medicine

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , , , , , ,

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:

(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. 

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , , , , , , ,
Clinical Snippets February 2024

Shownotes

Clinical Snippets February 2024

1.  ACE and ARB and statin use in pregnancy – DON’T

The NZF notes that ACE inhibitors should be avoided at all stages of pregnancy. Fetal skull defects have been reported following first trimester exposure to ACE inhibitors although evidence of teratogenicity is inconclusive. In the second and third trimesters ACE inhibitors can cause abnormalities including fetal growth retardation, oligohydramnios and fetal or neonatal renal failure. Fetal death in utero has also been reported. Pregnant women who are taking an ACE inhibitor should be changed to an alternative antihypertensive as soon as possible.  Like ACE inhibitors ARBs should be avoided in pregnancy, particularly in the second and third trimesters, as similar effects to those caused by ACE inhibitors in pregnancy are expected.  

NZF notes also that Statins should be avoided in pregnancy as congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development. The individualstatin monographs state the drug is contraindicated during the first trimester and adequate contraception is required during treatment and for 1 month afterwards.  However, a 2022 metanalysis and systematic review noted there are some patients for whom there may be a significant benefit of maintaining statin therapy, in particular in the second and third trimesters. The risk and benefit of statins treatment during pregnancy need to be evaluated in an individualized approach and every trimester apart.

2.  Monitoring lithium drug interactions

A September NZ Doctor article on monitoring drug interactions with lithium is a helpful refresher on monitoring recommendations for patients on lithium therapy:

(i)  Usual monitoring: (current reference range for chronic use is 0.6-0.8 mmoL/L):

  • Three to six-monthly (depending on stability) – serum lithium level, electrolytes, eGFR.
  • Six-monthly – thyroid function, calcium, weight.
  • Annually (if over age 40 or obese) – HbA1c, lipids, consider ECG.

(ii)  When adding or removing medicines:

  • ACE inhibitors – baseline serum lithium level and renal function tests, then weekly for six weeks or until stable. For “at-risk” people (impaired renal function, volume depletion or heart failure) consider further two-weekly checks for six weeks.

20 to 35 % of people will have an increase in lithium levels if an ACE inhibitor is added to their regime, usually by around 33 %. The interaction can be delayed for up to five weeks, so it is important not to be reassured by steady lithium levels initially.  ARB interaction less likely but dose dependent (ARB) increases in lithium levels of up to 20 % after up to five weeks of treatment have been reported. 

  • Diuretics – baseline serum lithium level and renal function tests, then weekly for four weeks.

If a thiazide needs to be introduced, there may be a rapid increase in serum lithium levels by 20-25 % in 3-10 days, although this effect may also be delayed.  Loop diuretics have less impact, with potentially only up to a 20% increase in levels, and potassium-sparing diuretics appear to have no effect.

  • NSAIDs – baseline serum lithium level and renal function tests, then weekly for two weeks or until stable.

This interaction is well described for decreasing lithium clearance and increasing its toxicity, although it is unpredictable. While the average decrease in lithium clearance is usually 10-25%, there is wide variation, especially in people with impaired renal function. It is unlikely that COX-2 inhibitors would be any different to traditional NSAIDs regarding this interaction.

The risk is cumulative with concomitant use of ACE inhibitors, diuretics and NSAIDs.

3.  Shared care clozapine

The October 2023 NZ Doctor includes a refresher on shared care prescribing of clozapine.  Points include:

(i)  Clozapine can only be initiated by a psychiatrist. In some localities within Te Whatu Ora, GPs and nurse practitioners can be responsible for ongoing prescribing under the supervision of a psychiatrist. GPs can also prescribe for those with stable illness in collaboration with a community mental health team.  Patients are considered stable if they have been taking clozapine continuously for two years, had no mental-health-related hospital admissions in the last 12 months, are not taking other medications requiring close monitoring by a psychiatrist, and have been adherent to treatment and attending appointments.

(ii)  Due to the risk of agranulocytosis, all patients prescribed Clopine in New Zealand must be registered to ClopineCentral™ (the Clopine Monitoring System) or CareLink Plus (the Clozaril Monitoring System) by a registered medical practitioner.  Prescribing physicians must also register themselves onto the relevant monitoring system to access patient information. Brand swapping between clozapine products is discouraged and should occur on the advice of the initiating clinician or team. 

(iii)  The adverse effect and drug interaction profile of clozapine is wide (in particular agranulocytosis, severe constipation and cardiomyopathy/myocarditis) and there are specific requirements for pre-prescribing screening and subsequent monitoring which are critical to reduce the risk of patient harm.  There is comprehensive practical information available on HealthPathways (not yet localised for Midlands) and in publications by BPAC (2017) and SafeRx. 

(iv) Clozapine levels are reduced by cigarette smoking; however, it is the constituents of smoke, not nicotine itself, that is responsible.  Elevated clozapine levels, up to double baseline, may occur when patients stop smoking and this is not affected by NRT.  If patients stop smoking it is advisable to monitor plasma clozapine levels, dose reduction may be required in conjunction with mental health service advice. Conversely, if a patient starts smoking during treatment, the therapeutic effect of clozapine may be reduced. The plasma concentration of clozapine can also be increased by a high caffeine intake (more than 400mg/day – colas, tea and many energy drinks contain significant amounts of caffeine). Clozapine levels can subsequently decrease by nearly 50% after a 5-day caffeine-free period.

(v)  The article concludes:  Every time a patient comes in, there is an opportunity to query about adverse effects (with a focus on smoking status and bowel habits), check they are taking their medication appropriately, and offer lifestyle advice. Blood test results should be checked and compared with baseline. It is also important to ensure patients are aware of the need for blood tests to be done on the day they are due.  The Porirua Protocol is an evidence-based bowel management regime for patients taking clozapine.  

4.  PAD – best practice and equity

Issue 106 of the Maori Health Review reported a recent retrospective study from the Midland region on prescribing of cardioprotective medications and the impact on survival for patients with peripheral artery disease that undergo intervention.  Findings included:

  • Overall, 80.7% of patients received a prescription for antihypertensive medication, 77.4% for lipid-lowering medication and 89.9% for antithrombotic medication with prescribing of all three noted as ‘best medical therapy’.
  • Patients with concomitant ischaemic heart disease were more likely to be prescribed cardioprotective medication. Women were less likely to be prescribed lipid-lowering medication than men and younger patients were less likely to be prescribed lipid lowering medication than older patients.  Māori men were less likely to be prescribed antiplatelet medication compared with non-Māori men although were more often prescribed antihypertensive agents and no significant difference in statin prescribing.
  • Lipid-lowering and antiplatelet medication showed a survival advantage on univariate analysis, while antihypertensive and anticoagulant medication did not. Best medical therapy was associated with better survival after adjustment for age, sex, end stage renal failure and presence of chronic limb-threatening ischaemia.

On the equity theme, there is a great article from Cook Street Medical Centre in the January edition of GP Voice about their equity journey and outcomes. 

5.  Medsafe monitoring communication

In January Medsafe released a monitoring communication regarding the DPP4 inhibitor vildagliptin (Galvus, Galvumet).  The communication requested reporting to CARM of any patients on the medication being diagnosed with ileus.  While there is insufficient evidence currently to confirm any association between use of DPP4 inhibitors and ileus, the association may have biological plausibility as DPP-4 inhibitors act by inhibiting the breakdown of endogenous glucagon-like peptide-1 (GLP-1), which has a role in inhibition of gastrointestinal motility.

6.  Resource 1:  Pregnancy-related and post-natal depression and anxiety

Online mental health provider, Just a Thought, has launched CBT courses titled Pregnancy Wellbeing and Postnatal Wellbeing for women who experience depression and anxiety during their perinatal journey. The courses are evidence-based and free of charge.  You can refer your patients and follow their progress via the on-line dashboard once you are registered as a clinician with Just a Thought, or the patient can self-access.

7.  Resource 2:  Skin Cancer Symposiums

Educational provider Skin Cancer Symposiums offers a variety of on-line and in-person courses aimed at facilitating accurate and timely diagnosis of skin cancers, particularly melanoma.  They are currently offering a complimentary on-line mini-course on the basics of dermatoscopy and diagnosing melanomas (Register here)  with the goal of the course described as: to facilitate the basic understanding of the visual “red flags” of diagnosing melanoma.  In all of the cases presented, we include clinical and dermatoscopic images. In some, the diagnosis will be evident in the clinical image and reviewing the dermatoscopic image will further reinforce this. In some examples, the diagnosis is only evident in the dermatoscopic image.

8.  Covid vaccine 2024

Manatu Hauora confirmed at the end of December that a vaccine to combat the newer strains of COVID-19 has been approved by Medsafe and will be available to New Zealanders in time for winter 2024.  The COVID-19 XBB.1.5 (Comirnaty® Omicron XBB.1.5) has been approved for the 12+ age group with no plan reported for any changes in current eligibility criteria.   Eligible people are encouraged not to defer booster shots of the existing vaccine if due in view of prevalence of Covid-19 in the community.  While the most prevalent subvariant currently internationally and in NZ is JN.1, the receipt of updated SARS-CoV-2 vaccines containing the monovalent XBB.1.5 spike protein is anticipated to provide protection against JN.1[1].

[1] https://www.idsociety.org/covid-19-real-time-learning-network/vaccines/will-covid-vaccines-continue-to-work-against-jn.1-and-other-new-variants#/+/0/publishedDate_na_dt/desc/