April 2021 Clinical Snippets

Summary

Dr Dave Maplesden and Dr Jo Scott-Jones discuss “snippets” of information that are important for general practice in New Zealand 

COPD, ACC, Covid vaccine, online death certificates and more 

Shownotes

Clinical Snippets – April 2021

1.  COPD 2021

• The latest New Zealand COPD guidelines (2021) are available on the Respiratory Foundation website.

• The burden of COPD among Māori is one of the most significant health disparities in New Zealand: hospitalisation rates for Māori are 3.5 times higher than non-Māori, non-Pacific, and non-Asian rates, and COPD mortality for Māori is 2.2 times higher.

• BPAC has published a new COPD tool for treatment escalation or de-escalation to be used at follow-up, after medicines have been initiated. This tool is based on the Global Initiative for Chronic Obstructive Lung Disease (2020) and New Zealand COPD (2021) guidelines.  A treatment initiation tool is available on the same website.

• Non-pharmacological interventions are first line:

• Smoking cessation
  • Regular exercise as able
  • Pulmonary rehabilitation
  • COPD action plan (Available in English, Te Reo, and Samoan)
  • Vaccinations – annual flu, consider pneumococcal (unfunded)

2.  COVID-19 Vaccine Comirnaty™

• The Immunisation Advisory Centre has put together an information page (COVID-19 vaccines: FAQ) covering off the most common queries regarding vaccine development and ingredients.  Further resources are available for health professionals.  The information is constantly updated. 

• Current recommendations include:  

• People who have received the Pfizer/BioNTech vaccine (Comirnaty™) should not have an influenza vaccine within the next two weeks, or any other vaccine, including MMR, within the next four weeks.   Please note that whilst a two-week gap between influenza and COVID vaccines is recommended there are no clinical safety concerns should the gap between vaccines be less than two weeks (update 30 March 2021)
  • Two doses of the Pfizer/BioNTech vaccine are given at least 21 days apart, therefore these restrictions apply when either dose is given. It is recommended that the COVID-19 vaccine course is completed before receiving influenza or MMR vaccines.
  • Pregnancy is a precaution for vaccination with the mRNA (Pfizer/BioNTech) vaccine because initial clinical studies have not investigated the vaccine given in pregnancy – trials are currently underway in the US including pregnant women.  It is recommended to delay vaccination until after delivery if the pregnant woman is at low risk of exposure, but for those at high risk of exposure to SARS-CoV-2, vaccination can be offered with informed consent.  There are no safety concerns about giving mRNA COVID-19 vaccine to women who are breastfeeding.

• A CARM adverse event reporting form for COVID-19 vaccines is now available. Healthcare professionals are encouraged to use this new reporting form which is completed and submitted online.
• The immunisation Advisory Centre (IMAC) has developed an online COVID-19 vaccine course for GPs. By the end of this course, you will be confident in your knowledge of the mRNA-CV, be able to answer the common concerns and questions raised by patients, and be able to supervise or administer the vaccine in your practice.  You will need to create a free account on the IMAC learning site to access the course. Once you have logged on, go to the bottom of the page, and enter the package code COVIDGPv1.

• Please do not share this code with other practice staff, courses for vaccinators and nurses are different and courses for them will be available in the near further.

3.  Treatment injury cover for COVID-19 vaccination injuries

 
ACC can provide treatment and support for injuries caused by COVID-19 vaccination if the criteria for treatment injury are met. This means there’s a physical injury caused by the vaccination, that’s not a necessary part or ordinary consequence of the treatment.

 
 For example, inflammation around the site of the injection is common with COVID-19 vaccination (an ordinary consequence) and is unlikely to be covered. Infections (such as cellulitis or septic arthritis) due to the vaccination, and anaphylaxis resulting in injury, are not ordinary consequences and are likely to be covered.

 
To make a treatment injury claim for a patient complete an ACC2152 treatment injury claim form as well as an electronic or manual ACC45 injury claim form.

 
To help with reporting, ACC need to know the COVID-19 vaccine brand name and whether it was the first or second dose of the vaccine. This can be noted:

• on the ACC45:  tick the treatment injury box, identify this as an adverse event in the drop-down menu and then enter the COVID-19 vaccine brand name and vaccination dose number in the open comments section
• on the ACC2152: in Section 3 – Treatment claimed to have caused the injury.

4.  Drug Updates

A.  Information on supply issues, discontinuations and brand changes will now appear at the top of each drug monograph in the New Zealand Formulary (NZF). This information is provided by PHARMAC on a weekly basis. There will be links through to the PHARMAC website where more information about each notification can be found. An index of all current PHARMAC supply notifications can be found in the NZF as well.

B.  Paroxetine:  Loxamine brand of paroxetine, is temporarily out-of-stock. An alternative brand, Paxine, will be listed from 1 March 2021 to cover the out-of-stock period (duration currently not specified). Paxine is the Australian version of Loxamine; the formulations are identical.

C.  Gabapentin and pregabalin:   A recent Medsafe spotlight on gabapentin and pregabalin for neuropathic pain includes the following key messages:

• Gabapentin and pregabalin are indicated for the treatment of neuropathic pain only. Use in other types of pain is unapproved.
• Cases of abuse and dependence have been reported with gabapentin and pregabalin. Evaluate patients for a history of substance abuse and observe for signs of misuse or abuse.
• Concurrent treatment with CNS depressants (eg, opioids) and gabapentin or pregabalin should be avoided. Observe patients carefully for CNS depression if concurrent use cannot be avoided.

D.  Vildagliptin and an ACE inhibitor:  Medsafe has also drawn attention to an increased risk of angioedema with combined use of vildagliptin and an ACE inhibitor compared to use of either medicine alone. Consider this possible drug-drug interaction if a patient taking these medicines presents with angioedema and ask patients on the combination to report any angioedema symptoms to their prescriber.

E.  Timolol will no longer be available once existing supplies are exhausted.  Pharmac advice is:

• ensure no new patients start on timolol tablets. From 1 March 2021, new patients will not be able to receive funded timolol 10 mg tablets.
• support your patients who are currently using timolol tablets to change to an alternative treatment as soon as possible. 

F.  Cilazapril is used in New Zealand much more than any other country. To reduce the risk of supply issues, Pharmac is asking prescribers to move away from the use of cilazapril.

• From 1 May 2021 no new patients will be able to be started on cilazapril.  Cilazapril will still be available for patients already on the drug.
• A Community Schedule endorsement “for existing cilazapril patients only” has been applied from 1 May 2021 (Pharmacists can annotate the prescription as endorsed where there exists a record of prior dispensing of cilazapril). 
• Pharmac is recommending considering changing patients already on cilazapril to a suitable alternative.
• BPAC has published a helpful article on ACEI prescribing – Prescribing ACE inhibitors: time to reconsider old habits.

5.  Change in notification level for lead

The current notification level of 0.48 (or greater) µmol/l is to be reduced:

• The new notification level will be 0.24 µmol/l (or greater).
• The new notification level comes into effect on 9 April 2021

The notification process is triggered when a person returns a blood lead test that shows an elevated blood lead level. If the results of the blood test meet or exceed the notification level then the health practitioner (or medical laboratory) reports this to their local medical officer of health for further follow-up. This allows the source of the lead exposure to be identified and health risks managed. Further information is available from the Ministry of Health.

6. On-line death certification

The Death Documents website will be down for maintenance from 9pm 9 April to late afternoon 11 April 2021.  Paper death certificates will need to be completed if required during this period and blank certificates can be downloaded from the website during the maintenance outage. Once maintenance is completed the site can no longer be accessed Internet Explorer but is supported on other common web browsers.