The New Zealand General Practice Podcast

Clinical Snippets April 2024

Shownotes :

Clinical Snippets April 2024

1.  Adrenaline auto-injectors – think twice

• Hosted content (Viatris – manufacturer of Epi-Pen) in the March edition of NZ Doctor noted a report by the Commission on Human Medicines’ Adrenaline Auto-injector Expert Working Group that highlights the latest safety advice including the recommendations of prescribing two AAIs, and patients should carry these at all times.

• For children attending daycare or school, this approach ensures that one Adrenaline Auto-Injector remains with the child at all times, whether at home or outside, while the second one is stored at the daycare or school for additional coverage.

• Similarly, for older children or adults weighing 50 kg or more, having two Adrenaline Auto-Injectors enables individuals to carry both with them at all times. This becomes crucial in situations where more than one dose of AAI may be required, offering an added layer of preparedness. This could include reasons such as ambulance delays, a biphasic reaction (3-20% of patients) or incorrect administration technique.

• EpiPen is fully funded for patients meeting the Pharmac eligibility criteria, including:
  • A patient who has had a previous anaphylactic reaction which required ED visit or hospital admission; OR
  • A patient who has had a significant anaphylaxis risk as determined by a relevant practitioner.

There is a maximum of 2 devices per prescription with additional prescriptions limited to replacement of up to two devices prior to expiry, or replacement of used device(s) for treatment of anaphylaxis.

2.  Scam Alert

The latest Medical Council newsletter reports actions taken by them on learning that the personal and professional details of several NZ practitioners have been utilised on a counterfeit telehealth platform, known as “prescripson.com.”   The Council recommends:

• We urge all registered doctors to remain vigilant and to monitor any unsolicited or suspicious activities related to your professional credentials. Regularly review your online presence and the use of your professional details on websites outside of your control.

• Should you encounter any unauthorised use of your details or receive questionable inquiries that seem related to this scam, please report them immediately to the authorities and the Medical Council for further action.

3.  Goodfellow Gem

• The latest Goodfellow Gem reviews a meta-analysis of the effect of NSAIDs on post-fracture bone healing.    In this analysis, six RCTs (609 patients) were included. The risk of non-union was higher in the patients who were given NSAIDs after the fracture, with an OR of 3.47. 
• However, once the studies were categorized into the duration of treatment with NSAIDs, those who received NSAIDs for a short period (<2 weeks) did not show any significant risk of non-union compared to those who received NSAIDs for a long period (>4 weeks).
• Indomethacin was associated with a significantly higher non-union rate and OR ranging from 1.66 to 9.03 compared with other NSAIDs that did not show a significant non-union risk. This is not the best evidence, but perhaps we should avoid indomethacin. 

4.  On Road Safety Test

• A NZ Herald article last month reported comments from NZ cognitive neuroscientist Dr Kerry Spackman criticising use of the SIMARD-MD test and other general cognitive screening tools in determining whether patients undergoing senior driving assessment medicals were safe to drive.  He cited a 2021 Canadian study which concluded the SIMARD-MD should not be used with either healthy drivers or those with cognitive impairment for making decisions about driving.

• An on-road safety assessment (ORST) usually carried out by a driving instructor may be considered when mild cognitive impairment is suspected or reassurance is required regarding the patient’s driving habits. The Waka Kotahi website contains information regarding the ORST including written advice for candidates.  Selected AA and VTNZ branches offer the service.  AA also offer senior driving coaching sessions for 65-74 yo ($80 member, $65 non-member) and for 74+ yo (members only – free). 

• The ORST is carried out in the patient’s vehicle and is in three parts:
  • Basic driving skills
  • Basic driving skills and hazard detection
  • More complex driving situations and hazard detection

• The AA website notes the patient may fail the ORST because of a few simple mistakes or small lapses of concentration. The average pass rate is about 56%. If the patient’s licence is still current, they can continue driving until it expires. If they wish to re-sit the test, they can book another appointment with the testing officer. They may re-book your first test once at no extra charge, but subsequent attempts will incur an additional test fee.

• Note the ORST is a limited test assessing the patient’s driving habits. Health Pathways advises a medical practitioner cannot use a driving instructor’s report to make a decision on someone’s fitness to drive. Instead, if an instructor has been used, this report can be forwarded to Waka Kotahi NZ Transport Agency (Waka Kotahi), along with the medical report from the medical practitioner, for Waka Kotahi to make a decision.  The ORST is not the same as a medical OT driving assessment which may be undertaken when the health professional is unsure whether the patient is medically fit to drive.  This is a comprehensive off-road and on-road assessment undertaken by an OT and driving instructor that includes checking of vision, range of movement, strength, sensation, coordination, judgement, memory, directional orientation, movement and decision-making times, cognition and comprehension and knowledge of road rules and signs in addition to practical driving skills and safety.  Private assessments cost up to $1000 and are not available in all areas.  TWO may fund assessments in some areas (see Health Pathways). 

• Detailed advice on medical aspects of fitness to drive are contained in the Waka Kotahi health practitioner’s guide.  The Goodfellow Unit has published a ‘how-to guide’ on driving assessment for patients with dementia using a case example.  The Health Pathways section on Fitness to Drive is useful and includes a section on alternative transport and assistance options for patients deemed no longer safe to drive.  

5.  Medication Communications

(i)  Medsafe – Eczema with CCBs:  As of 18 March 2024, CARM has received six reports of eczema where the suspect medicine was a CCB.  In one case the diagnosis of CCB-associated eczema was made several years after initiation of the drug.  Of these reports, five were associated with felodipine and one with diltiazem.  Medsafe is encouraging reporting of new-onset eczema with calcium channel blockers to further determine whether there is cause for concern. 

(ii)  Medsafe – Undeclared topical steroids:  Do not use NaturaCoco Moisturising Cream or Dok Apo Moisturiser Soothing Cream.  These topical cream products have been found to contain fluocinonide, a potent corticosteroid, which is not listed in the product ingredients.  If a patient not currently using steroid creams presents with symptoms consistent with use potent steroids, then consider use of the above products.

(iii)   Novo-Nordisk has given advance notice to Pharmac that supply of three of its insulin products – PenMix 30, PenMix 50 and Mixtard 30, will be discontinued from 30 September 2024.  It is recommended patients using these products be transitioned to suitable alternatives.   Expect further advice from Pharmac in the near future. 

(iv)  Pharmac – a request for proposal for supply of oestradiol gel (subsidized) for the NZ market was released by Pharmac earlier this month, partly in response to ongoing supply issues with transdermal oestrogen patches.   Suppliers mist apply by 13 May 2024 and the bids will then be evaluated by Pharmac and its clinical advisers.

6.  Chasing results

Te Whatu Ora has published a document outlining four high level principles aimed at ensuring patient safety and equitable health outcomes by clarifying areas of responsibility and reducing ambiguity, in particular when there are transfers between secondary and primary care.

• Principle 1: The clinician who orders an investigation (the requestor) is responsible, either personally or delegated, through defined team processes for review and actioning of the results regardless of subsequent transfer of care, unless explicitly agreed to and documented otherwise.

• Principle 2: Where information is shared to add value to care and continuity, copying results to other clinicians or service providers is appropriate. But clear, separate communication is required if the recipient is expected to act on the result.

• Principle 3: Any clinician copied into a significantly abnormal result needs to ensure appropriate action has been taken.

• Principle 4: The requirements for regular monitoring and follow-up must be agreed between the referring and receiving clinicians.

The document notes: Copying of results is not a transfer of care and results should not be routinely copied to any other clinician at the time of request. This ensures that ongoing responsibility lies unambiguously with the requester. If handover of responsibility is requested, this needs to be clearly communicated in writing and with closed loop communications – ie, by phone call.

7.  Cellulitis study

• Issue 231 of GP Research Review reported a recently published retrospective study from Dunedin comparing compare the safety and efficacy of outpatient parenteral antimicrobial therapy versus oral antimicrobial therapy in the treatment of cellulitis associated with the clinical pathway change from  IV cefazolin + probenecid, to oral flucloxacillin + probenecid.

• When comparing outcomes before and after the change, there were no significant

differences in the rates of clinical treatment failure (15.4% vs. 14.3%, respectively; p=NS), treatment changes due to intolerance (3.2% vs. 5.7%; p=NS) or inpatient admission within 28 days (12.2% vs. 12.9%; p=NS). The pathway change was also associated with substantial cost savings, with a significant reduction in scheduled ED reattendances (43.1% vs. 2.9% of cellulitis patients; OR 0.04; p<0.01), mainly due to the decreased need for intravenous support.

• Health Pathways gives comprehensive management advice including recommended antibiotic regimes for patients with history of mild and severe penicillin reactions or suspected MRSA.  Importance of screening for sepsis is emphasised with additional practical advice such as when wound swabs and blood tests including cultures might be considered (not routine) and:

• Treat Māori and Pacific patients early – Māori and Pacific patients have high rates of hospitalisation due to sepsis and cellulitis. Start effective treatment early and arrange a review acceptable to the patient to monitor progress.

• Be aware that the natural history of cellulitis shows increasing redness and swelling within the first 48 hours.  If the patient is improving overall at 48 to 72 hours after initiation of oral therapy, do not start intravenous therapy solely due the persistence of redness or swelling.

• Always reassess moderate cellulitis at 48 hours and monitor fever. This is the most important indicator of response to antibiotics.

8.  Mirena for contraception

• In January this year regulatory approval was received in the UK to extend the use of Mirena, for contraception only, to eight years from the previously recommended five years.  In the USA the FDA approved the device for eight years for contraception in August 2022.  The NZF and Medsafe data sheet in NZ currently retain the previous recommendation of five years so use for contraception beyond this time, while supported by evidence of efficacy, would require informing the patient such use in NZ is ‘off label’.  

• Note there has been no change to approval or recommendations for use of Mirena for the management of heavy menstrual bleeding, or for endometrial protection as part of hormone replacement therapy which remain, in New Zealand, as five-year duration of use for each. 

9.  Did you know that…

• The Australasian Menopause Society provides information on management of patients with endometriosis after menopause. They note that OCPs which contain oestrogen and progestin are often effective in controlling endometriosis in premenopausal women and it is prevention of ovulation by oophorectomy or medically, as in OCP use, or naturally by menopause, that has the major impact on the treatment of endometriosis.

• Although the evidence remains sparse there have been case reports of endometriosis recurrence or malignant transformation of extrauterine endometriotic deposits in women with a history of extensive endometriosis treated with unopposed oestrogen therapy following menopause. Current recommendations favour continuous combined oestrogen-progestogen preparations instead of unopposed oestrogens for women with a history of substantial endometriosis even after hysterectomy, especially if there has been extensive disease.