Clinical Snippets March 2024

Dr Dave Maplesden educates Dr Jo about….

CLINICAL SNIPPETS – MARCH 2024 

1.  Prescribing 

Health Pathways has released a new section on practical prescribing aimed mainly at new prescribers but some helpful reminders for veteran prescribers.  Covers most general aspects of prescribing including legal requirements.  Some practical information includes: 

• If you prescribe intermittent PRN medicines e.g., two tablets QID PRN, without ordering a specific amount then the pharmacy will dispense the maximum allowable amount i.e., 720 tablets for three months. If you continue to print this medicine automatically on your repeat prescriptions the patient is liable to receive excessive amounts. This has safety implications, especially if it is a medicine of potential abuse such as codeine-containing medicines. 

• When a patient tells a prescriber they have different numbers of each of their medications, write “Please vary quantities for patient stock management.” Pharmacists can then dispense the required quantities to bring medications into line. 

• Patients not eligible for pharmaceutical subsidies but covered by ACC  for an injury may be eligible to claim back the cost of usually subsidised prescriptions related to that injury using an ACC249 form (which the pathway suggest the prescriber gives to the patient) 

• Pharmacists check that a medicine or a dose of medicine is correct by comparing the new prescription with the patient’s medicine history.  To avoid the pharmacist needing to check with you that a change in the prescription is deliberate, please underline and annotate any change from the previous prescription. Annotation of changes is important. Pharmacists’ systems are not linked and if a patient does not return to the same pharmacy, the pharmacist may be unaware of a change in prescription for that patient. 

• Advice on medications that can be compounded into liquid form by the pharmacy is available on the Pharmaceutical Society website. 

2.  Concussion   

• BPACs Best Practice Bulletin: Issue 92 includes updated Sport Concussion Guidelines from ACC including a six-stage graduated return to education/work & sport protocol.  It is worth familiarising yourself with the protocol to ensure patients are given a consistent message regarding return to sport.  The protocol notes day 14 is the earliest time at which return to normal work/study and sports specific training should be considered, and day 21 is the earliest at which return to competitive sport should be considered.  

• There is reference to the recent ACC statement on post-concussion syndrome:  ACC considers that post-concussion syndrome is an unhelpful and out-dated clinical construct. Our view is that there are risks inherent in continuing to diagnose clients with this condition, not least that disabling symptoms will be misattributed to this condition rather than to potentially reversible medical, psychological, or psychiatric factors that remain undiagnosed and untreated. Consequently, ACC no longer accepts ‘post-concussion syndrome’ as a covered injury. Where clients/patients have persisting symptoms that clinicians consider are caused by concussion, the appropriate covered injury would be ‘concussion’. Symptoms that persist beyond three months are most appropriately described as ‘persisting concussion symptoms.’ 

• I’ll put in my regular plug for use of the Brain Injury Screening Tool (BIST-2) (not just for sports related concussion) which is validated for patients aged over 8 years and is designed to be completed in about six minutes.  It gives objective baseline and progress measures covering physical, vestibular-ocular and cognitive symptoms of concussion.   

• There is an excellent 2022 BPAC article on diagnosing and managing concussion in primary care.    

3.  Two defibrillators? 

• The February edition of NZ Doctor describes a new emergency procedure for cardiac arrest known as double sequential external defibrillation (DSED) which has been adopted here, the second country after Canada to do so.  The article notes that early defibrillation can dramatically improve the likelihood of surviving a cardiac arrest but around 20% of patients whose cardiac arrest is caused by VF or pulseless VT don’t respond to the standard defibrillation approach.  The use of DSED has been shown to double the survival rate of such patients.  

• DSED provides rapid sequential shocks to the heart using two defibrillators. The pads are attached in two different locations: one on the front and side of the chest, the other on the front and back. A single operator activates the defibrillators in sequence, with one hand moving from the first to the second. New Zealand ambulance data from 2020 to 2023 identified about 1,390 people who could potentially benefit from novel defibrillation methods. This group has a current survival rate of only 14%.   

• Relevant paramedic guidelines are to be updated reflecting the new approach including that if ventricular fibrillation or pulseless ventricular tachycardia persist after two shocks with standard defibrillation, the DSED method should be administered. Two defibrillators need to be available, and staff must be trained in the new approach.   

4.  Equitable prescribing 

• Issue 230 of GP Research Review reviews a recently published study on inequities in pre-pregnancy folic acid use in Central and South Auckland. The study notes that rates of neural tube defects are markedly higher among Māori (4.58/10,000 live births), and Pacific peoples (4.09/10,000 live births) as compared with non-Māori, non-Pacific peoples (2.81/10,000 live births).  

• Only 46% of the 400 women surveyed as part of the study reported using pre-pregnancy folic acid supplementation. Rates were lower among women who did not intend to become pregnant (21%) or were “pregnancy-ambivalent” (27%) than in those who intended their pregnancy (58%). Women who identified as European, Middle Eastern, Latin American or African were around five times more likely to use supplementation than Māori.  Supplementation was also more likely among those managed by a private obstetrician versus a midwife and in women aged over 30 years. 

• The study concluded Low rates of pre-pregnancy folic acid supplementation exist in Auckland with significant ethnic disparity. Mandatory fortification of non-organic wheat is important, but supplementation is still recommended to maximally reduce risk. 

5.  Medication supply issues and brand changes 

• Morphine oral liquid (RA-Morph) 1 mg per ml and 10 mg per ml strengths are out of stock, and remaining supply of RA-Morph 2 mg per ml and 5 mg per ml will expire at the end of March.  Re-supply RA-Morph 1 mg per ml is expected by June-2024. Other strengths of RA-Morph are expected later in 2024.  This leaves two unapproved but funded (s29) brands of 2mg per ml strength available – Wockhart and Oramorph.  Further detail and prescribing advice is available on He Ako Hiringa website.   
• Omeprazole 20 and 40mg capsules – monthly dispensing from 1 March 2024 until stocks arrive (expected April 2024) 

• Oestradiol valerate 1mg tabs (Progynova) – monthly dispensing from 1 March 2024 until stocks arrive (expected June 2024).  2mg tabs not affected. 
• Mesalazine 800mg tabs (Asacol) – shortage expected until July 2024.  Two x 400mg tabs suitable alternative 
• Olsalazine 250 and 500mg tabs (Dipentum) – both unavailable with 500mg expected available from April 2024.  Consider change to alternative medication eg mesalazine 
• The funded bisoprolol brand is changing from 1 April 2024 when bisoprolol-Mylan and Viatris will no longer be funded.   A patient information leaflet about the brand change is available on the Pharmac website.  
• From 1 March 2024, Pharmac has removed the requirement for annual renewal of SA numbers for patients taking sacubitril with valsartan (Entresto), for heart failure.  
• Modafinil – contra-indications (contraindicated in pregnancy), contraception and conception, pre-treatment screening, and patient advice has been updated in NZF.  This includes pretreatment screening with BP, ECG and excluding pregnancy, and Effective contraception is recommended during treatment and for 2 months after stopping treatment. Effectiveness of hormonal contraception (including contraceptive pills, implants, injectables and hormone releasing intrauterine devices) may be reduced.  The UK FSRH gives current guidance on contraceptive options in patients taking enzyme inducers.    

6.  Frank’s sign 

Issue 111 of Cardiology Research Review reports a Spanish study looking at Frank’s sign (Sanders T Frank – 1973) and cardiovascular risk.  Frank’s sign is a diagonal earlobe crease.   The estimated cardiovascular mortality risk was significantly higher in individuals who presented diagonal earlobe crease. The number of individuals with moderate, high, or very high cardiovascular risk increased significantly as the presence of the crease increased (23.8% had no crease, 35.6% had unilateral creases, and 58% had bilateral creases). The mean cardiovascular risk estimated was significantly higher for individuals with longest and deepest diagonal earlobe crease, and with accessory creases.  The conclusion:  The diagonal earlobe crease is independently associated with higher cardiovascular risk scores, especially when the crease is complete, bilateral, deep, and has accessory creases.  

7.  The limping adolescent 

• Beware the child with unexplained limp or knee pain.  I’ve recently reviewed a case of missed diagnosis of SUFE in a slim 11yo female which had disastrous consequences for her – stable mild slip converting to a severe acute slip. 

• Health Pathways has a section devoted to SUFE partly because of the potentially severe consequences of missed or late diagnosis.  This includes the practice point:  All children complaining of knee pain need exclusion of hip pathology. If there is no evidence of knee pathology on examination, arrange hip X-ray with AP pelvis and frog lateral view.  However, if you suspect an acute SUFE on the basis of history and examination, refer immediately for orthopaedic assessment rather than imaging.   

• As a quick refresher, SUFE usually occurs in the 8-15 year age group, more common in males and a more than half of sufferers are overweight or obese.   The most common presentation is a chronic slip with gradual movement of the epiphysis and the patient may present with vague chronic or intermittent aching pain in hip, groin, thigh or medial knee. 15% of patients only have thigh or knee pain. Pain worsens with physical activity and there is usually no preceding trauma. It may be bilateral (18-50%).  An acute slip presents after a sudden event with inability to weight bear and appearance of a hip fracture.  You can get an acute slip on background of a chronic slip (sudden exacerbation of symptoms in a setting of more consistent low-grade symptoms, may be episodic). 

• A chronic slip may present with persistent or episodic limp. Foot on the affected side may be out-turned. Loss of internal rotation at hip.  Leg length shortening may be present.  When the hip is flexed passively to 90º, the thigh will abduct and roll into external rotation. Examine the knee to rule out local process at the knee to account for knee pain.  With an acute slip there is a marked limp and Trendelenburg gait and often an inability to weight bear.  There may be an external rotational deformity of the hip and shortening of the affected leg. 

• The annual incidence of SUFE in the 0–16-year age group is around 5/100,000 meaning around 40-50 cases in NZ annually so you may never see one.  An Australian study suggests there is delayed diagnosis (weeks to years) in around 60% of cases of chronic stable slip, and most patients (76%) present initially to their GP.      

Clinical Snippets November 2023

1. Non-subsidised medications for beneficiaries

A recent issue of GP Voice described how patients can apply for non-subsidised pharmaceuticals to be included in Disability Allowance

The cost of an ongoing non-subsidised pharmaceutical can be included as an expense for Disability Allowance if you, as the client’s medical practitioner, verify that the pharmaceutical item is essential and there are no suitable subsidised or partly subsidised alternatives.

Examples of non-subsidised pharmaceuticals include melatonin, empagliflozin, dulaglutide, liraglutide, medicinal cannabis products and others, but to be considered it must be confirmed that any subsidised or partly subsidised alternatives are not suitable for your patient.

The application requires a Disability Allowance medical certificate and a letter from you confirming:

• the reasons for prescribing the non-subsidised pharmaceutical
• that there is not a suitable subsidised or partly subsidised alternative
• that the medication is essential and directly related to the client’s disability
• if PHARMAC funding has been applied for and declined, the reasons for this decision
• if there is no suitable subsidised or partly subsidised alternative, and if PHARMAC funding has not been applied for, the reasons why funding has not been sought.

For further information, please contact cathy.stephenson006@msd.govt.nz

2.  RNZCGP statement on medical cannabis prescribing

(i)  ARNZCGP statement on medicinal cannabis prescribing has been recently released. Pertinent points include:  The College…

• neither recommends nor encourages the use of medicinal cannabis products; however, it recognises that as specialists, GPs may offer to prescribe medicinal cannabis products. The sole medicolegal responsibility for prescribing rests with the prescriber.
• has assessed the evidence about the safety and effectiveness of medicinal cannabis products that have not been approved as medicines by Medsafe and has found it to be limited and inconclusive.
• asserts that medicinal cannabis products should only be considered when all first-line, conventional, evidence-based treatment options have been exhausted.
• supports specialist GPs who, based on their clinical assessment, decline to prescribe or to issue a repeat prescription in response to patient requests for medicinal cannabis products that have not been approved as medicines by Medsafe.
• reminds specialist GPs that if they have concerns about the prescribing or record keeping of a prescriber, they should talk to them directly in the first instance. If their concerns remain, they should consider notifying the Medical Council of New Zealand or the Health and Disability Commissioner.

(ii)  BPAC provided a comprehensive article on prescribing of medicinal cannabis last year.  The Ministry of Health constantly updates its medicinal cannabis product website with medicinal cannabis products that have met the minimum quality standard under the Misuse of Drugs (Medicinal Cannabis) Regulations 2019.  However, it is important to note the products that are listed as having been verified as meeting the minimum quality standard are unapproved medicines – there has been no assessment of their safety or efficacy. Being listed does not guarantee that the products is currently available in New Zealand.  Medsafe has published advice on use of unapproved medicines or approved medicines for unapproved conditions and this advice is contained in the NZMC statement on good prescribing practice which also notes:  Medicines or treatment must not be prescribed for your own convenience or simply because patients demand them. 

(iii)  On a related note, Medsafe has reclassified the medicinal cannabis product, cannabidiol (CBD), from a prescription-only medicine to a restricted (pharmacist-only) medicine, aligning the NZ approach with Australia, which made a similar change in December 2020.  While no CBD products are currently approved in New Zealand, this change means that from mid-October 2023, any low-dose CBD product which becomes approved in the future can be supplied by registered pharmacists to patients over 18 years.  The supply is restricted to medicines with dosing instructions for 150 mg or less CBD per day and containing not more than 4.5 grams, when sold in the manufacturer’s original pack. 

3.  IFNAR1 deficiency

Having recently reviewed a case of adverse reaction to MMR vaccination related to IFNAR1 deficiency, I came across a statement from Te Whatu Ora released in 2020 but last updated in June this year, which includes the following information:

• IFNAR1 deficiency is an extremely rare immune disorder that results in the individual’s immune system not responding to certain viruses. The disorder requires genetic testing to be diagnosed and cannot be prevented. IFNAR1 deficiency was only discovered in 2019.

• This genetic condition increases the risk of serious illness and death to the individual when they are exposed to certain viruses, including measles and COVID-19.

• IFNAR1 deficiency also increases risk of severe reaction from some vaccines containing weakened live virus such as MMR, yellow fever, and possibly varicella vaccines. Other childhood vaccines and COVID-19 vaccines can be safely given to someone who has IFNAR1 deficiency.

• The study identifying the mutation suggests that some Pacific groups (people with Samoan, Tongan and Niuean heritage) could be at more risk of having the deficiency than the general population. Initial estimates are that the number of children with two Samoan parents who may be affected is 1 in every 6,450 births. Although equivalent data in Tongan and Niuean populations is lacking, cases have occurred where parents are Tongan or Niuean. This may roughly equate to one child per year born in Aotearoa New Zealand, but much more work is needed. For comparison, cystic fibrosis affects about 1 in every 3,500 births.

• Health care providers may wish to inform aiga or whanau of children with Samoan, Tongan and Niuean heritage of the newly discovered risk as part of obtaining informed consent for the first dose of MMR at 12 months. It is important to also provide information about the risks associated with deciding not to vaccinate against measles, mumps and rubella. We know the risks of not vaccinating, are far greater than the risks of vaccinating. If an older sibling or relative had a severe illness following MMR this should be discussed with immunisation experts.

4.  Emergency contraceptive pill

Issue 224 of GP Research Review  reviewed an interesting Lancet article on combining piroxicam 40mg with standard levonorgestrel EC  (LNG-EC) dose of 1.5mg concluded the combination of levonorgestrel plus piroxicam prevented 94.7% of expected pregnancies versus 63.4% with levonorgestrel plus placebo. There were no differences in advancement or delay of the next period, nor in the adverse event profile.   A response to the article by the UK FSRH notes that LNG-EC acts to delay ovulation until sperm from unprotected sex that has already taken place are no longer viable, thus preventing fertilisation. There are not significant post-ovulatory contraceptive effects, therefore LNG-EC can be effective only if taken early enough in the menstrual cycle to delay ovulation.  The rationale for the trial of piroxicam was that as prostaglandins support ovulation, fertilisation, tubal function and implantation, COX inhibitors (which inhibit prostaglandin production) could act synergistically with LNG-EC to affect ovulation, and could also have post-ovulatory contraceptive effects.  The study did not compare effectiveness of use prior to ovulation with use after ovulation as it had intended, because too few individuals agreed to have blood tests. And no comparison was made between individuals with higher and lower BMI and weights.  FSRH concluded that while in certain settings, LNG-EC/piroxicam could offer an alternative to use of LNG-EC alone, their current guidance regarding emergency contraception remains unchanged.

Current Health Pathways guidance includes:

• Offer Cu‑IUD unless contraindicated.  Cu‑IUD is the first choice EC unless contraindicated because it is the most effective method of EC.

• LNG-EC is effective when taken as soon as possible after coitus, preferably within 12 hours, but within 72 hours. Pregnancy rate after taking oral LNG‑EC within 72 hours of unprotected sexual intercourse (UPSI) is approximately 2.2%.
• Efficacy has been demonstrated for up to 96 hours (unapproved indication).
• Efficacy diminishes with time.
• There is no evidence that oral emergency contraception is effective if taken after ovulation or more than 96 hours after UPSI.

The FSRH guideline on emergency contraception includes a useful one-page algorithm to aid in choosing EC taking into account factors such as time since UPSI, previous UPSI in the same cycle, and proximity of UPSI to ovulation.  Note there is an additional oral EC preparation available in the UK  (Ulipristal) which is a little more efficacious than levonorgestrel although again only if used prior to ovulation. 

5.  Urinary retention – what not to take

• I have reviewed a complaint recently relating to development of acute urinary retention in a man with pre-existing LUTS suggestive of bladder outflow issues (poor stream and frequency) who was prescribed oxybutynin for urinary frequency.  He was not provided with any information regarding the risk of urinary retention and had Googled the drug and noted contraindications included significant bladder outflow obstruction.

• Had he been provided with a NZF patient information leaflet, this refers to potential side effect of trouble peeing – inform your doctor  and also to remind your doctor before taking the drug if you have known prostate problems.

• The list of drugs that may cause retention is quite lengthy and includes some anticholinergic agents, SSRIs, calcium channel blockers, opioids, first generation antihistamines, TCAs, some NSAIDs, and many antipsychotics including quetiapine.  It is certainly worth considering your older male patient’s LUTS if you are considering prescribing any of these. 

6.  Advantages of retirement

NZ Research Review Issue 225 includes review of a study that examined the associations of retirement with cardiovascular risk factors and disease. Overall, 106,927 individuals aged 50–70 years were included in the analysis. During a mean follow-up of 6.7 years, there was a 2.2 percentage-point decrease in the risk of heart disease and a 3.0 percentage point decrease in physical inactivity among retirees compared with workers. In people with high educational levels, retirement was associated with decreased risks of stroke, obesity and physical inactivity. In people who retired from non-physical labour, retirement was associated with reduced risks of heart disease, obesity and physical inactivity. However, those who retired from physical labour were at increased risk for obesity.

7.  Resource – HQSC updated frailty care guides

• HQSC has released updated frailty care guides. The guides are focused on the aged residential care environment; however, they may be helpful in other health care settings serving older people living with frailty. They are designed for use by health care professionals, and they support and do not replace clinical judgement. 

• One guide quite applicable to frail patients inside and outside the  aged care facility environment is that relating to de-prescribing and includes a tool and associated algorithm which aid in identifying medications which are most often suitable for de-prescribing and when stopping or continuing a drug might be indicated.     

• On the horizon is the Polyscan tool developed in NZ, a primary care information technology tool, to triage older adults with polypharmacy who are prescribed potentially inappropriate medicines.  The initial study of the tool involving review of medical records of 300 older patients identified nine individuals (3%) with polypharmacy and indicators of potentially inappropriate medicine. Five unique indicators were detected. PolyScan achieved 100% sensitivity, specificity, and positive and negative predictive values.

Snippets of useful clinical information for New Zealand General Practice

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-September-2023-e2a4m9j/a-aaeded9

Clinical Snippets September 2023 

https://podcasters.spotify.com/pod/show/opotikigp/embed/episodes/Clinical-Snippets-September-2023-e2a4m9j/a-aaeded9

Shownotes

1.  Assessing capacity 

KEY PRACTICE POINTS 

• A person is presumed to have the capacity to make a decision unless there are good reasons 

to doubt this presumption (EOLC Act is an exception). 

• In general, capacity is assessed with respect to a specific decision at a specific time. 
• Assessment is of a person’s ability to make a decision, not the decision they make. A person is entitled in law to make unwise or imprudent decisions, provided they have the capacity to make the decision. 
• Supported decision-making involves doing everything possible to maximise the opportunity for a person to make a decision for themselves 
• Capacity assessment procedures need to consider tikanga Māori and cultural diversity. 

Legal Test for Capacity 

A person lacks capacity if they are unable to: 

• understand the nature and purpose of a particular decision and appreciate its significance for 

them; 

• retain relevant, essential information for the time required to make the decision; 

• use or weigh the relevant information as part of the reasoning process of making the decision and to consider the consequences of the possible options, (and the option of not making the decision); or 
• communicate their decision, either verbally, in writing, or by some other means. 

Useful resources: 

• A Toolkit for Assessing Capacity (Douglass, Young & McMillan) 
• Your local Community Health Pathway (section: Mental Capacity) 

• Goodfellow Unit online course:  Assessing decision-making capacity: the clinical basics and  Decision-making capacity: the legal aspects and the webinar Assessment for Mental Capacity 
• Forms required  for activating EPOA for Property (Form 4) and Personal Care & Welfare (Form 5) 

2.  HPV screening update 

From 12 September, 2023, HPV testing will become the primary cervical screening test in New Zealand.  The National Cervical Screening programme has released a second information pack  that contains information on training and responsibility changes for clinical and administration staff involved in the HPV primary screening process. 

Key points from the pack include: 

• From 12 September, 2023, only primary care clinicians who are accredited to perform cervical screening will be able to offer HPV testing (including offering self-testing); this includes nurses and nurse practitioners who have completed NZQA training in cervical screening as well as doctors and midwives 
• Requirements to allow those not currently accredited to perform cervical screening to offer HPV testing are being developed by the National Screening Unit 
• A summary of required training for specific roles is included.  The Clinical Modules: Cervical Screening using HPV Testing for Clinical – Cervical Sample-Takers, GPs, and Midwives is made up of four e-Learning modules and is available on LearnOnline (Cervical Screening Using Human Papillomavirus (HPV) Testing Programme).  The modules are: 

• MODULE 1 | Introduction to Cervical Screening using HPV testing (60 minutes) 

• MODULE 2 | Navigating the Cervical Screening pathways – practising using the pathways with various cases (30 minutes) 
• MODULE 3 | Cervical Screening in Aotearoa New Zealand – History and Context (30 minutes) 
• MODULE 4 | Talking about Cervical Screening and HPV (60 minutes) 

• Be prepared for a potential increase in uptake of cervical screening due to funding for some groups and the ability to self-test 
• Additional resources include the updated 2023 Clinical Practice Guidelines for Cervical Screening in Aotearoa New Zealand and Goodfellow Unit webinars 

3.  Changes to opioid prescribing 

At the end of July 2023, the Ministry of Health acknowledged the importance of Cabinet making the decision to reduce the maximum limit for opioid prescriptions from 3 months to 1 month. This new limit will apply to both Class B and Class C opioids.  This will bring the prescribing limit for Class C opioids – such as codeine and dihydrocodeine – in line with Class B opioids. Additional regulation changes will result in the re-classification of tramadol as a Class C2 controlled drug from 1 October 2023 although it is exempt from the requirement to be stored in a controlled drug safe.  This means once the relevant legislative changes are enacted (later this year) both codeine and tramadol will have one month prescribing restrictions.  However, methadone will be available as a three-month prescription when being used as part of an OST programme.   

4.  Ferrinject and hypophosphataemia 

A September 2021 NZ Doctor article reviewed hypophosphataemia associated with iron infusion therapy.  Key points included: 

• Iron infusion with ferric carboxymaltose (Ferrinject) is associated with a higher incidence of hypophosphataemia than other formulations.    
• Testing of serum calcium and phosphate levels before iron infusions should only be done for high-risk people such as those with a BMI <18kg/m2 , if the person has chronic diarrhoea or malnutrition, or if the person is to receive a second iron infusion within six months.  HealthPathways recommends seeking general medicine advice if pre-infusion phosphate is less than 0.8 mmol/L (ref range >16y 0.7-1.5), as treatment with calcitriol may be recommended. 
• Testing after an iron infusion is usually based on clinical symptoms.  The mean time to the nadir of hypophosphataemia is usually between one and six weeks. While most recover within three months, there are reports of prolonged recovery time up to two years,although this would require further investigation into cause. Clinical symptoms of hypophosphataemia include tiredness, weakness and muscle pain. 
• Treatment and monitoring of hypophosphataemia depends on severity.  Check calcium, magnesium and renal function. 

• Mild hypophosphataemia – 0.6 to 0.8mmol/L. 

• Phosphate replacement is not usually needed unless symptoms are present. 
• Increase phosphate-containing foods – chicken, seafood, dairy (milk, cheese, yoghurt), nuts and seeds, whole grains. 

• Moderate hypophosphataemia – 0.3 to 0.6mmol/L. 

• Phosphate 16mmol per tablet (Phosphate Phebra), up to one to two tablets three times daily.  Reduce dose if estimated glomerular filtration rate is less than 60ml/min/1.73m² or not tolerated at higher doses (diarrhoea, gastric irritation) 
• Do not give with calcium or antacids (reduces absorption). 
• Each phosphate tablet contains 20mmol sodium and 3mmol potassium; take care in people with heart failure. 

• Severe hypophosphataemia – less than 0.3mmol/L. Refer for intravenous therapy. 

• Monitoring depends on the severity of the hypophosphatasaemia. For severe hypophosphataemia, phosphate concentrations are checked every 24 to 72 hours, but mild hypophosphataemia could be monitored in one to two weeks. If hypophosphataemia is prolonged, check parathyroid hormone and vitamin D levels. 

5.  CAP in children 

Issue 7 of GP Practice Review commented on a recent systematic review and meta-analysis that compared shorter (≤5 days) versus longer treatment with antibiotics for children diagnosed with CAP.  The authors reported no significant differences between short and longer courses of antibiotics in the following areas; 

• clinical cure 

• treatment failure 
• relapse mortality risk 
• need to change antibiotic 
• need for hospitalisation 
• severe adverse events 

The reviewer concluded:  This study provides further evidence that there is no benefit to be gained from longer courses of antibiotic treatment for many infections that are managed in the community. In the case of paediatric community-acquired pneumonia, shorter treatments durations ≤5 days should be recommended with caregivers provided with education about the rationale, which may be counter to information they have previously received.  Current HealthPathways and BPAC guidance refers to a 5-7 day course of amoxicillin with a longer course for alternative antibiotics (7 days for erythromycin and 7-10 days for roxithromycin).   

6.  MHT Algorithm 

A recent article in the British Journal of General Practice gives a succinct summary of key considerations for primary care physicians when prescribing menopause hormone therapy including a helpful algorithm.  The four key considerations are listed as:  

1. Is HRT appropriate (including contraindications) 

2. What preparation and regimen are required 

3. What is the most appropriate route and dose to start on 

4. Is testosterone or vaginal oestrogen required in addition 

Drug names listed are different to NZ and not all formulations discussed are available here but the algorithm is a useful one-page reminder of issues to consider.  Last month Pharmac announced a procurement opportunity that may result in a wider range of transdermal oestrogen products becoming available including a topical gel.  With respect to testosterone therapy in menopause, Goodfellow Unit have a useful resource on this topic including reference to use of a commercially manufactured (not compounded) topical testosterone gel (Androfeme) which can be prescribed off-label under s29 of the Medicines Act at a cost of $153 for 100 days treatment at standard dose.    

7.  The goldilocks approach to measuring blood pressure 

Issue 81 of Best Practice Bulletin comments on the importance of having a variety of blood pressure cuff sizes available at your fingertips.  Most health professionals know that incorrectly sized cuffs can lead to inaccurate blood pressure measurements and the potential for misdiagnosis. A recent randomized crossover trial published in JAMA Internal Medicine reported on blood pressure measurements using an automated measuring device on 195 community-dwelling adults with a wide range of mid-arm circumferences.   Use of a regular BP cuff resulted in a 3.6 mm Hg lower systolic BP reading among individuals requiring a small BP cuff.  In contrast, among individuals requiring a large or extra-large BP cuff, use of a regular BP cuff resulted in 4.8 mm Hg and 19.5 mm Hg higher systolic BP readings, respectively.  Many home-monitoring devices come with a standard size cuff which may not be appropriate for the patient.  The AMA have produced a pamphlet to guide correct cuff-size selection based on mid upper arm circumference.   

8.  Breathe VQ 

 Issue 212 of Respiratory Research Review refers to a recent study validating a short six-item tool – Breathe VQ or the Breathing Vigilance Questionnaire – to assess ‘breathing vigilance’, an important component of dysfunctional breathing.  The reviewer notes that dysfunctional breathing is common in clinical practice. It cannot be fully explained by organic disease and isn’t specific to any specific respiratory disorder with overlap with many conditions including anxiety, asthma, and post-COVID Syndrome (long COVID).   The Nijmegen questionnaire is often used to assess dysfunctional breathing (although has some limitations in applicability) and the Breathe VQ adds another dimension to assessment.    

HealthPathways section on Dyspnoea gives further advice on assessment of patients with persistent breathlessness following recovery from Covid-19 infection and who do not have known respiratory disease.  There is recommendation to consider completing consider completing a 1MSTS test and mMRC score with recommendations for further management (respiratory specialist review, respiratory physiotherapist or respiratory physiologist) depending on results.    

The Goodfellow Unit has a 20 minute podcast on Dysfunctional Breathing Disorders (2021) with a presentation by a physiotherapist on Understanding Breathing Pattern Disorders scheduled for 17 October 2023.    

The New Zealand General Practice Podcast

Dr Dave Maplesden and Dr Jo Scott-Jones

Shownotes

Clinical Snippets – July 2023 

1.  Superficial venous thrombosis (thrombophlebitis) 

(i)  After reviewing a recent case of death from pulmonary embolus in a patient seen a few days previously with an apparent lower limb SVT, I have reviewed HealthPathways guidance as follows.  Superficial venous thrombosis is usually a benign self-limiting condition, when it involves the smaller tributary veins in the lower limb or in the site of an existing varicose vein.  However, when the larger veins are involved (e.g. great and small saphenous veins) or when adjacent to the sapheno-femoral junction, there is risk of a DVT. A DVT may coexist at the time of diagnosis or the clot may extend to the deep veins within 10 days. 

(ii)   The risk for VTE is the highest immediately following a diagnosis of SVT but persists over time particularly in the first three months and decreasing but still significantly higher after five years.  Diagnosis is made by clinical findings, e.g. tenderness, induration, pain, or erythema along the course of a superficial vein.  D-dimer is not considered sensitive or specific enough to predict DVT in superficial venous thrombosis. 

(iii)  Arrange an ultrasound to exclude DVT if any of: 

• There is an involved segment of vein of 5 cm or more. 
• Either the great or the small saphenous vein is involved. 
• There is asymmetrical leg swelling. 

D-dimer is not considered sensitive or specific enough to predict DVT in superficial venous thrombosis. 

(iv)  Consider full oral anticoagulation for 3 months 3 if:   

• superficial venous thrombosis is within 3 cm of the sapheno-femoral junction and/or if the length of the superficial venous thrombosis is more than 5 cm. Also seek vascular surgery advice as ligation at the sapheno-femoral junction may be recommended. 
• other risk factors for DVT (e.g. an inpatient). Also seek haematology advice. 

(v)  If no risk factors, provide local symptom relief and prevent progression to a DVT: 

• Use pain relief, e.g. NSAIDs, for 8 to 12 days if not contraindicated. 
• Treat with elevation of the leg and compression stockings for comfort and to reduce swelling. 
• Only use antibiotics if signs of infection. 
• Encourage the patient to remain ambulatory. 
• Arrange follow-up at 7 to 10 days or earlier if there is deterioration. 

• If symptoms do not resolve, arrange or repeat the ultrasound. 

2.  ACE inhibitors and angio-oedema  

(i)  The Centre for Adverse Reactions Monitoring (CARM) recently received a report of fatal angioedema with an ACE inhibitor. The patient had experienced minor tongue swelling with an ACE inhibitor previously. A different ACE inhibitor was started at a later date, and the patient developed angioedema with a fatal outcome. 

(ii)   Before prescribing an ACE inhibitor, ask patients if they have taken these medicines before and if they had any adverse reactions. Specifically ask about swelling.  Inform patients who are starting ACE inhibitors about the symptoms of angioedema and advise them to seek urgent medical attention if these occur. 

(iii)  Visceral angioedema due to ACE inhibitors has been described in a handful of case reports and reviews. Most commonly, this presents as diffuse abdominal pain and diarrhoea. In more than one-half of the case reports of visceral angioedema, symptoms began within 72 hours of starting ACE inhibitor therapy, although in other reports, angioedema developed after weeks or years of therapy.  Diagnosis is often delayed. 

(iv)  ACE inhibitors should not be prescribed to patients with a history of ACE inhibitor-induced angioedema. Educate patients who have experienced ACE inhibitor-induced angioedema about the need to avoid all ACE inhibitors in the future.  NZF also advises against use of sacubitril-valsartan (Entresto) in these patients.   Most patients can be cautiously switched to an ARB.  A proportion of patients will have recurrence of angio-oedema after stopping the culprit ACE – most commonly within the first month.    

(v)  Angioedema is thought to occur in around 0.1% to 0.7% of patients who take an ACE inhibitor. Onset is usually during the first weeks or months of therapy, but it can occur years into treatment. Angioedema has also been reported with angiotensin II receptor blockers (ARBs; eg, candesartan, losartan), but the risk is thought to be lower than with ACE inhibitors. 

3.  Ivermectin Special Authority criteria amended 

The Special Authority criteria for ivermectin were recently amended (June, 2023). Any relevant practitioner can now complete the Special Authority form for ivermectin in patients with scabies and close contacts who meet Special Authority criteria. Discussion with a dermatologist, infectious diseases specialist or clinical microbiologist is no longer required. 

For information on the management of scabies, including the role of ivermectin, there is an excellent 2022 BPAC update on the topic.   

4. Allopurinol and variable adherence 

A recent NZ Doctor article on allopurinol  prescribing for the non-adherent included some timely reminders: 

• In a person who has become non-adherent to allopurinol (even for one month), do not automatically restart at a previous dose – re-titration is required.  Titration is dependent on renal function (see 2021 BPAC article for details).  Extra caution must be made with repeat prescribing of allopurinol and assuming a person is administering the last prescribed dose when they may not be. 

• The important point around dosing is to commence allopurinol according to renal function using clinical pathways or 1.5mg of allopurinol per eGFR unit as a guide. Note that renal function is used to guide starting doses, but once a person is stabilised on a dose of allopurinol, the dose should not be routinely decreased if renal function deteriorates. 

• Remember anti-inflammatory prophylaxis (and remember to stop this when stable).  This may be low dose NSAID or colchicine (or prednisone if alternatives not tolerated) 

• To mitigate treatment failure, people must be forewarned of the increased risk of flares when initiating allopurinol. It is also necessary to plan for the eventual cessation of anti-inflammatory prophylaxis. Usually, only three to six months is required, although this may be much longer in people with a high urate burden with tophi. 

• For patients with gout and hypertension, losartan or calcium channel blockers are the antihypertensive medicines of choice as they reportedly have mild uricosuric (urate-excreting) properties. Patients who are taking diuretics for hypertension, for reasons other than heart failure, should be switched to an alternative antihypertensive, if possible. 

• Always advise people that if a rash (especially extensive) occurs, they must cease allopurinol and seek medical assistance promptly.  Rash affects around 2% of people taking allopurinol but could be a symptom of allopurinol hypersensitivity syndrome (includes DRESS, Steven-Johnson syndrome and toxic epidermal necrolysis – affects about 1-4:1000 patients prescribed allopurinol and has a mortality rate of up to 27%). Risk factors for AHS include: higher starting dose of allopurinol and rapid titration; recent commencement (6-8 weeks) of allopurinol; coadministration of diuretics (especially thiazide) and amoxicillin; comorbidities of CKD and cardiovascular disease; risk of AHS is nearly 100-fold higher in carriers of the HLA-B*58:01 allele than in noncarriers. Populations with high allele frequency include people of Han Chinese (6%–8%), Korean (12%) and Thai (6%–8%) descent and NZF recommends genetic testing in these high-risk patients and avoiding allopurinol in confirmed carriers unless there is no suitable alternative.  See SaferRx for more details.   

• Māori and Pacific peoples are inequitably burdened by gout. There is also evidence demonstrating Māori and Pacific peoples are less likely to receive regular allopurinol prescriptions.  You can analyse your gout prescribing on the Epic dashboard in He Ako Hiringa including percentage of patients being prescribed urate lowering therapy irregularly, and there are tips for improving gout prescribing equity.    

5.  Topical anaesthesia for chronic painful leg ulcers 

Prilocaine-lidocaine (EMLA) cream has a listed indication of topical anaesthesia of leg ulcers to facilitate mechanical cleansing or debridement with instruction to apply under an occlusive dressing 30–60 minutes before procedure.  Cost:  Around $45 for the Numit brand (30g) from the Chemist warehouse.  The cream has also been studied as a primary dressing for painful leg ulcers and has proved effective.   

 The NZ Palliative Care Handbook also notes use of topical morphine as local pain relief for palliative patients with fungating wounds or ulcers with instructions:   morphine injection added to a gel in a clean environment and used topically may help (0.05 to 0.1% morphine [i.e. 0.5 to 1 mg/mL] in IntrasiteTM gel, metronidazole gel or KY JellyTM).  More detailed instructions including precautions are available as NHS guidance and note this is off-label use of morphine.   Some systemic absorption will occur, and it is most effective for superficial ulcers.  Some studies have shown reduced healing rates in wounds treated with topical morphine.   

6.  Dense breasts 

GP Research Review Issue 216  summarised a 2023 meta-analysis of MRI imaging in screening women at high risk of breast cancer which showed that  MRI alone increased the detection rate of breast cancer versus mammography alone by 8 per 1000 women screened while MRI plus mammography had a better detection rate versus MRI alone by 1 per 1000 women screened.  The article reviewer noted there is conflicting evidence of the impact of ionising radiation from repeated mammography related to repeated mammographic breast screening in women at high risk of malignancy and taking this into account MRI alone may be considered as best choice in such high-risk women. 

This raises the issues of informed choice and equity, particularly if private screening is the only way MRI imaging can be accessed in this situation.  The issue of reporting of breast density and management of women with extremely dense breasts within the Breast Screen Aotearoa (BSA) national screening programme is ongoing with formal reporting of breast density not currently part of BSA reporting requirements (see BSA information sheet) or planned as part of a recent quality improvement review of clinical quality and safety of the programme.  Discussion was stimulated following publication of European Society of Breast Imaging (EUSOBI) recommendations last year which included that women should be informed of their individual breast density and the diagnostic and prognostic implications of having dense breasts, and that supplemental or standalone MRI screening is offered to women with extremely dense breasts, from age 50-70, preferably every 2-3 years.    

7.  On a lighter note… 

Two more fascinating studies summarised in GP Research Review Issue 216 

1.  A randomized controlled trial on the effects of light music played by piano on satisfaction, anxiety, and pain in patients undergoing colonoscopy showed, in the group with piano music, significantly lower anxiety scores and higher overall satisfaction scores, including satisfaction with pain management, following the procedure than the group with no music.  The reviewer notes the results appear to be perfectly tailored to a GP’s waiting room – less anxiety, more satisfaction and less pain. And at no cost! Probably worth swapping the blaring radio ads/music in the waiting room for something soothing like Mozart. 

2.  A randomized trial on the effects of a topical hop extract gel versus topical oestradiol cream for treatment of postmenopausal sexual dysfunction showed no significant differences in the total Female Sexual Function Index (FSFI) or sub-scores (sexual desire, sexual arousal, vaginal lubrication, satisfaction, orgasm, sexual pain) between the two groups. There were no adverse events. Humulus lupulus L. (hop) has been recognised as having antioxidant, anti-inflammatory, anticancer, and oestrogenic properties.  I could not find any vaginal hop creams currently commercially available on line, and the hopeful sounding Tired Hands Hop Cream turned out to be a beer! 

Clinical Snippets February 2023

Clinical Snippets February 2023

1.  Post-partum screening for diabetes

• A NZ retrospective study published recently sought to estimate the proportion of women with a first episode of gestational diabetes who received post-partum type 2 diabetes screening in accordance with local guidance. 
• The study showed only 40% of women were screened within 3 months post-partum and that only improved to 61% after 12 months. Additional findings included that Māori women and those with higher deprivation were less likely to be screened, and there was extreme variation by postcode (15.3–67.5% screened by 12 months). 
• HealthPathways notes the Increased risk of patients with gestational diabetes developing type 2 diabetes following the pregnancy:

• The cumulative risk has been estimated to be as high as 50% within 5 years postpartum, depending on ethnicity and time from index pregnancy.
• There is good evidence that the risk of developing type 2 diabetes can be reduced by either lifestyle or pharmacological interventions (e.g., metformin) in the non-pregnant population
• Post-partum screening advice for women who developed gestational diabetes is to check HbA1c at 3 months and annually thereafter

2.  Referral guidelines and unmet need

The end of year BPAC bulletin commented on some criticism the agency had received that some referral criteria and advice documented in various articles aren’t realistic, there is no way that patient will be seen…”. 

The comments noted BPAC is presenting what should happen, based on clinical trial data and consensus guidelines to improve patient outcomes. If we don’t refer based on the presumption that the referral will be declined due to resource constraints, the health system cannot measure unmet need. Te Whatu Ora in the October, 2022 “Planned Care Taskforce – Reset and Restore Plan” acknowledges that there is “no current effective measure of unmet need” and there is also no ability to measure the “not to refer” decisions that are based on a presumption that the outcome of the referral will be a denial of access. “Decline rates” are the simplest measure of unmet need, until other tools are developed to assess this.

3.  EpiPen funded from February, 2023

A recent Pharmac decision means that EpiPen and EpiPen Jr will be funded from 1 February, 2023, for people who have previously experienced anaphylaxis or who are at high risk.

• Funding restrictions include a maximum of two devices per prescription, and replacement of up to two devices prior to expiry or after a device is used
• Special Authority eligibility criteria include previous anaphylactic reaction which has resulted in presentation to an emergency department, or assessed by a relevant practitioner (including general practitioners, nurse practitioners and pharmacist prescribers) as being at significant risk of anaphylaxis; renewals of approval are not required
• Patients being prescribed an Epipen can register on the supplier’s website (Mylan EpiClub ) to order a free training pack and practice pen. There are also videos on how to use the pen and other resources.

4.  Meningococcal B vaccination wider funded access

Access to the meningococcal B vaccine, Bexsero, will be widened from 1 March, 2023, to include all children aged up to 12 months and people aged 13 to 25 years in their first year of a specified close-living situation.

• Pharmac eligibility criteria for the 13-to-25-year age group are: 

Either:

• Two doses for individuals who are entering within the next three months, or in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons; or
  • Two doses for individuals who are currently living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons, from 1 March 2023 to 28 February 2024. 

• Existing eligibility criteria for patients over one year of age are: 
  • up to two doses and a booster every five years for patients pre- and post-splenectomy and for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited), or pre- or post-solid organ transplant; or
  • up to two doses for close contacts of meningococcal cases of any group; or
  • up to two doses for person who has previously had meningococcal disease of any group; or
  • up to two doses for bone marrow transplant patients; or
  • up to two doses for person pre- and post-immunosuppression (Immunosuppression due to corticosteroid or other immunosuppressive therapy must be for a period of greater than 28 days)

5.  Soft tissue ultrasound

(i)  A recent Te Whatu Ora Waikato newsletter commented on the significant volume of requests being received for non-specific soft tissue mass USS.  There is reference to national imaging guidelines which include standard indications for community imaging referral as:

• Soft tissue mass with red flags; however, specialist assessment is preferred, so only request imaging if there is likely to be a delay before the patient is seen
• suspicion of a foreign body where not covered by ACC.

(ii)  Red flags include a soft tissue mass with any of the following characteristics:

• growing
• >5 cm in size
• deep to deep fascia (limited mobility, less mobile with muscle flexion)
• painful (most malignant lumps are painless; pain suggests nerve or bone involvement)
• recurring after a previous excision.

(iii)  Additional guidance is:

• Apply caution in the use of ultrasound, as its ability to characterise solid mass lesions is limited and incorrect diagnosis can lead to significant treatment delays.
• Consider requesting a plain X-ray as well.
• If a sarcoma is suspected, reserve biopsy for an orthopaedic or sarcoma specialist.

(iv)  A localised HealthPathway for Soft Tissue Lumps and Sarcoma has been recently published.  The pathway reiterates the limitations of ultrasound in determining whether or not a mass is likely to be malignant although it can determine  if a mass is present, superficial or deep to fascia, and solid or cystic.     

(v)  If a lump is not being investigated or referred:

• advise the patient to report any changes promptly.
  • reassess at 3 months if any concern.
  • consider discussing with a general practitioner colleague for a second opinion.

6.  Ramadan and Diabetes

• Ramadan 2023 is expected to run from the evening of Wednesday 22 March to the evening of Thursday 20 April.  The Research Review series has published an excellent guide on diabetes management during Ramadan.

• Many Muslims with diabetes have a strong desire to participate in the Ramadan fast, even though they may be exempted due to their underlying condition.  Be proactive about asking Muslim patients about their intention to fast as they may not volunteer this information. A pre-Ramadan assessment is essential for patients with diabetes who wish to fast.

• Individualised risk stratification forms the basis for shared-decision making and recommendations regarding lifestyle, blood glucose monitoring and dose adjustments for glucose-lowering therapies. Patients at low risk should be able to fast safely, while those at moderate risk may be able to fast safely with appropriate education and monitoring. Patients at high risk should be discouraged from fasting.

• Reassure patients who are at high risk that there are alternatives ways of obtaining spiritual rewards if they do not fast; consider engaging with a local Iman if the patient is uncertain about any of the medical recommendations provided.

• Education about the risks associated with fasting and the provision of individualised strategies to preventing adverse outcomes are essential for the safety of patients with diabetes. Avoiding dehydration by drinking adequate quantities between Iftar and Suhoor is important.

• SMBG is important for all patients with diabetes who are fasting and doing so does not break the fast. Patients at low risk should SMBG at least once during the day and following Iftar, as well as whenever they feel unwell or have symptoms of hypoglycaemia or hyperglycaemia. Patients at higher risk should test more frequently.

• All patients with diabetes should break the fast if at any stage:
  • Blood glucose <3.9 mmol/L
  • Blood glucose >16.6 mmol/L
  • Symptoms of hypoglycaemia or acute illness develop.

• Information about dosing and/or timing adjustments should be provided to all patients taking glucose-lowering therapies, especially those using insulin.  It is recommended that patients be on a stable treatment regimen before beginning the Ramadan fast.

• A post-Ramadan follow-up is recommended to review what went well for the patient and to discuss challenges to make any future fasts safer and more rewarding.

7.  Asymptomatic bacteriuria in the elderly

A recent Tools for Practice summary looked at the question:  In elderly, does asymptomatic bacteriuria (ASB) cause altered mental state and will treating ASB improve clinical outcomes?

The context:  Ordering urine culture is associated with antibiotic use.  ASB is common in elderly: 5-20% in community age>80 (females>males) and institutionalization (25-50% women/15-40% men).

ASB guidelines recommend:

• Avoiding ASB treatment in elderly without clear infection signs/symptoms. 
• Assessment for other causes; careful observation; attention to contributing factors like dehydration.

BOTTOM LINE:   Due to important evidence limitations, it is not confirmed that ASB, or even Urinary Tract Infection (UTI), is clearly associated with altered mental state. Treating ASB does not improve clinical outcomes (including altered mental state) but may increase adverse events from 1% to 7%. In elderly patients with ASB and altered mental state, antibiotics should be avoided without clear signs/symptoms of infection, and alternative reasons for altered mental state should be considered.