Summary
Dr Dave Maplesden and Dr Jo Scott-Jones discuss clinically important “snippets” of information relevant to general practice in New Zealand
A video version of this podcast is available on the Pinnacle Practice Website https://www.pinnaclepractices.co.nz/resources/clinical-zoom-meeting-snippets-march-2021/
Shownotes
Clinical Snippets – March 2021
1. Type 2 diabetes management
If you have trouble working out whether to use a SGLT2i, GLP1RA or a DPPIVi, the Ministry of Health and NZSSD have developed a useful management algorithm available on the NZSSD website. This includes links to Special Authority criteria for the various drugs and preferred second- and third-line agents.
- Currently available SLGT2i are empagliflozin and dapagliflozin, both also available in combination with metformin. NB risk of diabetic ketoacidosis which can occur with normal blood glucose levels, and need to stop with any intercurrent illness or 2 days before an elective surgical procedure. SA required for funding.
- The only funded GLP1RA is dulaglutide (expected to be available mid-2021) given by SC injection once weekly. SA required. Unfunded GLP1RAs are exenatide (indication – diabetes) and liraglutide (indication for treating obesity). DPP-4 inhibitors must be stopped if initiating GLP1RA and should be withheld during an acute GI illness.
- GLP1RA and SLGT2i can be used together if indicated with additional likely benefits but currently only either group (not both concurrently) will be funded under SA.
- DPP-4 inhibitors (funded version vildagliptin (available in combination with metformin)) and unfunded versions sitagliptin and saxagliptin. May be used as 2nd line agent as weight neutral and will not cause hypoglycaemia in or of itself.
2. Increased access to chest X-rays (Waikato DHB)
- From 1 March 2021 Waikato DHB is opening up access to ordering of chest X-Rays though community radiology providers via the e-referral process.
- When making the referral a drop-down box will give access to the private providers involved.
- The criteria are that the GP feels that getting a CXR will help them with managing that patient – however the hope is that freeing up access will result in earlier diagnosis of lung cancer and help address the large equity gap between Maori and non-Maori in lung cancer prognosis.
- Note that a 2018 systematic review of sensitivity of chest X-ray for lung cancer suggested that chest X-ray does not identify approximately 25% of cases of lung cancer, although the findings may be affected by publication bias.
A. If the patient presents with one or more of the following red flags, then the referral should be triaged as ‘High Suspicion of Cancer’.
- Chest x-ray or other imaging suggestive/suspicious of lung cancer (including new pleural
effusion, pleural mass, and slowly resolving consolidation)
- Persistent or unexplained haemoptysis in high-risk individuals over 40 years of age
- New pathological diagnosis of lung cancer
B. An urgent chest X-ray is required for lung cancer in people aged 40 and over if they have:
- Any persistent or unexplained haemoptysis
- Unexplained/persistent (more than 3 weeks)
- cough
- shortness of breath
- chest/shoulder pain
- weight loss greater than 10%
- abnormal chest signs
- unresolved chest infection
- hoarseness
- Finger clubbing
- Features suggestive of metastasis from a lung cancer (e.g. in brain, bone, liver or skin) as part of appropriate work up
- Cervical and/or persistent supraclavicular lymphadenopathy
Any person who has been referred for an urgent chest x-ray for the above indications and has been found with consolidation should have a repeat chest x-ray 6 weeks later to confirm resolution.
C. Chest x-ray normal. If any symptoms or signs detailed above persist for longer than 6 weeks despite a normal chest x- ray, consider referral to respiratory services
D. Mesothelioma. Suspected mesothelioma should also be triaged as above. It is essential that a careful career history is taken to identify any possible occupations at high risk of asbestos exposure.
E. High risk factors. When making a decision to refer, assess and document risk factors for lung cancer. These include:
- smokers or ex-smokers
- history of exposure to asbestos,
- pre-existing lung disease particularly COPD or interstitial lung disease
- history of cancer
- family history of lung cancer
It should be noted the incidence of non-smoking related cancer is increasing particularly in women and East Asians
4. Modified release nitrofurantoin (Macrobid)
- PHARMAC has announced a decision to fund a new modified-release formulation of nitrofurantoin for the treatment of uncomplicated urinary tract infections.
- The Macrobid brand of nitrofurantoin modified-release 100 mg capsules will be funded from 1 March 2021.
- Nitrofurantoin standard-release 50 mg and 100 mg tablets are currently funded and usually are taken four times a day. The new modified-release formulation of nitrofurantoin only needs to be taken twice a day, meaning that treatment is more convenient for people and it is likely that more people will complete their course of treatment.
- Contraindications to nitrofurantoin treatment include eGFR < 60 ml/min/1.73m2 and pregnant women in whom labour and delivery may be imminent.
- The risk of pulmonary and hepatic adverse reactions increases with prolonged use. Monitor lung and liver function regularly in patients taking prophylactic nitrofurantoin and periodically check for signs of peripheral neuropathy (see Medsafe guidance March 2020).
5. Criteria for direct access to outpatient colonoscopy/CTC
- At the end of 2019 the Ministry of Health released updated criteria for direct access to outpatient colonoscopy/CTC.
- The criteria have been incorporated into the local Midlands HealthPathway for colorectal symptoms and the e-referral for colonoscopy.
- BPAC have produced a useful education refresher on the updates which emphasises the fact that people of Māori or Pacific ethnicity have worse outcomes than people of other ethnicities following a diagnosis of bowel cancer, have more advanced disease at diagnosis, and are more likely to be diagnosed after presenting to an emergency department.
- Delayed diagnosis of cancer, including bowel cancer, is a common source of complaint to HDC. Following the guidance discussed above should reduce the risk of delayed diagnosis. Some features I see relatively frequently include:
- Inadequate assessment of a patient presenting with rectal bleeding (no DRE, assumption of ‘haemorrhoids’)
- No structured follow-up for patients with ongoing or progressive symptoms who may not have initially fulfilled criteria for direct access to colonoscopy
- No referral for surgical/gastroenterology review when patient does not fulfil criteria for direct access to colonoscopy but has progressive lower GI symptoms that remain undiagnosed
- No discussion of option of private colonoscopy where delays in accessing colonoscopy, where it is felt to be clinically indicated, might be expected
- Iron deficiency anaemia treated as a disease rather than a symptom
[1] From: Ministry of Health. Faster Cancer Treatment: High suspicion of cancer definitions. April 2016
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