocrine/SH/psychologist) required if the patient wants to stop use of AASs and that on-demand sildenafil or daily tadalafil can be used temporarily to improve erectile function, as a component of the MDT plan. Isolated on-demand prescription of sildenafil for anabolic steroid induced hypogonadism (as requested by the patient) is futile as it is doomed to failure and can only serve the unhelpful purpose of delaying the comprehensive management of the syndrome.  However, one survey of AAS users found that 58.1 per cent of respondents felt it was unlikely or very unlikely they would stop AAS use in the next five years.  Message:  Ask about AAH use in younger patients presenting with ED. 

5.  PRESCRIBING UPDATES

(i)  Pharmac is funding the first single inhaler triple-therapy from 1 May 2024. Fluticasone furoate with umeclidinium and vilanterol (branded as Trelegy Ellipta) will benefit around 15,000 people with chronic obstructive pulmonary disease (COPD) in the first year of funding. For most people, this will mean switching from using two or three separate inhalers to using just one. NZ Formulary notes the indications as:  maintenance management of asthma in those not adequately controlled with combination inhaled corticosteroid and long-acting beta₂-adrenergic agonist; maintenance treatment of moderate to severe chronic obstructive pulmonary disease.

(ii)  May NZF updates refer to a new section on Testosterone and management of menopausal symptoms.  This notes topical low-dose (10 mg/mL) testosterone cream may be considered for post-menopausal females who experience concern with hypoactive sexual desire dysfunction.  [Ssection 29, unapproved medicine – Androfeme $153 – 50mL tube, dose 0.5 – 1 mL daily.  The subsidised male formulations, Testogel, come in a 1% and 1.6% formulation with amounts dispensed per actuation of 12.5mg and 20.25mg respectively].     Careful education and correction of modifiable biopsychosocial factors affecting sexual desire should be trialled prior to testosterone treatment and referral to a specialist should be considered. Measure base-line testosterone level, liver function, full blood count, HbA1c, and lipids prior to treatment. Testosterone level should be measured again after 4–6 weeks to ensure the normal pre-menopausal female range is not exceeded. Reassess all parameters 6 and 12 months after initiation and then at least annually thereafter once treatment is stabilised. Discontinue after 6 months if no improvement in sexual function. Long-term safety data (longer than 24 months) for the use of testosterone in females at physiological doses is lacking, refer to product literature.

(iii)  ACEs – new starting dose for hypertension in individuals who are elderly, on concomitant diuretics, or at risk of ACE inhibitor-induced hypotension: 

• Quinapril, lisinopril,   5mg daily
• Captopril 6.25 – 12.5mg
• Perindopril 2mg
• Enalapril 2.5mg

(iv)  Quinolones:  new note added to cautions: Quinolones have been associated with prolonged, disabling, and potentially irreversible serious adverse reactions with reference to a September 2023 Prescriber Update .  Potential adverse reactions listed under this heading are:

• Tendon damage
• Aortic aneurysm/dissection
• Heart valve regurgitation
• Seizures
• Psychiatric changes
• Peripheral neuropathy

(v)  Aspen NZ, the supplier of Eltroxin® (levothyroxine) has informed Pharmac that the 50mcg and 100mcg tablets are changing in appearance. The new Eltroxin® (levothyroxine) 50mcg and 100mcg tablets were listed on the Pharmaceutical Schedule from 1 May 2024.  Aspen NZ has provided some materials to prepare you, and people who take Eltroxin, for this change:

• Eltroxin® health care professional letter
• Eltroxin® Tablet Guide for health care professionals
• Your Eltroxin® is changing (Thyroid Medication) – patient flyer

(vi)  Medsafe have released a safety alert regarding oral promethazine products with the following information:

• Promethazine (oral) is now contraindicated in children under 6 years of age (previously under 2 years of age).
• A safety review identified a high risk of psychiatric and central nervous system side effects in this age group, including psychomotor hyperactivity, aggression and hallucination. Difficulties in learning and understanding, such as reversible cognitive deficit and intellectual disability, may also occur when high doses are given.
• Use alternative treatment options for children under 6 years of age requiring allergy or nausea treatment. Refer to local guidelines.
• There will be a time lag before medicines with updated package labelling are available in pharmacies.
• Remind consumers who may have this medicine at home not to use it in children under 6 years of age and to consult a pharmacist or doctor for alternative treatment options and advice.

6.  He Ako Hiringa and the EPIC Dashboard

• Pharmac sponsorship of He Ako Hiringa ends on 30 June 2024 but the service will continue under new ownership although with reduced staffing resource which will mean a reduction in publication of new resources.  Prescribing data is currently available as at 31 December 2023. 

• The EPiC dashboard uses dispensed medicine data to create an interactive, personalised, report-style dashboard. Once logged in, you can explore prescribing trends for your patient population, your practice and nationally for a range of defined themes with RNZCGP approved audit and reflection templates available for completion.  Prescribing themes you can explore currently include antibiotic use, type-2 diabetes, asthma, opioids, gout, CVD and youth mental health. 

7.  The end

The early May issue of NZ Doctor (requires log-in) contains a medicolegal article on knowing your rights in the face of threatening behaviour from patients.   It is presented as a series of scenarios including: 

• The patient is verbally abusive and rants at staff, causing us to feel unsafe. We want to call the police, but the patient says that if we do, it will be a breach of their privacy. What can we do?   Rule 11 of the Health Information Privacy Code 2020 provides that you can disclose information if it is “necessary to prevent or lessen a serious threat to public health or public safety, or to the life or health of the individual concerned or another individual”. The disclosure must be to someone who can do something about the threat (eg, the police).

• The patient yelled at the receptionist and upset waiting patients. We don’t feel safe having them on our books, but no other practice has room for new patients. Do we have to keep them as a patient?  No. You can end the relationship or, as a compromise, enter into a behaviour contract to give the patient another chance. As long as the patient does not require urgent care, then the Medical Council of New Zealand guidelines for ending a doctor–patient relationship specifically allow that “if the patient is abusive, violent or poses a significant safety risk to you or your colleagues”, you can end the relationship. This is provided the steps are followed as set out in the MCNZ guidelines.

• The article also covers issues such as when and how to issue a trespass notice and when you might consider applying for a restraining order.  Of course lower level resolution of issues that might lead to such behaviours is preferred and de-escalation training is available through a number of agencies (eg WorksafeReps) and a 1 hour training webinar is presented on My Health Hub.