The New Zealand General Practice Podcast

Clinical Snippets March 2022

https://anchor.fm/opotikigp/episodes/Clinical-Snippets-March-2022-e1i6ir6

Show notes :

Clinical Snippets March 2022

1.  Naloxone and non-intentional opioid overdose

• A recent NZ Doctor article noted concern from the NZ Drug Foundation at the limited availability of naloxone to selected patients with opioid dependence as a means of decreasing fatalities from accidental overdose (around 50 per year).

• In 2020, an emergency kit containing two naloxone (Nyxoid) nasal sprays was approved for sale without a prescription. However, because it is not funded, at $92 it is out of reach for many people. It is also difficult to source with few pharmacies contacted in the article actually stocking the kit and is not subsidised if prescribed.
• Naloxone ampoules (for injection) continue to be available by prescription-only (PSO – maximum of 5 ampoules) but are available as an emergency kit in some countries. 
• Health Navigator has resources regarding community initiated use of naloxone including pamphlets developed by Waitemata DHB for use of intramuscular and intranasal naloxone.
• The incidence of iatrogenic opioid use disorder is around 3% over 2 years but causation is uncertain.  The Prescription Opioid Misuse Index (POMI), a 6-point questionnaire with strong predictive ability for OUD, may be a reasonable case-finding tool.  Medsafe have recently published a pamphlet outlining the risks of opioid medications.
• The HQSC Atlas of Healthcare Variation (large PHO comparison) shows that in 2019 2.0 people/1000 enrolled with practices in the MHN Waikato PHO region were dispensed a strong opioid for more than six weeks – slightly below the national average of 2.1.  Rates ranged from 1.5 (Procare) to 2.9 (WellSouth PHO).

2.  COC and VTE

Medsafe have recently published a Prescriber Update following reports of a fatal PE in a young woman taking a COC.  Points include:

• Prescribers are reminded to counsel patients about the symptoms and signs of venous thromboembolism (VTE) when prescribing combined oral contraceptives (COCs).
• VTE may occur at any time during use of a COC. However, the risk of VTE is highest during the first year after starting a COC and when restarting after a break of four weeks or more.
• Ensure COC users know to seek medical attention if they experience symptoms or signs of VTE.
• COC use is associated with a 3- to 3.5-fold increase in the risk of VTE compared with non-use although absolute risk is low.  Reassess the risk of VTE periodically during COC use as risk factors may change over time.
• Consider the possibility of VTE in COC users who present with non-specific symptoms.  Patients with VTE may be asymptomatic or present with non-specific symptoms such as calf tightness, chest pain or cough. Always be mindful of the possibility of VTE in COC users and follow local guidelines for the investigation and management of suspected VTE as necessary.

3.  Rosuvastatin funding

• From the end of last year the very high potency statin rosuvastatin has been funded using SA for selected patient groups: 

LDL-C level eligibility for rosuvastatin funding

• Note the NZ Guidelines give an LDL-C target of < 1.4 mmol/L in people at high risk
• Use the Dutch Lipid Clinic Network Score (DLCNS) to determine the likelihood of familial hypercholesterolaemia diagnosis if suspected
• Further information on rosuvastatin dosing, contraindications and precautions can be found in a recent BPAC article  

4.  Ovarian cancer

A recent NZ Doctor article included the following points regarding ovarian cancer: 

• Ovarian cancer is a significant health issue in New Zealand – incidence and mortality rates are higher in Pacific and Māori women and compared with Australia, 16 per cent fewer women survive five years in New Zealand.
• GPs have an essential role to rule out ovarian cancer in symptomatic women and diagnose those with cancer in a timely manner.  Practitioners in countries with better survival are more willing to order an ultrasound at first visit for the following scenario: a 53-year-old woman who had her last period six months ago and has experienced abdominal pain for the past three weeks; she has had no other symptoms and the same sexual partner for 20 years.
• On average, a GP with 2000 patients will see one patient with ovarian cancer every four and a half years.
• Ovarian cancer is much more common in the postmenopausal population. However, in New Zealand, it is worth noting that one in eight cases occur in women younger than 45 years, and in the 20–44 age group, ovarian cancer remains the fifth most common cause of female cancer death. Younger age is a risk factor for delayed diagnosis.
• The symptoms women present with are variable but can include one or more of: bloating/distension, early satiety, urinary frequency/urgency, abdominal/pelvic/back pain and bowel habit changes. Other symptoms are also possible, including indigestion, nausea, fatigue, abnormal vaginal bleeding/discharge, unexplained weight changes and painful intercourse.  While it’s true these symptoms are very common in general practice, in women without ovarian cancer, they are usually mild and occur on five or fewer days a month.  In contrast, symptoms in ovarian cancer occur more frequently.
• Investigation for ovarian cancer usually includes a pelvic exam, cancer antigen 125 (CA-125) blood test and transvaginal ultrasound (TVUS).  Though pelvic exam has a low sensitivity when used as screening, it remains an important part of assessment in symptomatic patients. DHBs report decreased wait times for TVUS when pelvic exam is positive.
• Further detail on local recommendations regarding interpretation of CA-125 levels and referral for ultrasound and gynaecological assessment or advice can be found in HealthPathways.   A downloadable symptom diary can be found here. 

5.  Methotrexate and trimethoprim

Key points in a recent Medsafe Prescriber Update following a death associated with co-prescribing of methotrexate and trimethoprim include: 

• Severe bone marrow suppression has been reported in patients on methotrexate who have received trimethoprim or co-trimoxazole (trimethoprim with sulfamethoxazole). Some cases have been fatal.
• Trimethoprim and co-trimoxazole should be avoided in patients taking methotrexate.
• If this drug combination cannot be avoided, warn patients about the symptoms of bone marrow suppression. Advise them to seek immediate medical attention should these symptoms occur.

6.  Supply issues affecting FundaPen2 rollout

EpiPen® auto-injectors have been available through the FundaPen2 initiative from Wednesday 9 February 2022.  However, Allergy New Zealand has hit supply issues with 300mg adult EpiPens® due to global COVID freight delays. To ensure as many people as possible benefit from FundaPen2, it is important to keep prescribing under the FundaPen2 protocols. Patients will receive their free EpiPen® as soon as the stock is available, April 2022 at the earliest.

A reminder of the process:

1. The GP establishes that the patient is clinically eligible for FundaPen (doctor-diagnosed with an allergy that puts them at risk of anaphylaxis, and needing an EpiPen® as per prescribing guidelines)

2. The GP completes the patient’s prescription for ONE EpiPen® as usual and e-mails to Allergy Pharmacy info@queenstownpharmacy.co.nz .  Please include the patient’s weight on the prescription so that the correct Epipen® is dispensed. (As per ASCIA guidelines more than 20kg qualifies the patient for an Adult Epipen® auto-injector regardless of age).

3.  Additional Pharmacy details are:  Fax 03 441 0591;    Allergy Pharmacy, PO Box 157, Queenstown.

4.   Allergy Pharmacy assesses that the prescription meets the FundaPen qualification criteria and dispenses the EpiPen® to the prescribing GP. 

5. GP receives the EpiPen® and contacts the patient to return for training (if required) and dispensing. 

6. Only one FREE EpiPen® is available per eligible patient.  Once the available subsidised supply (fixed funding) has been exhausted, normal fees and charges will apply.