mental-health

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare, rural, Uncategorized , , , , , ,

https://open.spotify.com/episode/5zPf8bAGVqeeIKF9sGd7zT?si=xGcqfnVjRaGp8jhaCPrbeg

Clinical Snippets October 2025

Clinical Snippets October 2025

1. Suicide prevention

(i) A recent Goodfellow Gem drew attention to the NHS guidance Staying safe from suicide (2025) which includes references to NICE Guideline NG225: Self-harm: assessment, management and preventing recurrence.  Of note, the NICE guideline strongly advises against the use of risk assessment tools and scales, or global risk stratification into low, medium, or high risk, to predict future suicide or repetition of self-harm or to determine who should or should not be offered treatment or be discharged. 

(ii) The NHS guidance has 10 key principles:

  • relational safety: build and maintain trusting, collaborative therapeutic relationships. These are the strongest predictor of good clinical outcomes
  • biopsychosocial approach: address safety as part of a broad biopsychosocial approach aimed at improving overall well-being by considering biological, psychological and social aspects
  • safety assessment and formulation: reach a shared understanding with the individual about safety and changeable factors that may affect this
  • safety management and planning: consider the need for immediate action and work with the individual to navigate safety and the factors impacting this over time.
  • dynamic understanding: regularly assess and adapt formulations and safety plans based on the individual’s changing needs and circumstances
  • evidence-based practice: base work on the latest research and understand population-level risk trends
  • involving others: encourage the involvement of trusted others, where possible and as appropriate
  • inclusivity: Ensure practices are inclusive and adaptable, particularly for marginalised and high-risk groups
  • clear communication: use simple language tailored to the individual and don’t use jargon. Use interpreters or approaches like drawing, if needed
  • continuous improvement: regularly review and refine approaches based on outcomes and feedback

(iii) A written, prioritised list of coping strategies and/or sources of support that the person who has self-harmed can use to help alleviate a crisis. Components can include recognising warning signs, listing coping strategies, involving friends and family members, contacting mental health services, and limiting access to self-harm methods.  The NZ Mental Health Foundation provides an editable Personal Safety Plan which is also available as hard copy.  Other suicide related resources are also available.   

(iv) Community Health Pathways has sections on Suicide Prevention in Adults and Suicide Prevention in young People.  The Pathways do currently include risk stratification but also emphasise the most important priorities are to engage the patient, provide hope, and look at ways to keep them safe. Hopelessness has a high correlation with eventual suicide.  The Pathway also emphasises the importance of building a strong therapeutic alliance by:

  • Communicating empathy and understanding for patient’s extreme suffering.
  • Providing reassurance that recovery is possible.
  • Reinforcing the patient’s help-seeking behaviour in coming to see you for treatment.

2. Ondansetron in pediatric gastroenteritis

Issue 259 of GP Research Review looked at a double blind study published in NEJM in which just over 1000 children between the ages of 6 months to <18 years with acute gastroenteritis associated vomiting whose carers were provided with 6 doses of oral ondansetron or placebo at the time of ED discharge, with instructions to use in the case of ongoing vomiting. Outcomes were measured in symptom continuation and deterioration, duration, total number of vomiting episodes and the need for further medical intervention. In the 7 days after enrolment, those prescribed ondansetron had significantly less chance of deterioration and reduced episodes of vomiting. Adverse events were balanced between study arms. Take-home message: Ondansetron is effective in reducing vomiting from gastroenteritis in those aged between 6 months and 18 years. NZFC notes acute gastroenteritis-related vomiting associated with dehydration is an indication for a single dose of ondansetron in children. 

3.  HIPC Rule 11

A recent issue of NZ Doctor contained an article from the office of the Privacy Commissioner on Rule 11 of the HIPC which links to last month’s discussion around suicide prevention.   

The question is presented: When a patient insists that their parents not be told about what’s going on in their life, but you think their mental health is at risk and parental support could lessen that threat, what should you do?  If a patient refuses consent to share their health information, but a GP believes their safety is at risk, Rule 11 of the Health Information Privacy Code may allow the doctor to act.

Rule 11 of the HIPC permits the disclosure of health information if it is necessary to prevent or lessen a serious threat to the life or health of any person, or to public health or safety (the serious threat exception). In each case, specific requirements must be met for the serious threat exception to apply. If another piece of legislation requires or allows you to share the health information in question, you should rely on that legislation rather than Rule 11. For example, if sharing is permitted by the Oranga Tamariki Act 1989 you should rely on that as your authority. You don’t need to also make an assessment under Rule 11.

If no other piece of legislation applies, you need to assess the disclosure under Rule 11. There are four steps to work through.

(i) Has the person authorised you to share their health information?  If yes you can release information as agreed with the person.  

(ii) If you do not have authorisation, it reasonably practical to seek authorisation? For the serious threat exception to apply, you need to have reasonable grounds to believe that it is not desirable or practical to seek the individual’s authorisation. If you request authorisation to disclose the information but the individual does not grant it, you must consider why the authorisation was not granted and whether it is appropriate to proceed with the steps. If the threat is serious enough, you might find that it outweighs the need for authorisation. If it is not desirable or practicable to seek authorisation, go to step three.

(iii) Is there a serious threat to the life or health of a person?

The serious threat exception applies to serious threats to the life or health of the person whose information it is, that of any other person, or public health or safety. When considering whether there is a serious threat, you need to use your clinical judgement to assess the likelihood of the threat occurring, the seriousness of the threat and the harm that could eventuate and the imminence of the threat. If the threat does not meet the “serious threat” threshold, you cannot rely on this exception. If there is a serious threat, go to step four.

(iv) Is the disclosure to someone who can help lessen or prevent the threat?

You can only disclose health information under this exception if you are sharing the information with someone who can help lessen or prevent the threat, and only as much information as is needed to do so. For example, if you have gone through these four steps and concluded that involvement from a patient’s loved one in their care would lessen the threat, you should still only share as much information as is necessary to do that.

As always, it will be crucial to document your decision-making process. It may help to record the answer to the four steps sequentially in your notes as you are deciding on the best course of action, as well as your rationale for these answers.  The full guidance on this exception is available in the resources and learning section at privacy.org.nz.

4. Long-acting insulin

  • A recent Tools for Practice from the College of Family Physicians of Canada looked at the evidence comparing once-weekly insulin icodec (Awiqli) compared to daily long-acting insulins in type 2 diabetes?  The bottom line was that once-weekly insulin icodec is as effective as daily long-acting insulin (glargine or degludec) in lowering HbA1c. Safety and hypoglycemia risk appear similar, though data are limited for patients or situations at risk for hypoglycemia such as sick days or in frail patients. 
  • Insulin icodec is not yet approved for use in New Zealand but is approved in Australia for type 2 diabetes in adults and adult type 1 diabetes with some restrictions.   Insulin icodec (Awiqli™ 700 units/mL, 2100units/pen) is an ultra-long-acting insulin.  In insulin naive patients, initial recommended dosage is 70 units once per week, equivalent to 10 units daily. Maximum dose per injection 700 units. When switching from another long-acting insulin, use the equivalent total weekly dose but a one-time 50% higher loading dose may be considered.  However, it may be a while before it is approved in New Zealand – it is more expensive than other long-acting insulins.  Approximate costs per month for 40 units/day or 280/week: Glargine: $70; Degludec: $100; Icodec: $115  NZD equivalent. 

5. Insomnia medication

The Research Review Educational Series has published an update on recent advances in the management of insomnia.  Behaviour therapy is the recommended first line treatment for insomnia with hypnotics being used as adjunctive or alternative therapy. Health Pathways has a comprehensive summary of accepted insomnia management practices. 

The publication reviews the various available hypnotics including dual orexin receptor antagonists (DORAs) which are a newer class of hypnotic. In December 2024, the Minister of Health consented to the distribution of the DORA lemborexant (Dayvigo®) in New Zealand for treatment of insomnia in adults. The following ‘take home’ messages relate to lemborexant. 

  • RCTs, meta-analyses and network analyses have shown lemborexant has favourable efficacy and side effect profiles compared to placebo and benzodiazepine receptor agonists. Lemborexant significantly reduced time to sleep onset and increased overall sleep time compared to placebo and zolpidem at 1 month, and compared to placebo at 6 months with these effects maintained to 12 months.
  • Discontinuation of lemborexant therapy was not associated with rebound insomnia and lemborexant did not significantly impair next-day memory or driving, compared to placebo and benzodiazepine agonist receptors.
  • Lemborexant was well tolerated with a TEAE (treatment emergent adverse event) rate similar to placebo.  TEAEs most commonly associated with lemborexant are somnolence, headache, nightmares and/or abnormal dreams. A single retrospective study found Lemborexant was associated with a lower rate of falls in hospitalised patients compared to benzodiazepine receptor agonists.
  • Information on dosing and precautions is available in NZ Formulary and the Medsafe data sheet.  The drug is not currently subsidised and is an unapproved medicine (s29).   The Better Sleep Clinic website has a page dedicated to comparing the various medications used in insomnia management which might be a useful resource for patients.  The cost of a four week supply of Lemborexant in NZ (Pharmacy Direct) is $113 for the 5mg tab and $143 for the 10mg tab. 
  • There is a recent Goodfellow Gem briefly summarising relevant prescribing data 

6. Triple therapy for COPD

A recent NZ Doctor article on triple therapy for COPD  includes the following take home points:

  • For mild COPD, monotherapy with a bronchodilator is usually adequate; start a regular LAMA early; if symptoms increase, add a LABA.
  • An eosinophil count ≥0.3×109/L helps identify people with frequent exacerbations who are most likely to respond to an ICS.
  • If an ICS is indicated, it should be part of triple therapy (ICS + LAMA + LABA not ICS + LABA).
  • Strongly recommend vaccinations (encourage the unfunded vaccines, especially pneumococcal) and pulmonary rehabilitation (refresher course every two to three years).
  • The debate around the benefits and risks of therapy for COPD involves the place of inhaled corticosteroids. When we had limited inhaled therapy options for COPD, many people with COPD were initiated on an ICS + LABA combination. Subsequently, different phenotypes of COPD have been identified, and those with frequent exacerbations (two or more exacerbations in 12 months) have been shown to have fewer exacerbations when on an ICS. Those without frequent exacerbations derive no benefit but are at increased risk of adverse effects from ICS therapy, such as pneumonia.

7. Resource – iron studies and anaemia

A recent Research Review Educations Series titled What the ferritin? Is well worth an hour of CME.  It covers the basics of iron metabolism and then the various blood test used to asses iron status.  There is a very helpful table to aid distinguishing iron deficiency from anaemia of chronic disease and an acute phase reaction, and algorithms aiding differentiation of absolute versus functional iron deficiency.  The importance of investigating an underlying cause of absolute or functional iron deficiency is emphasised.  Take home messages include:

  • Low serum iron is not a reliable indicator of depleted iron stores (diurnal variation and inter-individual variation, sensitive to recent iron intake, acute and chronic illness.
  • Low transferrin saturation (TSAT) with low ferritin is consistent with iron deficiency (ID). High TSAT with high ferritin indicates iron overload. TSAT alone is not a reliable marker of iron status.
  • A normal or raised serum ferritin level does not necessarily exclude ID; it is important to distinguish between absolute and functional ID, especially in patients with inflammation or chronic disease.  However, serum ferritin is a sensitive and specific test for ID.  Low ferritin levels are highly specific for ID; high ferritin levels do not necessarily indicate iron overload.
  • The reticulocyte haemoglobin equivalent RET-He test is a rapid, inexpensive indicator of ID in chronic disease.
  • If patients are started on oral iron replacement therapy, they should be checked at 6 weeks to ensure the medication is being tolerated and that haemoglobin levels are increasing.  Patients who receive IV iron replacement therapy should have a full blood count at 2–3 months post-infusion to check for haemoglobin normalisation. 

8.  Follow-ups

(i)  Adult ADHD management:  MyHealthHub has hosted a webinar ADHD in Adults – the Primary Care Perspective by Auckland psychiatrist Dr Sidesh Phaldessai.  The hour-long webinar is eligible for PD points and explores explore the diagnosis, referral, management and long-term care of adult ADHD.  Dr Phaldessai is also hosting an online Adult ADHD GP Masterclass which is a series of six webinars 7.30pm-8.30pm every Wednesday from 22 October until 26 November 2025 covering all aspects of adult ADHD diagnosis and management.  It is RNZCGP endorsed (12 CME points) and if you are unable to attend on the given date and time – the webinar will be recorded and you can access it later. 

(ii)  Further to a discussion in the last Snippets regarding medications that can affect the QTc interval, Christchurch Medicines Information Service have recently published a succinct 2-page bulletin on the issue including predisposing risk factors, culprit drugs and drug interactions and how best to manage the risk.   There are links to the CredibleMeds website which enables you to search individual medications and categorises them as:

  • Known Risk of Torsade de Pointes (TdP) – These drugs prolong the QT interval AND are clearly associated with a known risk of TdP, even when taken as recommended.
  • Possible Risk of TdP – These drugs can cause QT prolongation BUT currently lack evidence for a risk of TdP when taken as recommended.
  • Conditional Risk of TdP – These drugs are associated with TdP BUT only under certain conditions of their use (e.g. excessive dose, in patients with conditions such as hypokalemia, or when taken with interacting drugs) OR by creating conditions that facilitate or induce TdP (e.g. by inhibiting metabolism of a QT-prolonging drug or by causing an electrolyte disturbance that induces TdP).
  • Drugs to Avoid in Congenital Long QT Syndrome (cLQTS) – These drugs pose a high risk of TdP for patients with cLQTS and include all those in the above three categories (KR, PR & CR) PLUS additional drugs that do not prolong the QT interval per se but which have a Special Risk (SR) because of their other actions.

The New Zealand General Practice Podcast

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

April 2025

Clinical Snippets April 2025

1.  Sudden sensorineural hearing loss (SSNHL)

(i) The March issue of GP Voice referred to information from the New Zealand Audiological Society (NZAS) regarding the importance of prompt assessment and treatment of Sudden Sensorineural Hearing Loss (SSNHL) given the research showing that early treatment can improve the chances of hearing recovery.  The reader is referred to a 2024 article in the Australian Journal of General Practice which gives an excellent summary of the diagnosis and management of SSNHL including differentiating between conductive and sensorineural heating loss. 

(ii) Key points from the article include: 

  • Sudden sensorineural hearing loss is an otologic emergency.
  • Prompt diagnosis and initiation of treatment with high-dose corticosteroids improves patient hearing outcomes
  • Do not delay treatment while awaiting investigations (ie audiogram).
  • Prompt referral through to an ENT service and/or an emergency department is recommended.
  • Consider adjuncts to therapy including hyperbaric oxygen therapy, audiovestibular services and/or intra-tympanic dexamethasone.

(iii) The gold standard for confirmation of SSNHL is diagnostic audiometry (urgent same day – usually community provider) but use of tuning fork tests (Weber and Rinne) is advised in the article and in our Community Health Pathways.  A 512Hz tuning fork is used (cost $10-30).

(iv)  There is some difference in content between the various regional Community Health Pathways so I recommend consulting your specific pathway, particularly with respect to steroid treatment.  In general, the criteria for sudden sensorineural hearing loss (SSNHL) include:

  • Hearing loss that is sensorineural in nature
  • Hearing loss of at least 30 dB over at least three consecutive frequencies
  • Hearing loss that occurs within a 72-hour period (and best outcomes are seen when the patient is treated within 72 hours of hearing loss onset).

Characteristics of SSNHL include:

  • Acute onset with rapid progression of symptoms, generally within 72 hours
  • Almost always unilateral hearing loss
  • Patients may awaken with hearing loss or blocked feeling, with or without associated tinnitus, and occasionally vertigo
  • May occur at any age but is more common in those aged in their 40s or 50s.
  • Spontaneous improvement in hearing occurs in 2 out of 3 patients but recovery may not be complete. Recovery is more likely in younger age groups and in those with milder losses.
  • SSNHL is commonly misdiagnosed as otitis media due to an overlap of symptoms (e.g. acute hearing loss, aural fullness, tinnitus and sometimes preceding viral infection).
  • Most cases (85 to 90%) are idiopathic but consider other potential causes.

2. Goodfellow Gem – ADHD Treatment

 A recent Goodfellow Unit Gem looked at a Swedish study published in JAMA which examined 2-year mortality risk in patients with a diagnosis of ADHD comparing those who received pharmacotherapy for the disorder with a similar cohort who did receive pharmacotherapy.  The median age at diagnosis was 17.4 years (6-64 years). The 2-year mortality risk was lower in the initiation treatment strategy group (39.1 per 10 000 individuals) than in the non-initiation treatment strategy group (48.1 per 10 000 individuals). Among individuals diagnosed with ADHD, medication initiation was associated with significantly lower all-cause mortality, particularly for death due to unnatural causes. (e.g., unintentional injuries, suicide, and accidental poisonings).  There is a chance that more safety-conscious people will get preferential access to medication but this is the best available data.

3.  No more RICE?

A NZ Doctor sports medicine article published earlier this year looked at the evidence behind the age-old RICE advice we give to patients with acute soft tissue injuries.  The rationale behind RICE is to use rest to prevent any further soft-tissue injury, cryotherapy (ice) to induce vasoconstriction and limit bleeding and swelling, compression to limit swelling by physical means, and elevation to reduce the effects of gravity. Cryotherapy also has an analgesic effect. However, on reviewing the medical literature the author concluded there is no evidence to support the use of cryotherapy for acute soft-tissue injuries, but if used, it should probably only be in the first few hours after injury. Do not apply ice for more than 10 to 15 minutes as there are reports of damage to underlying superficial nerves (eg, the common peroneal nerve) with prolonged application, and superficial burns if applied directly to the skin.  The key points from the article were:

  • Acute management of soft-tissue injuries should include protection (rather than prolonged rest), elevation, compression and education.
  • Load optimisation and exercise, without exacerbating pain, are important after the first few days.
  • There is no evidence to support the use of cryotherapy or anti-inflammatories.

4. NZF Update – SSRIs and venlafaxine

The March NZF Update includes reference to cautions and patient advice updated and new pre-treatment screening and monitoring sections added for SSRIs and venlafaxine.

(i)  Pre-treatment screening advice is to perform an ECG in those at high risk of QT-interval prolongation.  Christchurch Medicines Information Service have a handy one pager on risk factors but note they include use of two or more drugs that cause QTc prolongation independently (includes macrolide and quinolone antibiotics) and use of one or more drugs that may cause electrolyte disturbance (e.g. diuretics, β-agonists, proton pump inhibitors), bradycardia (e.g. β-blockers, donepezil) or other effects that predispose the individual to the QTc prolonging effects of another drug.

(ii) Monitoring recommendations are:

  • Monitor closely for suicidality (suicidal behaviour, unusual changes in behaviour, self-harm, irritability, agitation, increased anxiety). Review patient regularly (e.g. weekly during the first month of treatment) and specifically ask about suicidal thoughts or actions, particularly at the beginning of treatment, when the dose is increased or decreased, or when the antidepressant is stopped.  
  • Perform an ECG in those at high risk of QT-interval prolongation 4 weeks after starting treatment, following any dose increase, and following addition of an interacting medicine. Consider stopping treatment if QT-interval is greater than 500 milliseconds or has increased by greater than 60 milliseconds.

5. Coffee and atrial fibrillation

Issue 250 of GP Research Review looked at a Swiss study examining coffee consumption and adverse cardiovascular events in patients with atrial fibrillation.  The study involved over 4000 patients and at a median follow-up of 4.7 years, patients with AF who were ‘daily’ coffee consumers had a lower incidence rate of a major cardiovascular event (MACE) than ‘not-daily’ consumers (5.09 vs 7.49 per 100 person-years, respectively). Following adjustments for confounders, AF patients who consumed coffee daily had a 23% lower risk of MACE and the reduction in MACE risk was greatest for those who consumed 2-3 cups of coffee per day.  Daily coffee consumers also had lower risks of all-cause mortality and hospitalisation for acute heart failure.  The reviewer noted there is existing evidence that coffee consumption increases longevity in general although there is also some evidence of the association of high coffee consumption with development of AF. However, continuing to drink coffee after diagnosis of AF does not appear to be harmful. 

6. Resource – Dermnet Newsletter

I am sure most of us are aware of the Dermnet dermatology website launched in 1996 by Hamilton dermatologists Dr Amanda Oakley, Dr Mark Duffill and Dr Marius Rademaker and now described as the world’s leading free dermatology resource. It is worth considering subscribing to the Dermnet newsletter which summarises content updates and new cases and provides links to professional education resources such as the Dermnet Lecture Series available on Youtube.  This series is designed to cover the core medical undergraduate dermatology curriculum and is a great ‘refresher’ resource for practicing GPs.

7.  Bits and pieces

(i)  Updated guidelines for the prevention of legionellosis in NZ were published this month.  Common sources of infection include exposure to the bacteria via compost and also spa pools, so it is worth asking about both of these potential sources when reviewing patients with possible atypical lower respiratory tract infections. 

(ii)  Pharmac has announced that varenicline (Champix) is available again from 1 April 2025. People will need to meet the funding criteria to access funded Champix, one of which is that the person is part of, or is about to enrol in, a comprehensive support and counselling smoking cessation programme, which includes prescriber or nurse monitoring.  Champix is a three-month course. There is a starter pack, followed by two repeats of Champix 1 mg (56-tablet pack).

(iii) Just a reminder that there is WINZ funding available for dental treatment for eligible clients of up to $1000 per 52-week period.  The grant does not have to be paid back eligibility depends on income and asset assessment (details on the WINZ website).  The grant covers immediate and essential treatment, which can include extractions, fillings for tooth restoration (not for cosmetic or for non-oral health issues), treatment of infection, and root canal treatment (except molars).  It does not include regular dental check-ups, cosmetic treatment, scale and polish, and teeth cleaning (unless this treatment is required because of gum infection), cast restorations, orthodontic treatment, molar root canal treatment or dentures. The client’s dentist needs to  complete a Dental Treatment information form.

(iv) The Otago Medical School Hauora Māori curriculum contains a te reo glossary intended to alert students and staff to words that are commonly used (as reflected in the glossary levels) within the health environment in Aotearoa New Zealand. The glossary is aligned with the Aki Hauora App that is available on both android and apple devices.  This is a  game based app to facilitate familiarity with the glossary.

(v) Tools for Practice #386 examined the question ‘does reducing sodium intake or substituting table salt with sodium-potassium alternatives improve cardiovascular outcomes?’  The bottom line was that based on one large randomized, controlled trial in patients with hypertension/previous stroke with above average daily salt intake (eg 4.8 g/day), replacing table salt with a salt substitute may decrease mortality (from ~4.5% to ~4%) and stroke (from ~3.5% to 3%) per year. Whether reducing sodium by other means reduces mortality or cardiovascular events is unknown.  The article notes that many guidelines recommend specific sodium reduction (example: <2g/day) but there is no reliable way for patients to estimate sodium consumption.  According to our last national nutrition survey, adults in Aotearoa New Zealand eat on average about 8.5 g of salt a day (3.4g sodium/day).

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

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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/