Clinical Snippets November 2021

Summary

Dr Dave Maplesden and Dr Jo Scott-Jones talk about frailty of old age, medicinal cannabis, a new use for Empagliflozin, Penicillin allergy, Baclofen and a touch of the covid19s. 

Shownotes

Clinical Snippets November 2021

1.  Medicinal cannabis

From 1 October 2021, the Ministry of Health is requesting doctors and pharmacies to prescribe and dispense only products that have met Minimum Quality Standards.

• Currently there are only TWO brands that are on this list of quality-verified medicinal cannabis products, an offshore Canadian company called Tilray (4 products), and a New Zealand company called Helius Therapeutics (2 products).
• The prices for Helius Therapeutics SubDrop CBD are as follows:
  • Helius SubDrops CBD25, 25mg/ml, 30ml bottle: $60 (750mg total CBD)
  • Helius SubDrops CBD100, 100mg/ml, 30ml bottle: $150 (3000mg total CBD)
• For many people on an average dose of 50mg CBD per day, that calculates to $2.50 per day for the Helius SubDrops CBD100. The lower entry price of $60 for the Helius SubDrops CBD25 may be a good first trial product for patients wanting to try but not spend too much money in the first instance.
• The Goodfellow Unit has a webinar on prescribing medicinal cannabis products and consultation on a draft BPAC article ‘An overview of medicinal cannabis for health practitioners’ has recently been completed.  Practical prescribing advice is contained in the Cannabis Clinic Handbook. 

2. Empagliflozin and HFpEF

• There are no previous medications that change CVD outcomes in CHF with preserved ejection fracture (HFpEF). This includes Candesartan, Spironolactone and a neprilysin inhibitor.
• A study recently published in the NEJM showed empagliflozin 10mg daily has a 21% reduction in the primary outcome of hospitalised HF or CV death (HR 0.79; P<0.001). It worked for patients at the lower and higher ends of the >40% range of EF and whether or not the patients had diabetes. Adverse events discontinuation of treatment occurred in 19.1% of patients in the empagliflozin group and 18.4% in the placebo group.
• Uncomplicated genital and urinary tract infections and hypotension were more common in the empagliflozin group. Empagliflozin (Jardiance) is only funded in NZ for patients with diabetes on special authority. Individuals without diabetes can pay for it at about $80 per month.

3.  Frailty of old age

• The Ministry of Health has announced that ‘Frailty of old age’ can now be entered as the sole entry in Part 1(a) of a medical certificate of cause of death (MCCD) in limited circumstances, effective immediately. This diagnosis is applicable to a patient aged ≥ 80 years who dies as a result of gradual multi-system decline in function, that:
• Has been clinically assessed over a period of several months or years for the specific organ system disease before death; and
  • Is attributable to atrophic degenerative changes of ageing; and
  • Has occurred in the absence of any specific organ system disease
• This change is intended to offer a more suitable option for health practitioners to use when completing the MCCD for an elderly frail patient who has died suddenly, apparently of natural causes, but the exact cause of death cannot be determined without an autopsy.
• If there is a more specific chronic diagnosis that has resulted in death, or if death is due to acute illness or trauma, these should be preferentially entered in Part 1a. If ‘Frailty of old age’ is used as the diagnosis in Part 1a, any additional chronic conditions that contributed to the patient’s steady decline should be entered in Part 2 of the MCCD in order of severity, in addition to the corresponding time interval in brackets after each condition.
• There is a helpful Youtube video available on using the Death Documents website and the Ministry of Health provides further written information on completion of death documentation.    

4. Penicillin allergy

• District Health Boards (DHBs) across New Zealand are working collaboratively via Antimicrobial Stewardship and Infection Pharmacists to raise awareness about the potential for incorrect penicillin allergy labelling and the associated harms. DHBs are inviting patients who think that they have penicillin allergy to talk to their healthcare team – so be prepared!  A bulletin outlining the initiative is available here. 

• Despite being the most common adverse reaction reported, nine out of ten people who believe they have a penicillin allergy, do not actually have an immune-mediated allergy. Incorrect labelling of penicillin allergy can result in the use of second-line antibiotics that may be less effective, broader spectrum and associated with an increased risk of adverse effects.

• When prescribing an antibiotic, consider the accuracy of an allergy label as:

• Immune systems change over time; approximately 50% of people who had a positive skin prick test to penicillin are no longer allergic after five years and approximately 85% are no longer allergic after ten years.
• Allergy labels may not always be correct. In many cases, the “allergy” was an adverse effect, and patients may find they can tolerate the antibiotic after an initial reaction.
• Formal referral pathways for determining presence of significant penicillin allergy are not yet established for primary care. Focusing on patients with negligible risk of penicillin allergy (without the need for oral amoxicillin challenge or engagement with speciality services) might be the most straight forward way of incorporating this into practice currently. For resources and further information on this initiative, click here. 

5.  Early identification of COVID-19 pneumonia

A paper this month in the BMJ reviewed clinical studies on the early detection of symptoms and signs likely to lead to COVID-19 pneumonia, when monitoring patients in the community.

Summary of key findings and advice:

• Most people with COVID-19 will have resolution of symptoms without a significant clinical event.  Typical symptoms are similar to the common cold or influenza and begin to improve within two to three days
• The early detection and correction of hypoxia is likely to be one of the key determinants of disease progression
• A patient with any of the following symptoms requires urgent clinical contact: shortness of breath, confusion, persistent fever
• Other symptoms with a predictive value for disease progression are: dyspnoea, fatigue, dry cough, chest tightness, abdominal pain, diarrhoea, vomiting
• In COVID-19 pneumonia, low oxygen levels can sometimes occur without breathlessness; this can be detected by pulse oximetry and requires urgent medical attention. This is termed “silent hypoxia” and may be associated with other symptoms such as confusion, altered mental state or severe/exertional fatigue. People with silent hypoxia appear to have a poorer prognosis.
• Observations including pulse, respiratory rate, blood pressure, temperature and oxygen saturations are likely of high value in detecting a patient who is deteriorating due to COVID-19 or other presentations, e.g. bacterial pneumonia, sepsis, pulmonary embolism; oxygen saturations are the most predictive of COVID-19 progression
• Chest x-ray has limited clinical value in a community setting
• Clinical examination is of uncertain value, but an “eye ball” assessment is useful
• Blood tests are usually not required but monitoring CRP can be useful, especially if point-of-care testing is available; a level >30 mg/L may indicate progression and a risk of viral pneumonia, it is less reliable in people aged >75 years – use a lower threshold of > 20 mg/L 
• Duration of symptoms is not predicative as deterioration was found to occur at any stage of the illness

  6.  MEDICATION ALERT – BACLOFEN ORAL LIQUID

• The National Medication Safety Advisory Group (NMSAG) and the Compounding Working Group (CWG) are aware of a number of serious overdose and underdose medication errors related to the inconsistency in the concentration of baclofen suspension and liquid used across hospital and community healthcare settings.

• The standardised baclofen oral suspension batch sheet will change to a 1 mg/mL concentration, effective 1 November 2021. This change will promote consistency and help to reduce harm from medication errors, especially at transitions of care.

• Please refer to the medication alert for more information and for actions to be taken.