April 2022
Clinical Snippets April 2022
1. Eating disorders
Some useful resources for parents while they wait include (Goodfellow Gem):
- F.E.A.S.T info for parents
- EDANZ
- Eating disorders. Mental Health Foundation
- Eating disorders. Health Navigator NZ
- Centre for Clinical Interventions https://www.cci.health.wa.gov.au/
For clinicians: Regional clinical pathways. Also links to multiple resources for patients and whanau together with advice on management and monitoring.
Private options include:
2. BPAC update on weight loss
BPAC has recently released an update on weight loss: the options and the evidence. Some key practice points include:
- The overriding principle of weight loss is that energy intake needs to be less than energy expenditure; there is no consistent evidence that any one calorie-restricted diet is better than another at achieving weight loss
- At least 2.5 hours of moderate intensity physical activity per week should be included in all weight loss interventions
- Contrary to popular belief, rapid weight loss is not associated with an increased risk of weight regain compared to gradual weight loss
- Pharmacological interventions may be considered only after dietary, exercise and behavioural approaches have been initiated and evaluated for people who are obese or as an adjunct to diet and lifestyle interventions, after the potential harms and benefits of treatment have been reviewed
There are two new pharmacological interventions approved in New Zealand (but not funded) for weight management:
Liraglutide (a GLP 1 receptor agonist – Saxenda) – daily SC injection, cost about $500 per month
Naltrexone + bupropion (Contrave) – tablet uptitrated over 3 weeks, cost about $220 per month
Cost comparison: phentermine Duromine (30mg caps) $100/month; orlistat (Xenical) $180/month
Indication: BMI ≥30 or 27-30 if at least one weight-related co-morbidity
Recent Tools for Practice question: Is naltrexone/bupropion (Contrave®) effective for weight loss?
Bottom line: Over 28-56 weeks, at best, ~50% of patients taking naltrexone/bupropion achieved a >5% loss in body weight, compared to ~20% in control. Naltrexone/bupropion adverse events (examples nausea, constipation) lead to withdrawal in 23% of patients versus 12% on placebo.
3. Depo-Provera dose interval update
In the April 2022 NZF update a change to dosing recommendation for Depo-Provera is noted as:
- Individuals should be advised to return every 13 weeks for a repeat injection of intramuscular DMPA (outside the product licence for intramuscular DMPA). Health practitioners should be aware that this is an evidence-based recommendation and signals a change in practice in New Zealand. This recommendation may differ from the Manufacturer data sheet.
- Good practice points: An injection of DMPA can be administered up to 7 days late (up to 14 weeks after the last injection) without the need for additional contraceptive precautions (outside the product licence for intramuscular DMPA). If necessary, an early repeat injection of DMPA can be administered from 10 weeks.
4. Supply issues with smoking cessation treatments
All patients who smoke should be encouraged to stop and provided with cessation support, including both behavioural and pharmacological treatment. Currently, the options for pharmacological support are limited due to supply constraints.
- Varenicline has been unavailable for almost 12 months due to a manufacturing safety issue, and bupropion supply is now being managed in New Zealand due to increased global demand and manufacturing constraints.
- This leaves nicotine replacement therapy (patches, gum or lozenges) as the remaining funded pharmacological option; note that this is usually the first-line recommended treatment for smoking cessation. Nortriptyline (funded) may also be an option for some patients. Read more about smoking cessation treatments here.
- Vaping is not an approved smoking cessation method, but health care professionals can provide information to help smokers make an informed choice: read more here.
5. Chronic pain guideline for primary care
A recent Goodfellow Gem looked at the work of a Canadian panel that filtered 74,000 papers to get a summary for chronic pain management of osteoarthritis, low back pain, and neuropathic pain. The findings are summarised in a table that might be useful for discussion with patients.
Some findings of note include:
- Placebo is fairly effective 29% to 40%.
- Physical activity is essential for OA and back pain.
- For OA (NZ available drugs) – steroid injections, oral and topical NSAIDs are effective.
- Glucosamine and chondroitin are of uncertain benefit as the publicly funded trials found no benefit while the industry-sponsored ones did show benefit.
- For low back pain – spinal manipulation, oral NSAIDs, and TCAs.
- The authors felt cannabinoids and opiates showed that harms exceeded benefits.
6. The dangers of psychosis induced violence
Findings of a recent Coronial inquest into the deaths of five people who were killed in 2015 and 2016 by patients who were in a florid psychotic state have been summarised in GP Pulse with learnings for GPs documented as:
- When you are concerned about a patient and refer them, be ASSERTIVE. Say what you think and if it is a phone call, identify exactly who you are talking to.
- Insist on talking to a consultant psychiatrist if you have concerns.
- If you have an expectation about the type of care required, you need to state it clearly. You should also state that if your recommendation is not to be acted upon, then you should be contacted (leave your contact number) and you may wish to speak to a more senior member of the mental health team.
- These cases are monumentally complicated, and a peer-to-peer discussion is the safest form of communication. You may well be the person who has the greatest insight into the case.
- Once you have made a referral, document it carefully.
- If something goes wrong, you may find that other health professionals have a very different interpretation of what you said/documented.
- Keep clinical antennae up with patients who are guarded in their communication. Despite being psychotic, some patients can be wary of health professionals who may insist on treatments that they find intolerable.
- When family members or indeed other members of the public report abnormal behaviour you need to talk to and listen to them. This is not breaking patient confidentiality and may be critical to everyone’s welfare. You need to interview these people often without the patient present.
- We have a duty of care to our patients and their families and better outcomes for both should be paramount in our thinking.
Don't Shoot.. 