Summary

Dr Dave Maplesden educates Dr Jo Scott-Jones with some snippets of important clinical information this month with a vaguely anatomical theme. 

Transcription

Clinical Snippets February 2022

1.  Peripheral artery disease and walking

From a recent Tools for Practice:  In patients with PAD, exercise therapy improves maximum walking distance and pain-free walking distance by up to ~200 meters over 2 to 78 weeks compared to usual care. No benefit has been demonstrated for amputation or mortality. The most commonly studied exercise is supervised walking 2-3 times per week for 30-60 minutes, although other supervised activities (example resistance training) may be beneficial in those who cannot tolerate walking.

• Patient understanding of physical activity for PAD should be explored:
• 63% identified walking as the primary aetiology for their pain, 90% thought walking would worsen symptoms.

2.  Electronic communication and the internet

Last year MCNZ released an updated statement on Use of the internet and electronic communication  which includes the following points (and I recommend reviewing the whole document):

• Inappropriate communication, including use of social media, can be considered unprofessional, whether this is directly related to a doctor’s work or not.
• Patients who get information from the internet may wish to discuss this with you. You should use this as an opportunity to talk about how sometimes the information obtained from these sources may be of poor quality, incorrect, or create unrealistic expectations. Provide sound reasons for the views you express and, where possible, provide documentation, to support the alternative advice or treatment that you are recommending.
• There are security issues specific to the use of email. It is difficult to verify a person’s identity from an email; some families and groups share a common email address; and computers (particularly family computers) may be accessed by a number of different people. For these reasons, check with the patient before sending them sensitive information by email.

3.  Aotearoa New Zealand STI Management Guidelines – Chlamydia

• There is growing evidence that sexually transmitted Chlamydia trachomatis establishes a persistent rectal reservoir that is refractory to treatment with azithromycin stat.
• The evidence is very strong for men who have sex with men, but is growing for women too.
• Contemporary guidelines are abandoning azithromycin stat and reverting to doxycycline 100mg BD for seven days with stat azithromycin only if doxycycline contraindicated or patient is highly likely to be non-adherent.
• Symptomatic anorectal infection generally requires specialist advice as further testing and management is complex

4.  Recurrent Bacterial Vaginosis (BV)

A recent article in NZ Doctor includes the following key points on recurrent BV:

• There have been no major advances in the treatment and cure of bacterial vaginosis, perhaps because the pathophysiology is complex, multifactorial and not fully understood.
• Standard therapy is seven days of twice-daily metronidazole, but many women are looking for alternative treatments that may provide longer duration between recurrences.
• Intravaginal boric acid capsules have been used historically and may be considered an alternative, though unfunded, treatment to use in conjunction with antibiotic therapy.

DermnetNZ lists a number of alternative treatments including gels to reduce vaginal pH and a vaginal antiseptic dequalinium.  It does not appear any of the recommended products are in NZF but Aci-Jel is available OTC (around $30 per 100g tube).    Boric acid vaginal pessaries can be bought on-line – eg pHD $199 for 72 caps (about five courses)

A 2009 Cochrane review concluded that research at that time research did not provide conclusive evidence that probiotics are superior to or enhance the effectiveness of antibiotics in the treatment of BV.  However, a 2019 meta-analysis concluded that probiotic regimes are safe and may exhibit a short-term and long-term beneficial effect for BV treatment.  There are many OTC preparations available.  Probiotics do not form part of HealthPathways or Aotearoa New Zealand STI Management Guidelines recommendations for management of BV. 

DermnetNZ also discusses cytolytic vaginosis as a cause of possible of persistent vaginal discharge.  This is the result of a hyperacidic vaginal environment due to overgrowth of lactic acid producing bacilli, with management aiming to reduce vaginal pH (baking soda douching). 

5.  Extended use of intrauterine devices

Tools for Practice examined the evidence around effectiveness of intrauterine devices for prevention of pregnancy when used beyond the manufacturer recommended use period.  The conclusion was:

If it is not possible or desirable to replace a levonorgestrel 52mg or copper-T380A intrauterine device (IUD) at the end of the approved duration of use, small observational studies demonstrated similar efficacy and safety for up to two additional years, with little evidence afterwards. Guidelines suggest that with patient-informed discussion, deferral of IUD replacement for up to twelve months is reasonable.

6.  Antipsychotic switching tool

A useful tool is available from NPS Australia that assists prescribers when changing a patient’s antipsychotic treatment. Using the interactive tool, the prescriber enters the formulation (oral or depot), the current medicine the patient is prescribed and the medicine they want to switch the patient to. This then generates prescribing information about how to stop one medicine and start the next, along with key clinical issues to be aware of. All antipsychotic medicines currently funded in New Zealand are included in the tool.

7.  Serotonin syndrome – a reminder

A relatively common prescribing complaint I see relates to patients concerned they were not warned of the risk of serotonin syndrome, or that they experienced serotonin syndrome, usually secondary to co-prescribing of two serotonergic agents.  The most common combinations I see are tramadol and SSRI, SNRI or TCA, or when a TCA is added to an existing antidepressant regime.  A 2015 communication from Medsafe discusses the issue in more detail and is worth a quick review. 

Summary

Dr Dave Maplesden and Dr Jo Scott-Jones discuss antibiotic stewardship tips and tricks, Emoquol 100 a screening test for mood assessment, covid and pregnancy, covid and budesonide, covid and myocarditis, and nothing to do with covid Melanoma follow up. 

Transcription

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.

1.  EOLC Act snippet

The EOLC Act requires the SCENZ (Support and Consultation for End of Life Choice in New Zealand) group to oversee assisted dying service lists for:

• Replacement attending medical practitioners (where a person seeks the name of a practitioner to provide the service for them). This practitioner will support someone who is terminally ill to make an application for assisted dying, and undertake a first assessment
• Independent medical practitioners (to undertake the second independent assessment)
• Psychiatrists (required if one or both of the initial assessments was unable to determine that the person is competent to make a decision).
• The SCENZ group will also hold a list of willing nurse practitioners. Nurse practitioners can be involved in the planning of assisted dying with the person and their whānau, and can be with the person to administer medicines or supervise self -administration if that is what the person chooses

A medical practitioner who does not provide assisted dying services due to a conscientious objection (or belief it is outside their scope of practice) is legally required to:

• inform the person asking about assisted dying of their objection

• tell the person they have the right to ask the SCENZ group for the name and contact details of a ‘replacement’ medical practitioner who is willing to participate in assisted dying.

A person will also be able to contact the SCENZ group directly for help to find a medical practitioner if they do not want to speak to their own medical practitioner about assisted dying.

The schedule of payments for providing EOLC services is now available and additional learning modules are available on the Learnonline website.     

2.  Concussion

• The current ACC referral system poses significant barriers to both GPs and to patients. As it stands, patients wait an average of eight weeks before being able to access the appropriate concussion treatments through ACC. A new treatment and referral model which involves funding for extended primary care consults and embedding of specific management tools into the PMS is currently being trialled.  In the meantime…

• The ACC Concussion Clinical Expert Group has reviewed current tools for TBI assessment and found for the most part they were limited, overly complicated, and didn’t support decision making. As a result, a tool has been developed to help health practitioners assess and treat TBI patients, called the Brain Injury Screening Tool (BIST). 

• BIST runs patients through a checklist of 16 items and takes six minutes from start to finish, leaving the practitioner enough time within the 15-minute consult to also provide treatment advice. It is simple enough to use even with young children. The series of questions look at the impact of the patient’s symptoms in the context of their life and the results categorise the patient in terms of their risk factor (low, medium, or high risk).  

• The tool indicates problem areas to be aware of, suggests additional questions or assessments to be completed, and supports the healthcare professional to confidently assess and treat the TBI patient. Each assessment results in a total symptom score, allowing practitioners to graph their patient’s recovery over time using a standardised outcome assessment. 
  
  

3.  Prostate cancer

The Prostate Cancer Quality Improvement Monitoring Report is now available on the Te Aho o Te Kahu website.  Some key findings in relation to equity included:

• Pacific and Asian men were in some cases more likely to be diagnosed following presentation at an ED (10.7 percent and 8.0 percent) than European/Other ethnic group men (5.8 percent).

• Men aged 75 and over were more likely to be diagnosed around the time of presentation at an ED (17.2 percent) compared to men in younger age groups (5 percent or less).

• Men who lived in areas of high social deprivation were more likely to be diagnosed following presentation at an ED (8.7 percent) than men living is areas of low social deprivation (3.9 percent).

• Māori are less likely than non-Māori to be diagnosed with prostate cancer and are more likely to have poorer survival rates once they are diagnosed.

The primary care management of suspected prostate cancer is clearly outlined in the Ministry of Health Prostate Cancer Management and Referral Guidance which has a useful algorithm for quick reference.  The relevant HealthPathway provides similar guidance.  The PSA ‘discussion’ is not so clear cut and useful resources to aid this discussion are available on the Kupe website (including a PSA decision support tool).  The Health Navigator website also contains useful resources (including two videos on the pros and cons of PSA screening). 

4.  Early Pregnancy Treatment Clinic (Waikato DHB)

EPAC is now EPTC. The clinic is aimed at pregnancies of <16 weeks gestation and the role of the EPTC is to:

• Establish a MANAGEMENT plan following a DIAGNOSIS of a miscarriage (expectant, medical or surgical management.)
• Establish a MANAGEMENT plan where a confirmed presence of RPOC exists following miscarriage in a symptomatic patient.
• Coordinate molar pregnancy management.
• Coordinate follow up for a woman who has received methotrexate or expectant management as part of her ectopic pregnancy of unknown location treatment as per Waikato DHB protocol.

Appropriate referral to EPTC requires CONFIRMED miscarriage by ultrasound or CONFIRMED RPOC following a miscarriage. The clinic will not accept referrals for ultrasound scans for uncertain dates, viability or seeking confirmation of miscarriage. Patients with hyperemesis gravidarum, those patients deemed too clinically unstable to delay assessment and patients who have high suspicion of ectopic pregnancy should be referred to Acute Gynaecology.

This is NOT an acute service.  patients can expect to be called within 5 working days.

Advice on management of suspected miscarriage and ectopic pregnancy is available on HeathPathways although has not yet been adapted for the Waikato region.   Some important reminders:

• Always consider an ectopic pregnancy if positive pregnancy test and abdominal pain or bleeding
• Check haemodynamic stability and palpate the abdomen
• Consider if anti-D immunoglobulin might be required (first trimester miscarriage is an indication but the NZ Transfusion Medicine Handbook notes before 12 weeks gestation, in cases of either spontaneous complete miscarriage where the uterus is not instrumented or mild painless vaginal bleeding, the risk of fetomaternal haemorrhage is negligible.
• If monitoring hCG, ongoing intrauterine pregnancies are usually expected to have a rise of 67% or greater over 48 hours in the first trimester. Rarely, smaller rises have been reported in normal pregnancies.  Pregnancies that are miscarrying usually see hCG levels fall by 50% or more. Continue to monitor weekly until the hCG returns to zero.   Referring to an hCG doubling time calculator can be helpful given the wide range of ‘normal’ hCG levels.   

5.  Educational relaxation…

The Good GP is a series of relatively brief (usually around 15-20 minutes) educational podcasts on a huge range of primary care-related topics.  A new podcast each week.  Most recently:   OCD, venous disease, LARCS.  

6.  More on conscientious objection

New abortion legislation enacted in March this year includes some changes in the responsibilities of a health practitioner who is requested by a patient to provide, or assist with providing, any of the following services: contraception services; sterilisation services; abortion services; information or advisory services about whether to continue or terminate a pregnancy.

If the practitioner has a conscientious objection to providing, or to assisting with providing, to the patient the service requested, the practitioner must tell the patient at the earliest opportunity—

(a) of their conscientious objection; and

(b) how to access the contact details of another person who is the closest provider of the service requested.

The closest provider is to be determined taking into account:

• the physical distance between the providers; and
• the date and time the patient has made their request
• the operating hours of the provider of the service requested.

This section does not override a health practitioner’s professional and legal duty to provide prompt and appropriate medical assistance to any person in a medical emergency.

PS

Dave’s  opera recommendation :

Elīna Garanča – Saint-Saëns: ‘Mon coeur s’ouvre à ta voix’ from Samson et Dalila (Romantique)

Clinical Snippets – September 2021

Dr Dave Maplesden and Dr Jo Scott-Jones discuss “snippets” of clinical information relevant to New Zealand General Practice in this monthly conversation. This time, referring patients – the importance of using agreed processes for acute admissions and bowel screening, emaglifozin side effects, boron containing medications, hyperkalaemia, the choice of an ACEi or an ARB, and how not to prescribe Ivermectin for covid. 

1.  Waikato DHB – deferred acute referrals

A new directive is in place for what should happen when, after discussion with the registrar, it is deemed that the patient does not need to be seen acutely, but should have an outpatient appointment:

• If it is decided that the patient needs urgent follow up in clinic then the registrar is expected to organise this themselves.
• If it is considered that the patient may benefit from a semi-urgent or routine outpatient appointment then the GP/ Nurse Practitioner will be asked to refer. It cannot be guaranteed that the appointment will definitely occur as it will still have to go through the SMO triage process.

2. National Bowel Screening FOT Positive referrals

In BPAC search bar type FIT to display correct referral. It is not only important to refer participants through to the hospital but just as important to do the same referral if the participant wants to be seen PRIVATELY. NBSP is then able to update their information and close the loop knowing the participant has been followed up.  

3. Empagliflozin side effects

• Empagliflozin (Jardiance/Jardiamet) is used in the treatment of type 2 diabetes mellitus, to improve glycaemic control and reduce the risk of cardiovascular events in adults.
• Diabetic ketoacidosis and Fournier’s gangrene (necrotising fasciitis of the perineum) are rare, but serious and life-threatening conditions that can occur in patients on empagliflozin treatment.
• Inform patients about these potential adverse effects when initiating empagliflozin, including their signs and symptoms and when to seek medical attention.
• Patients taking empagliflozin should have a personalised ‘sick-day’ plan. See Health Navigator for information to include in such a plan and for excellent patient information leaflets on empagliflozin and empagliflozin/metformin.
• See the September 2021 Prescriber Update for more details

4.  Boron-containing medicines and fertility concerns in children

• The Medicines Adverse Reactions Committee (MARC) has recommended that a statement be added to medicine data sheets of boron-containing medicines, such as chloramphenicol eye drops, based on theoretical evidence that use may adversely affect future fertility. This advice specifically relates to use of boron-containing eye drops in children aged under two years.

• Chloramphenicol eye drops administered as one drop four times a day for the treatment of bacterial conjunctivitis is unlikely to exceed the threshold for boron in children aged under two years. Chloramphenicol ointment does not contain boron and therefore can be used as an alternative if caregivers are concerned.

5.  Reminder: hyperkalaemia caused by amiloride or spironolactone

Key Messages from theSeptember 2021 Prescriber Update

• Hyperkalaemia is a well-established risk of treatment with potassium-sparing diuretics such as spironolactone and amiloride.  The risk of hyperkalaemia is increased in patients with renal or hepatic impairment, the elderly, and those receiving concomitant medicines that can increase potassium.
• Examples of medicines that increase potassium include angiotensin-converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs) and non-steroidal anti-inflammatory drugs (NSAIDs)
• Regular monitoring of serum potassium is recommended especially when therapy is initiated, when dosages are changed or with any illness that may cause renal dysfunction
• Relevant preparations include frusemide/amiloride (Frumil), amiloride/hydrochlorothiazide (Moduretic) and spironolactone (Spiractin, Spirotone)
• An 2011 BPAC article on primary care management of electrolyte disturbances gives lots of practical advice including:  Urgent referral to secondary care is recommended for patients with serum potassium ≤ 2.5 mmol/L or ≥ 7 mmol/L, rapidly decreasing or increasing levels, neuromuscular symptoms or ECG changes, or if the patient is systemically unwell. 

6.  ACEi or ARB

• A recent Goodfellow Gem was headed ‘Time to switch from ACEis to ARBs – same efficacy but safer’ noting  ahead-to-head comparison trial of ARBs vs ACEis exhibited no difference in outcomes except for fewer drug withdrawals due to adverse effects with ARBs.

• In another study, ARBs had significantly lower risks of angioedema, cough, pancreatitis, and GI bleeding than patients on ACEis. The hazard ratio of angioedema associated with ACEis versus ARBs is over 3.  Although rare (incidence 0.1-0.7%), it remains an adverse event of concern as occasionally it can be fatal.

• In New Zealand, Pharmac fully funds Losartan and Candesartan, so there is no longer any funding barrier to ARB usage.

• A recent BPAC article on ACEi prescribing notes ACEi should be considered first line in patients with heart failure or following an MI while ARB can be considered equal first line with an ACEi for hypertension, CKD and diabetic nephropathy.

7.  Prescribing or authorising import of Ivermectin

(i)  The MCNZ statement ‘Good prescribing practice (2020)’ includes: 

• Be familiar with the indications, adverse effects, contraindications, major drug interactions, appropriate dosages, monitoring requirements, effectiveness and cost-effectiveness of the medicines that you prescribe.

• Prescribe in accordance with accepted practice and any relevant best practice guidelines. Prescribing outside of accepted norms should only occur in special circumstances with the patient’s informed consent.

• You may prescribe unapproved medicines or prescribe medicines for a purpose for which they have not been approved. However, if you decide to do so, you must take responsibility for overseeing the patient’s care, including monitoring and any follow-up treatment. You must make a clear, accurate and legible record of your reasons for prescribing any unapproved medicines and of the patient’s consent.

• Medicines or treatment must not be prescribed for your own convenience or simply because patients demand them.

(ii)  A recent Tools for Practice publication titled ‘Opening a can of helminths:Ivermectin for COVID-19’ poses the clinical question ‘Does ivermectin improve clinical outcomes in COVID-19?’.  The current evidence is reviewed with the conclusion:   The best available evidence does not show that ivermectin improves clinically important outcomes in COVID-19. Use in COVID-19 is discouraged.

(iii)  The RNZCGP has published a statement by College medical director Dr Bryan Betty that includes:  Ivermectin can, and does, cause harm when misused.  Prescribing it could well mean that even if the patient had given consent, the doctor could still be held liable for making an ill-informed decision on a medication that at this point has not been shown to provide benefit and could cause harm. It would be difficult to justify this position with either the Medical Council or the Health and Disability Commissioner.

(iv)  Medsafe has recently published a Prescriber Alert that includes:

• Medsafe and the Ministry of Health strongly recommends that ivermectin is not used for prevention or treatment of COVID-19. Ivermectin is NOT APPROVED to prevent or treat COVID-19, which means that Medsafe has not assessed the safety and efficacy for this use. Inappropriate use of ivermectin can be dangerous.

• Ivermectin is not approved in New Zealand (or in other OECD countries) to prevent or treat COVID-19 disease in humans.  When ingested in high doses, ivermectin can have a serious effect on humans, with symptoms including low blood pressure, worsening asthma, severe autoimmune disorders, seizures and liver damage.

• Regarding a prescriber’s authorisation of Ivermectin imports:  The authorised prescriber must be satisfied that the individual’s clinical need for the medicine outweighs the risks of taking the imported medicine. By authorising release, the authorised prescriber takes responsibility for prescribing the medicine for that individual.

• Medsafe has not evaluated the safety, quality and effectiveness of medicines imported by patients. These medicines may be of poor quality, sub or super potent, contaminated, adulterated or counterfeit. Taking these medicines can put people at serious risk of unpredictable or severe side effects.

Summary

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

This month Acc consent, the end of life choice act, a new statin, acute coronary syndrome in women 

A video version of this podcast is available on the Pinnacle Practices website here https://www.pinnaclepractices.co.nz/resources/clinical-zoom-meeting-snippets-august-2021/&nbsp;

Transcription

Summary

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

This month Acc consent, the end of life choice act, a new statin, acute coronary syndrome in women 

A video version of this podcast is available on the Pinnacle Practices website here https://www.pinnaclepractices.co.nz/resources/clinical-zoom-meeting-snippets-august-2021/&nbsp;

Shownotes

Clinical Snippets – August 2021

1.  ACC Consent

You no longer need to record and maintain a patient’s signature when you lodge a claim with ACC. Instead, you can record their consent in their clinical record. 

To confirm consent, you need to read these statements to your patient (or an authorised representative), and note their response: 

• Do you declare that you have provided true and correct information and you’ll tell ACC if your situation changes?
• Do you authorise me as your (name of health profession: GP, physiotherapist, etc) to lodge your claim with ACC?
• Do you authorise your records to be collected or disclosed to ACC to help determine cover for your claim, determine what you’ll be entitled to, or for research purposes (such as injury prevention, or assessment, and rehabilitation)?

2.  Childhood Eczema Resources

BPAC has recently published an update on managing childhood eczema.  Information includes:

• The funded brand of emulsifying ointment is now sodium lauryl sulphate-free which means it can be used as a leave-on emollient as well as a soap substitute.  Following a skin infection, discard the current tub of emollient and replace with a new tub.

• Use the lowest potency topical corticosteroid needed to control the patient’s symptoms; avoid the term “use sparingly” and encourage appropriate use.  For children with frequent flares, eg. two flares per month, “weekend treatment” with topical corticosteroids may reduce the frequency of flares and overall corticosteroid use.

• A short (10-15 minute) warm bath twice daily with moisturising after can improve symptoms.  Research does not support bleach baths, bath additives or water softeners for eczema symptoms.

• Treatment adherence can be improved by prescribing simple regimens and ensuring patients and caregivers know how to follow them.  Some helpful resources include:

• Instructional videos on the use of moisturisers, bathing and topical corticosteroids:
  • Printable information sheets for parents including general and patient specific eczema management and managing infected eczema (does still emphasise bleach baths)

• There is increased access to pimecrolimus and tacrolimus cream (via SA) for treatment of eyelid and facial eczema when steroids are ineffective or contraindicated.   

3.  End of Life Choice Act

Just a reminder this legislation comes into force on 7 November 2021.  The LearnOnLine education module about the Act takes around 20 minutes to complete and gives a clear review of a medical practitioner’s responsibilities, eligibility criteria, assessment of capacity etc. 

The Ministry of Health is hosting a forum for the health workforce who may be involved in delivering parts of the assisted dying service on 29 and 30 September 2021.  Registration details are available here. 

4.  Alternatives to in-person consults

A great and practical set of resources on many aspects of tele-consultations has been developed by PHOs and is available here.  The resource includes a Doxy.me toolkit, PMS specific set-up instructions as well as generic ‘how to’ guides, and various practical tips for getting the most out of a consultation.  Some practical tips I appreciated were:

• Use of screen sharing to show the patient relevant information eg anatomical diagrams during a consultation
• Use of standardised patient information leaflets which are emailed to the patient immediately following the consultation and might cover issues such as red flags for headache, shortness of breath, abdo pain etc. 

Further information for providers and patients is available on the Health Navigator website including a tip sheet for patients preparing for a video consult.   The Telehealth Leadership Group has offered in a useful one-pager some initial guidance to health providers as they rapidly adapt to Telehealth and additional resources are being developed by the group. 

5.  Rosuvastatin

• PHARMAC has announced that from 1 December, 2021, rosuvastatin will be funded with Special Authority Approval as a treatment for people with an increased risk of cardiovascular complications associated with high lipid levels.

• Māori and Pacific patients are specifically listed in the Special Authority criteria and can access funded treatment as first line if they are “considered to be at high risk of cardiovascular disease”.  Patients can also access funded treatment if they have a calculated five-year CVD risk of ≥15% and high lipid levels, despite treatment with atorvastatin and/or simvastatin. Any relevant practitioner can apply for the Special Authority funding.

• Rosuvastatin is considered the most potent statin available and is associated with a comparable safety profile to other medicines in this class with no greater risk of myopathy or serious renal injury when dosed appropriately.   Rosuvastatin tablet strengths are 5, 10, 20 and 40mg (5mg approximately equivalent potency to 40mg simvastatin).  For recent upodated information on prescribing statins, including dose equivalency, see: https://bpac.org.nz/2021/statins.aspx

6.  Acute coronary syndrome in women

A systematic review and meta-analysis of sex differences in symptom presentation in acute coronary syndrome published by the American Heart Association last year included the following conclusions:

• Symptoms experienced by men and women with confirmed acute coronary syndromes show substantial overlap.
• Yet some sex differences in symptoms exist as women have higher odds of experiencing pain between the shoulder blades, nausea or vomiting and shortness of breath, and lower odds of experiencing chest pain or diaphoresis.
• These differences and similarities between women and men with confirmed acute coronary syndromes in symptoms experienced have been established in literature for more than a decade.

What Are the Clinical Implications?

• Symptoms of acute coronary syndromes should no longer be labelled as “typical” or “atypical” for women and/or men.
• Attention for sex differences in symptoms of acute coronary syndromes should be proportional to the large overlap in symptoms of acute coronary syndromes between women and men.

The NZ Heart Foundation is currently running a TV ad campaign emphasising how women with ACS may present in a different manner to men.  I have recently seen two cases where women with marked nausea and shoulder ache were (falsely in hindsight) reassured they weren’t having a heart attack when they queried the diagnosis.  

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.