The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , ,

Clinical Snippets March 2024

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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. 

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.      

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/

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare ,

Clinical Snippets January 2024

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-January-2024-e2g4c8q

Shownotes

Clinical Snippets January 2024

1. Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE)

The December edition of Prescriber Update includes an article on symmetrical drug-related intertriginous and flexural exanthema (SDRIFE).   This is a type 4 delayed hypersensitivity reaction presenting as a well-defined symmetrical V-shaped erythematous rash of the gluteal region or groin, hence its original name of ‘baboon syndrome’. There is often involvement of at least one other skin fold or flexural area, such as the armpit and behind the knees. 

The lack of systemic symptoms is a key characteristic of SDRIFE. Aside from the rash, the person is generally well with no other symptoms. The most common medicines associated with SDRIFE are beta-lactam antibiotics (eg, penicillins, cephalosporins), which are implicated in about 50 percent of SDRIFE cases.  SDRIFE is self-limiting and should resolve when the suspect medicine is withdrawn. Re-exposure to the suspect medicine usually causes SDRIFE to recur. Topical steroids may help to resolve the rash more quickly.

More details can be found on Dermnet (including  images and a list of known culprit drugs).

2. Sodium valproate in people who can father children

Medsafe has updated its alert information on use of sodium valproate in people who can father children following re-analysis of data from retrospective observational study.  Recommendations for health professionals are:

  • Use of sodium valproate within the 3 months prior to conception by people who are able to father children has been linked to a potential increased risk of neurodevelopmental disorders in children compared to those who took lamotrigine/levetiracetam.
  • The potential risks to children fathered more than 3 months (the time taken for new sperm to be formed) after stopping sodium valproate are unknown.
  • Inform patients of this potential risk and consider alternative treatment options for those wishing to father a child.
  • Discuss the need for effective contraception when starting sodium valproate and periodically throughout treatment. If discontinuing treatment, continue effective contraception for 3 months.
  • Inform patients to avoid donating sperm while taking sodium valproate and for 3 months after stopping treatment. The company has produced a guide which should be provided to all male patients of reproductive potential using sodium valproate.

3. Accelerated silicosis

In November, Bunnings and IKEA announced they would discontinue selling engineered stone because of the adverse effects on tradespeople working with the product.  I have previously talked about the Accelerated Silicosis Assessment Pathway and  BPAC have recently published a comprehensive article on accelerated silicosis including details of the assessment pathway.   Health Pathways also gives a helpful succinct guide to the assessment pathway and would be my go-to resource if you are dealing with an AS assessment request for the first time.   The BPAC article is an excellent resource for the background, management and prognosis of AS

All tradespeople who have worked with engineered stone for more than six months in the past 10 years are being encouraged to see their GP.  As at September 2023, 190 claims have been lodged with the Accelerated Silicosis (AS) Assessment Pathway

Very briefly, the pathway involves an initial GP assessment (which may be undertaken via telehealth) to establish exposure history, risk factors and presence of symptoms.  This includes past and current silica exposure, safety and hygiene measures used to reduce exposure, symptom history (respiratory, dermatological and rheumatological), smoking history, workplace monitoring (spirometry), respiratory examination if practical and consent for information to be provided to ACC.   If the patient is at possible risk of AS (if they have worked with engineered stone for more than 6 months in the last 10 years) an ACC claim is completed.

ACC assess the claim and direct further investigation if required.  This includes a funded 30-minute more comprehensive GP assessment including completion of the  Adapted Crystalline Silica Health Form – Medical Section , spirometry and arranging of further investigations and/or specialist referral as requested by ACC.  Psychosocial support may also be required for patients with confirmed AS.  

4. Cyanobacteria and cyanotoxin poisoning

The December Waikato Public Health Bulletin notes that during the warmer summer months Waikato’s lakes are often affected by blooms of cyanobacteria which can release a toxin harmful to animals and humans. 

Detail on identification and management of cyanotoxin poisoning can be found in a helpful 2020 BPAC article.  Points include:

  • There is no test available to confirm cyanotoxin poisoning; diagnosis is based on clinical symptoms and signs in association with a history of exposure (e.g. swimming or boating on a river or lake with a current toxic cyanobacterial bloom) and exclusion of other causes.  Non-specific laboratory tests or investigations that may be indicated based on the patient’s symptoms and signs
  • Symptoms are related to type of exposure eg Urticaria, dermatitis, perioral and perinasal blisters, other types of rashes with skin contact.  Bronchospasm, rhinitis, sore throat, pneumonia and occasionally severe allergic reactions with inhalation.  Gastroenteritis, malaise, elevated liver enzymes and neurological symptoms (dizziness, vertigo, hearing loss, visual disturbance, seizures) with ingestion (contaminated water, shellfish, algae-based supplements).
  • The time to onset and duration of symptoms is highly variable; typically, symptom onset will be within 24 hours of exposure and can last several days.
  • There are no antidotes to cyanotoxins; treatment is symptomatic/supportive and based on the type and severity of symptoms.  Boiling contaminated water or cooking contaminated fish or shellfish will not inactivate cyanotoxins; in some instances, heating can result in higher concentrations of cyanotoxins as the cyanobacteria break down. Cyanotoxins are also not removed by normal water filtration systems.
  • A reminder that any case of suspected cyanotoxin poisoning should be notified to the Medical Officer of Health. This can be done using the Hazardous Substances Disease and Injury Reporting Tool (HSDIRT) [incorporated into some PMS or via e-referral] or by contacting the Public Health Service directly.   

5.  Respiratory Resources 

(i)  The Asthma and Respiratory Foundation NZ launched a new COPD handbook to help those living with a severe respiratory condition. This handbook provides information about COPD, from the various symptoms patients may experience, to the different types of treatment and medication. It includes tips and advice about self-management and general lifestyle management. 

(ii)  The foundation has also released a reference guide to support rangitahi to quit vaping. This guide aims to help health professionals who work with adolescents and young adults (AYA) to tackle vaping and e-cigarette addiction through five important steps: screening, assessment, behavioural support, pharmacotherapy, and follow-up.

6.  Coroner’s advice regarding metoclopramide requests 

The RNZCGP E-pulse December edition includes a note from College Medical Director Dr Luke Bradford referring to a recent coroner’s finding into the use of sodium nitrite being used in six suicides in New Zealand.

  • The use of sodium nitrite has been promoted on several suicide and euthanasia websites, with people being advised to see their GP first to get a prescription for metoclopramide to take alongside it to prevent nausea and vomiting. Four of the six cases did just this.   A Canadian man has recently been charged with 14 counts of second-degree murder in relation to deaths in Ontario province associated with sodium nitrite suicide kits he was selling on-line, and 90 similar deaths in the UK are being investigated.  He had apparently distributed over 1200 kits to people in 40 countries including NZ. 
  • For GPs, these findings come as a timely reminder to have awareness around patients who specifically request a prescription for metoclopramide, especially patients with a history of mental health disorders, or patients who are known to be going through trauma or having suicidal ideation. These requests should trigger further exploration by the GP.
  • The chemical causes methaemoglobinemia and is actually available in injectable form to treat cyanide poisoning.   It is also used orally in powder form in food preservation and animal control, and in car care products (rust inhibitor) and is available commercially in NZ.

7.  Court of Appeal ruling

In a recent Court of Appeal ruling, ACC has failed in an attempt to reject an earlier High Court ruling that a 20-year-old patient (known as AZ) with spina bifida should be eligible for ACC cover as the congenital defect was not detected at the mother’s 20-week scan and, had it been detected, the mother states she would have terminated the pregnancy.

The misdiagnosis and failure to terminate was a treatment injury that caused AZ’s personal injury, spina bifida, the court determined.  “The only option to prevent the birth of a child with spina bifida was termination of the pregnancy,” the decision said. “Therefore, termination of the pregnancy would have been treatment of AZ which operated to prevent the continuation of spina bifida even though the outcome of the termination would have been to prevent AZ’s birth”.

The lawyer for ACC had argued that said the High Court was incorrect in applying the Accident Compensation Act because the treatment — the 20-week scan — did not cause the injury and that the proposed treatment, a termination of AZ in utero, was not a medical treatment of the condition, “it just ends the life”.

8.  An eye to the future

A single injection of the investigational antihypertensive agent zilebesiran effectively lowered blood pressure in adults with mild to moderate hypertension for up to 6 months, with what appeared to be an encouraging side-effect profile, in the phase 2 dose-ranging KARDIA-1 study.  Ambulatory systolic blood pressure measured over 24 hours was significantly decreased with all zilebesiran regimens being studied, with a mean reduction in systolic BP from baseline to month 6 of around 10 mm Hg

Zilebesiran is a subcutaneous injectable that targets hepatic angiotensinogen (AGT) synthesis by RNA interference. There were four nonserious adverse reactions leading to discontinuation in the zilebesiran groups: two instances of orthostatic hypotension, one of blood pressure elevation, and one of injection site reaction.

The New Zealand General Practice Podcast

opotikigp Uncategorized

December 2023

Dr Joe Bourne ( revisited)

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

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

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

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

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

Read more about Dr Joe Bourne in New Zealand Doctor:

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

Shownotes

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

Fighting Talk

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

Kermode and Mayo Film Review

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

https://www.kermodeandmayo.com/

This too shall pass – Tom Hanks

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , ,
Shownotes :

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.

The New Zealand General Practice Podcast

opotikigp general practice , ,

October 2023

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-October-2023-e2c4468/a-aakkqri

Shownotes

Clinical Snippets October 2023 

1. Acne 

Two recent Goodfellow Gems looked at acne treatment.  A recent meta-analysis of treatments concluded the most effective treatment was oral isotretinoin, followed by triple therapy containing a topical antibiotic, a topical retinoid and benzyl peroxide. 

For monotherapies, oral or topical antibiotics, or topical retinoids have comparable efficacy for inflammatory lesions, while oral or topical antibiotics have less effect on noninflammatory lesions. 

In NZ the only topical antibiotic available for acne is clindamycin and benzoyl peroxide (trade name Duac – cheapest I could find on-line was $64 for a 30g tube). Topical mupirocin and fusidic acid should not be used as topical antibiotics for acne as they are generally reserved for clearing bacterial nasal carriage. 

An earlier Gem reported an expert opinion study regarding monitoring of patients on oral isotretinoin suggesting current recommendations may be excessive.  A systematic review on actual lab test results found that even with 40 mg or more per day, there were few laboratory abnormalities and most NZ primary care clinicians rarely go above 10 mg per day. 

Consensus statements included:  

  • Check alanine aminotransferase (ALT) and triglycerides within a month prior to initiation and at peak dose but not monthly or after treatment completion (unless abnormalities)  
  • Do not check complete blood cell count or basic metabolic panel parameters at any point during isotretinoin treatment. 
  • Do not check other liver tests or lipid tests, or C-reactive protein.  

A 2017 BPAC article states:  A pragmatic approach would be to ensure there is a recent assessment of the patient’s hepatic function and lipid profile and to monitor patients with risks factors, e.g. a history of either hepatic dysfunction or hyperlipidaemia. Isotretinoin dosing should be reduced or treatment withdrawn in patients with persistently raised serum lipids, or transaminase e.g. ALT greater than three times the upper limit of normal. Discussion with a dermatologist is recommended for patients with significantly elevated serum triglycerides; levels > 9 mmol/L have been associated with acute pancreatitis. 

NZF:  Monitor liver function 1 month after starting then every 3 months (reduce dose or discontinue if transaminases persistently raised). Measure serum lipids 1 month after starting then every 3 months (reduce dose or discontinue if serum lipids persistently raised; discontinue if uncontrolled hypertriglyceridaemia or pancreatitis).  HealthPathways:  Variable advice: Liver function, lipids, CBC pre-treatment, at one month, then every three months (Canterbury).  Midlands – no need for further testing unless clinically indicated if results at one month are normal 

NB Pregnancy prevention requirements presented in NZF:  In females of child-bearing potential, exclude pregnancy up to 3 days before treatment (start treatment on day 2 or 3 of menstrual cycle), every month during treatment (unless there are compelling reasons to indicate that there is no risk of pregnancy), and 5 weeks after stopping treatment—perform pregnancy test in the first 3 days of the menstrual cycle.  

Females must use effective contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment. Females should be advised to use at least 1 method of contraception, but ideally they should use 2 methods of contraception. Oral progestogen-only contraceptives are not considered sufficiently effective. Barrier methods should not be used alone, but can be used in conjunction with other contraceptive methods.  

2.  Prescribing and Burnout 

Issue 222 of GP Research Review looked at a UK study published in the British Journal of General Practice examining the association between strong opioid and antibiotic prescribing and practice-weighted GP burnout and wellness between December 2019 and April 2020.  Associations were found between greater strong opioid prescribing/greater antibiotic prescribing and increased emotional exhaustion, depersonalisation, job dissatisfaction, diagnostic uncertainty, and turnover intention in GPs. GPs who worked longer hours exhibited increased strong opioid and antibiotic prescribing.   

EAP:  All RNZCGP members can access free EAP services confidentially by calling 800 327 669 (international number +64 9 353 0906). They have clinical psychologists, budget and financial advisors, legal advisors, and other professionals ready to support you. Please mention The Royal New Zealand College of General Practitioners when you call. View more information on the EAP website.  A similar service is available for clients of MAS and MPS – details on their websites.   

Goodfellow Unit:  There is a webinar available on the Goodfellow Unit website titled Practical tips to encourage wellbeing and avoid burnout   

If you want to see how your opioid prescribing has altered over time compared with national and practice data check your He Ako Hiringa EPIC dashboard.   

3.  Medication withdrawals 

(i)  Medsafe has announced that approval for PHOLCODINE to be sold in New Zealand will be withdrawn on 12 January 2024.  The decision was made on safety grounds as there is a small risk that taking pholcodine in the previous 12 months may make patients more susceptible to anaphylaxis during surgery involving neuromuscular blocking anaesthetic agents. 

Pharmacists may continue to sell pholcodine-containing medicines until 11 January 2024. Pholcodine will not be recalled to help manage the winter cold season. 

Recommendations for health professionals include: Inform consumers about the small but potential risk of perioperative anaphylaxis to NMBAs from prior pholcodine exposure. 

(ii)  TRIAZOLAM  – The latest Pharmac update states Hypam 125 mcg tablets have run out. Supplies of the 250 mcg tablets are expected to run out in Oct/Nov 2023. Both tablets will be delisted on 1 February 2024.  This may be a time to review appropriateness of long-term benzodiazepine prescribing and He Ako Hiringa have developed some resources to aid in this decision-making including advice on withdrawal strategies.     

4.  Gout management resources 

  • The Gout Guide builds on findings from several gout projects including the Whanganui GOUT STOP programme and ProCare Gout Collaborative. It provides practical tools and insights for a fresh take on gout treatment. 
  • Contains a whole range of practical resources including team education, treatment pathways, point of care testing, involvement of community pharmacy and standing order examples.  There is a focus on improving inequities in gout diagnosis, treatment and outcomes with heaps of advice and examples on how to approach this issue as a practice care team.   
  • The Benecheck meter referred to in the guide (Blood Glucose / Total Cholesterol / Uric Acid) is currently available from Pharmacy Direct for $82.70 with uric acid test strips less than $2.00 per strip.   

5.  Prostate cancer again 

A recent Research Review Expert Forum on prostate issues included an update on efficacy of PSA as a screening tool.  Comments include: 

Initial research published in 2012 after 11 years of follow-up showed the number needed to screen to prevent one death from prostate cancer was 1055 and the number needed to diagnose was 37. Follow-up of this study cohort 5 years later (16 years of follow-up), revealed that in order to prevent one death from prostate cancer, the number needed to screen had decreased to 570 and the number needed to diagnose to 18, which is similar to other screening programmes such as mammography. 

A 2013 study showed that even just a single PSA measurement for a patient in their 40s is very useful for predicting future risk of prostate cancer.  The study involved a random sample of 268 men aged 40-49 years followed for a median of 16.3 years. The risk of Gleason 6 prostate cancer diagnosis by 55 years was 0.6% for men with a baseline PSA <1.0 ng/mL and 15.7% for men with a baseline PSA ≥ 1.0 ng/mL.   

The increasing use of multiparametric-MRI of the prostate in men referred with elevated PSA has been shown to reduce the need for biopsy and subsequent overdiagnosis (although the false negative rate is around 10%).  MRI targeted trans-perineal biopsy is being used increasingly with much lower rates of post-procedure sepsis compared with trans-rectal biopsy.     

Use of PSMA PET-CT enables accurate detection of prostate cancer spread and assists with individualising treatment options.   

Some case studies are presented including:   

  • A 47-year-old man with a family history of prostate cancer presents requesting a PSA measurement. This man’s PSA can be tested, as it is a very good measurement for stratification of future risk of prostate cancer in this age group. It is good to establish a baseline PSA. Men from families with the BRACA mutation and history of early breast cancer and prostate cancer have a much higher risk of developing prostate cancer, and these individuals should be monitored carefully. 
  • A 72-year-old man with a PSA of 6.5. In this man, the PSA measurement should be repeated. His physiological age rather than just his chronological age should be considered and if he is very fit and well for his age, then this should be included on the referral letter, as according to the current 2015 Ministry of health guidelines, his PSA would not be considered abnormal, but given his potential lifespan, further assessment or treatment may be appropriate. 

Updated recommendations for PSA testing can be found in a position statement from the Urological Society of Australia and NZ released last year.   

6.  September Prescriber Update 

September Prescriber Update included information on: 

  • The importance of slow tapering of antidepressants to reduce the risk of withdrawal symptoms and discontinuation syndrome.  Patients should be provided with information on antidepressant withdrawal and monitored for withdrawal symptoms.  Medsafe provide a patient information leaflet regarding stopping antidepressants.  Specific advice on tapering regimes varies and factors such as dose, duration of treatment, drug pharmacokinetics and emergence of symptoms (withdrawal or relapse) need to be considered.  Recent NICE guidelines recommend a hyperbolic dose reduction strategy ( eg each dose reduction being 50% of the previous dose and consider dropping to 25% reduction at lower doses) which may take months but is less likely to cause withdrawal symptoms than more rapid reduction. 
  • Adverse reactions associated with fluroquinolones continue to be reported.  Tendonitis and tendon rupture may occur at sites other than the ankle.  Time to onset has varied from within 48 hours after treatment initiation up to several months after discontinuation. The risk is increased in older patients, patients with renal impairment or solid organ transplants, and during concurrent treatment with corticosteroids. Peripheral neuropathy has also been reported in patients receiving fluoroquinolones.  Very rare cases of prolonged, disabling and potentially irreversible muscle pain or weakness, joint pain or swelling, fatigue, depression, problems with memory, sleeping, vision, hearing, and altered taste and smell have also been reported.  
  • New warning information on datasheet for gabapentin:  women of childbearing potential must use contraception during treatment (NZF states:  Females of child-bearing potential should use two forms of effective contraception during treatment to avoid unplanned pregnancy). 

7.  End of Life Care resources 

Useful one-page algorithms on symptom control at end of life adapted from the Ministry of Health Te Ara Whakapiri resources have been produced by Te Whatu Ora Te Wai Pounamu.  Topics include Pain Management Flowchart, Pain (with renal impairment), Dyspnoea/breathlessness Agitation/delirium/restlessness, Nausea/vomiting and Excessive respiratory tract secretions.  For a more comprehensive review of end of life care, including important cultural aspects to consider,  there is a recently published BPAC article  Navigating the last days of life: a general practice perspective which provides a wealth of practical information and advice. 

Clinical Snippets September 2023

opotikigp family medicine, general practice, Healthcare , ,

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: 

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) 

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) 
  1. What preparation and regimen are required 
  1. What is the most appropriate route and dose to start on 
  1. 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

opotikigp Uncategorized

Clinical Snippets August 2023

Shownotes

Clinical Snippets August 2023

1.  Varicella and pregnancy

  • Every effort should be made to confirm the diagnosis in the suspected positive contact and assess significance of exposure. Exposure or symptoms in the final two weeks of pregnancy should always be discussed with a specialist.  Exposure to varicella or zoster for which ZIG is indicated for susceptible persons includes: living in the same household as a person with active chickenpox or herpes zoster; face-to-face contact with a case of chickenpox for at least 5 minutes; close contact (eg, touching, hugging) with a person with active zoster.
  • If immune status of the pregnant patient is uncertain check serology urgently.  NB In people with no history or recall of the rash, 70 to 90% are still found to be immune.  Immunosuppressed patients are susceptible to chickenpox at all times.  For pregnant women who are immunosuppressed and those with negative varicella serology,   IMAC recommends discussing the clinical circumstances with an infectious diseases physician before deciding on which course of action is best.
  • If seronegative and exposure is ≤ 10 days earlier give Zoster Immune Globulin (ZIG) as soon as possible and if 7-10 days post exposure, give oral acyclovir or valaciclovir if the mother is at risk of varicella pneumonitis (is in the second half of pregnancy; has underlying lung disease; is immunocompromised; or is a smoker).  ZIG requires NZ Blood Transfusion approval to be dispensed. 
  • If exposure is >10 days previously, closely observe for symptoms of varicella infection and treat promptly with acyclovir or valaciclovir if symptoms develop.  However,  if the mother is at risk of varicella pneumonitis and exposure occurred less than 14 days ago, treat with acyclovir of valaciclovir rather than waiting. 
  • If a pregnant woman develops symptoms of chickenpox, treat urgently with antivirals and seek acute obstetric advice. Reduce antiviral dose in renal impairment.  Counsel pregnant women exposed to varicella about the risks of congenital varicella syndrome. The risk is highest in the first 20 weeks of pregnancy (0.4% in first 12 weeks, up to 2% in weeks 13-20).

2.  I take a green one at night

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

3.  Implicit bias

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

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

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

4.  Ocular NSAIDs and corneal melting

  • The June edition of Prescriber Update noted that in NZ more than 11,000 people per year are dispensed an ocular NSAID. A rare but potentially devastating side effect of ocular NSAIDs is corneal melting which can lead to corneal perforation and vision loss.
  • Various conditions can cause corneal melting, including eye infections, sterile inflammation, certain medical conditions (such as rheumatoid arthritis), and surgical or chemical injury to the cornea. Use of ocular NSAIDs has recently been linked to corneal melting. However, the mechanism behind this association is unknown.
  • Consider the possibility of corneal melting in patients using ocular NSAIDs who complain of blurred/distorted vision, worsening eye pain, eye irritation and hypersensitivity and/or ocular discharge. Check these patients for corneal damage.
  • Certain situations may increase the risk for NSAID-induced corneal melting, including (list not exhaustive):
  • frequent application and/or prolonged treatment duration
  • concomitant use of corticosteroids
  • concomitant conditions such as acute eye infections, rheumatoid arthritis, diabetes mellitus, ocular surface disease
  • recent complicated ocular surgery or patients with repeat ocular surgeries within a short period of time.
  • Advise patients to seek urgent medical attention if they experience signs/symptoms suggestive of corneal melting. Early diagnosis and treatment are critical to prevent further corneal damage.  Patients with evidence of corneal epithelial breakdown should immediately discontinue ocular NSAID treatment and be closely monitored. Due to the risk of corneal perforation and vision loss, patients with corneal melting are usually managed in a specialist setting. Management of corneal melting may involve medical and/or surgical intervention.

5.   Nasopharyngeal cancer (NPC)

  • NPC is a rare undifferentiated form of SCC with variable rate of occurrence ( 1 case per 100,000 in European populations and up to 25-50 cases per 100,000 in Southern China).  There is a male preponderance and risk factors are genetic susceptibility, previous EBV infection, and environmental factors such as smoking, alcohol and nitrosamine containing foods. 
  • Presenting symptoms are variable but include:
  • Nasal symptoms (around 80%):  including unilateral nasal obstruction, epistaxis, post-nasal drip, hyponasal speech, or cacosmia.
  • Otological symptoms (around 50%): secondary to Eustachian tube obstruction by the tumour, such as conductive hearing loss, middle ear effusion, or aural fullness. An adult with unilateral middle ear effusion requires visualization of the nasopharynx to exclude neoplasm.
  • Neurological symptoms:  Cranial nerve palsy is found in 20% of nasopharyngeal carcinoma patients and may be the presenting symptom. The most commonly involved nerve is the abducens (VI) nerve (lateral rectus palsy – horizontal diplopia when looking to affected side)
  • Nodal involvement: One of the most common presenting features is an enlarged cervical lymph node. Lymph nodes of the apex of the posterior triangle and the upper jugular are initially most commonly involved.  Supraclavicular nodes are the last to be involved and are a sign of advanced disease. 
  • More information is available in a StatPearls publication. 

6.  Funded meningococcal vaccine

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

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

7.  Family history of colorectal cancer screening update

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

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

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

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

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

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

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

8.  Child and adolescent forearm fractures

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

Clinical Snippets July 2023

opotikigp family medicine, general practice, Healthcare , ,

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 June 2023

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Shownotes

Clinical Snippets June 2023

1.  Stopping antidepressants

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

  • A proportionate dose taper should be used where the dose is reduced by a proportion of the previous dose e.g. 50% of previous dose, depending on certain factors such as the patients symptoms and whether the available formulations of the SSRI allow the preferred reduction in dose.  Smaller dose reductions, e.g. 25% of previous dose, might be considered when low doses are reached and this might require alternate day dosing.
  • Dose tapering should occur slowly over months to years depending on individual circumstances. Higher doses of SSRIs, longer durations of use and SSRIs with shorter half-lives, e.g. paroxetine, are generally associated with more severe symptoms of withdrawal and patients may require tapering of the dose at a slower rate.
  • Monitor patients for symptoms of withdrawal and differentiate between withdrawal and relapse:  Symptoms of withdrawal include irritability, sleep disturbance, hallucination, suicidal ideation dizziness, headaches, sweating and are reported by more than half of patients when discontinuing SSRIs. Reinforce the use of coping strategies, e.g. exercise, mindfulness-based techniques, sleep hygiene and be prepared to slow the taper if withdrawal symptoms occur.  Symptoms of withdrawal are more likely to begin within days of discontinuation or reduction of the SSRI. In contrast, symptoms of relapse typically occur weeks to months after cessation of the SSRI.
  • Discuss the possibility of withdrawal symptoms, including the importance of following the tapering protocol to minimise any symptoms. Advise that they should not abruptly stop taking the SSRI. A patient information sheet developed by Medsafe is available here.

Additional resources: 

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

2.   Miconazole gel and warfarin

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

3.  Goodfellow Gem on lung cancer

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

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

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

•          Cough >3 weeks

•          Haemoptysis

•          Chest or shoulder pain

•          Dyspnoea

•          Hoarseness

•          Weight loss >10%

•          Unresolving chest infection

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

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

4.  Can PPIs help crying babies? 

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

  • Frequent effortless regurgitation of feeds is common in early infancy (affecting ≥40%).
  • Regurgitation accompanied by distress symptoms (e.g., crying, back arching, irritability) have traditionally been attributed to gastroesophageal reflux disease. While PPIs improve oesophageal pH in infant RCTs, they do not improve symptoms.
  • Guidelines recommend against empiric trials of acid-suppressing drugs for crying/distress or regurgitation.  Parents can be reassured that frequent regurgitation can be normal and frequently settles (90% have resolution at age ≤1 year).

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

5.  Aspirin and primary prevention of CVD

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

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

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

6.  Winter virus action plans

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

7.  Sodium valproate in males

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

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