Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) have been available in New Zealand from 2018. Since then, guidance and funding have been updated to increase access for those who would benefit from it. Both PrEP and PEP are available fully funded with Special Authority approval for people at high risk of HIV infection and can be prescribed by general practitioners and nurse practitioners in primary care (except for PEP in occupational HIV exposures). Given the reported barriers to accessing PrEP, it is important that your key patient populations for PrEP know that this is available for them. Also, consider how you approach these discussions; non-judgmental communication is critical to facilitate open discussion and improve sexual health outcomes, particularly for men who have sex with men (MSM).

Click here to read the full article. B-QuiCK summaries on PrEP and PEP are also available.

Pneumonia is a significant cause of mortality in children and older people, particularly among Māori and Pacific peoples. In New Zealand, Māori males are six times more likely to die from pneumonia than non-Māori males. Prompt identification and treatment will enable patients with initially less severe community-acquired pneumonia to be managed at home, reducing hospitalisation and mortality. As vaccination provides some protection against community-acquired pneumonia, ensure that patients are up to date with vaccinations they are eligible for, including seasonal influenza, COVID-19, pneumococcal and childhood immunisations. This article covers the clinical diagnosis and management of community-acquired pneumonia in children and adults.

Read the full article here. A B-QuiCK summary is also available here.

Persistent fever is one of the characteristic signs of pneumonia in children. However, it can be difficult in young children to distinguish whether the cause of their fever is a life-threatening bacterial infection or a self-limiting viral illness that can be managed in the community. This resource, now updated based on 2024 guidelines, describes the symptoms and signs for assessing the risk of serious illness in children aged under five years presenting with fever.

Read the full article here

Key symptoms and signs that may suggest a diagnosis of bowel cancer include rectal bleeding, changes in bowel habit, weight loss and iron deficiency anaemia. Age and family history also impact the likelihood of cancer, and whether patients will meet referral criteria. Asymptomatic patients with a family history of bowel cancer indicating moderate to high risk can also be offered direct access to surveillance colonoscopy.

The introduction of bowel screening has led to an increase in the number of people being diagnosed with stage I bowel cancer. Diagnosis at an early stage offers a significant survival benefit; the five-year survival rate reduces from approximately 94% for localised (early stage) bowel cancer to approximately 13% for distant (late stage).

People aged 60 – 74 years are currently eligible for funded bowel cancer screening every two years using the faecal immunohistochemical test (FIT). The eligibility age is in the process of being lowered across all regions for Māori and Pacific peoples to age 50 years, to address the increasing incidence of bowel cancer in this population.

Pharmac has announced that from 1^st July, 2024, levetiracetam injections will be funded without restriction for people who experience seizures. It was originally proposed that levetiracetam injections would be funded only for people experiencing seizures while receiving palliative care, however, following feedback, this has now been widened to anyone whose current treatment is not controlling their seizures. Many primary care clinicians will have patients with epilepsy, and while levetiracetam injections may not be initiated in primary care, it is important to be aware that this will be a funded treatment option.

Supply issues affecting morphine oral liquid remain ongoing (last reported in Bulletin 95). Stock of RA-Morph 1 mg/mL is now available; other strengths of RA-Morph are expected to arrive later in 2024. Pharmac is advising pharmacists to dispense Oramorph 10 mg/5 mL (2 mg/mL; Section 29) in place of the three other strengths: 2 mg/mL, 5 mg/mL and 10 mg/mL, until stock of the other strengths of RA-Morph arrives.

N.B. Oramorph 10 mg/5 mL (2 mg/mL) contains ethanol 10% v/v and may not be suitable for some people, e.g. children or people with, or recovering from, alcohol use disorder or dependency.

There are ongoing supply issues affecting stock of Rivastigmine BNM patches (as reported in Bulletin 83). Rivastigmine Patch 9.5 mg/24 hours (BNM 10) is now out of stock again and there is no alternative product available. Resupply is expected early July, 2024. Pharmac advises that there is currently stock in the supply chain, however, there will likely be a short period where the Rivastigmine patch BNM 10 is not available.

The supplier has advised that the shipment of Rivastigmine Patch 4.6 mg/24 hours (BNM 5) has been delayed until July, 2024. An alternative product, Exelon Patch 5 has been listed on the Schedule since October, 2023, and will remain available until stock of the Rivastigmine BNM 5 patch arrives.

Cold and flu preparations containing pseudoephedrine are now pharmacist-only medicines in New Zealand, as reported in Bulletin 100. Pseudoephedrine is a sympathomimetic with nasal decongestant effects, however, there are certain groups in whom use in is not appropriate, including people with uncontrolled hypertension or severe coronary artery disease, those taking monoamine oxidase inhibitors or with known hypersensitivity to pseudoephedrine. Pseudoephedrine is classified as a controlled drug; pharmacists should ensure all sales are recorded and provide advice as appropriate. Approved pseudoephedrine products can be found using the Medsafe Product/Application Search. Read more here.

There are numerous potential causes of hyperkalaemia. Prescription medicine use is often considered during assessment in patients with elevated serum potassium (e.g. ACE inhibitors, beta blockers, NSAIDs), however, clinicians should also ask about use of dietary supplements. This includes products explicitly marketed as being potassium supplements, as well as herbal preparations in which potassium is an ingredient, e.g. products containing stinging nettle, evening primrose, turmeric, dandelion. Read more here.

In the March, 2024, meeting, the Medicines Adverse Reactions Committee (MARC) recommended updates to medicine data sheets including: ibuprofen should be updated to state that the risk of renal tubular acidosis and severe hypokalaemia increases with higher doses of ibuprofen and following acute overdose (it may also occur within the recommended dose range); SSRI data sheets should be updated to contain consistent information about the risks associated with alcohol consumption (updates relating to alcohol have already been made to the data sheet for the SNRI, venlafaxine). Click here to read more.

As reported in Bulletin 97, Medsafe has issued a Monitoring Communication to seek more information from clinicians on the risk of new-onset eczema associated with the use of calcium channel blockers, e.g. amlodipine, diltiazem. Responses can be submitted to CARM until 8^th October, 2024 (at which time the risk will be assessed; any adverse effect reports should continue to be submitted after this date).

• Medicine-induced hyponatraemia is more likely in older people due to a combination of risk factors, and should be considered when reviewing medicine regimens.
• Reminder about potential for serious adverse effects with dexamethasone use, e.g. adrenal suppression, severe psychiatric reactions, osteonecrosis and immune suppression; use at the lowest effective dose and withdraw gradually.
• Reminder about bioequivalence when switching between medicines. Generic medicines are bioequivalent to the innovator (“brand name”) medicines, meaning that efficacy and safety is expected to be comparable. However, extra care is needed for certain medicines when switching patients to a different brand (e.g. levothyroxine) as clinically relevant differences can still occur despite bioequivalence being shown.

Testing

Vitamin D testing is not routinely recommended for asymptomatic pregnant people and infants, but it may be appropriate for select groups, e.g. pregnant people with a history of vitamin D deficiency/insufficiency, those with abnormal laboratory results such as unexplained elevated serum alkaline phosphatase, low calcium or phosphate.

A new recommendation is that testing may be considered for pregnant people with all of the following risk factors for vitamin D deficiency:

• Naturally dark skin and/or of South Asian, African or Middle Eastern heritage
• Live south of Nelson/Marlborough during winter or spring
• Spend limited time outdoors (or have minimal sun exposure due to religious, cultural, personal or medical reasons)

Supplementation

Vitamin D supplementation (colecalciferol) should be prescribed to pregnant people if they have any risk factors for deficiency (listed above), or if they have confirmed deficiency (doses differ depending on whether supplements are for maintenance/prevention or deficiency; see NZF). People at lower risk of vitamin D deficiency during pregnancy can be advised that they may benefit from supplementation, particularly during the third trimester.

For infants, vitamin D supplementation (one drop [400 IU] colecalciferol oral liquid per day) is recommended for all exclusively or partly breast fed infants, initiated by age four weeks, continuing until age one year. This a key change to the 2020 recommendations, which recommended supplementation in infants who were exclusively or partly breast fed only if they had one or more risk factors for deficiency. The reason for the change is that sun exposure is the main source of vitamin D for young infants, and this is now no longer recommended. Breast milk alone is not likely to contain adequate levels of vitamin D for most infants, but is strongly supported to provide infants with essential nutrition, energy and immune benefits.

Infants receiving 500 mL or more of formula per day do not require supplementation as infant formula is fortified with vitamin D and intake should be sufficient. Infants who are exclusively formula fed also do not require supplementation.

• The study population involved approximately 33,000 participants from the United Kingdom (UK) Biobank^*. Participants had reported hyperglycaemia alone (fasting glucose ≥ 5.56 mmol/L; n = 25,472) or reported hyperglycaemia and type 2 diabetes (n = 7,969). Participants with already established microvascular complications or missing dietary information were excluded.
• Participants’ original dietary information^† was assessed using the Alternate Mediterranean Diet (aMED) index where a score of zero or one is assigned based on whether certain food groups are consumed at lower or higher levels than the sex-specific median level of the study population. A higher overall score (out of nine) suggests the participants diet more closely resembled a Mediterranean diet.
  • Points were assigned for higher consumption of fish, fruits, legumes, ratio of monounsaturated to saturated fat, nuts, vegetables and whole grains, moderate alcohol consumption and lower consumption of red and processed meats
• The primary outcomes were microvascular complications associated with diabetes, i.e. nephropathy, neuropathy and retinopathy (determined by hospital records and death registries)
• Approximately 17% of participants in the hyperglycaemia group and 13% in the type 2 diabetes group had aMED scores of six to nine. In both groups, higher scores were associated with smaller waist circumference, lower level of socioeconomic deprivation and lower HbA_1c.
• Overall, 3,392 microvascular complications were reported in 404,918 person-years of follow-up (median 12.3 years). This included 2,184 cases of nephropathy, 632 cases of neuropathy and 1,084 cases of retinopathy. Some participants were diagnosed with more than one microvascular complication.
• An inverse association was found between aMED score and diabetic nephropathy in participants with type 2 diabetes after adjusting for confounders (hazard ratio [HR] = 0.64, 95% confidence interval [CI] = 0.50 – 0.83) meaning participants who more closely followed a Mediterranean diet reduced their relative risk of diabetic nephropathy by 36%. A protective effect was still observed in participants with only hyperglycaemia and higher aMED scores; however, it was substantially reduced (HR = 0.98, 95% CI = 0.77 – 1.25).
  • Analysis of the individual components of a Mediterranean diet revealed that higher consumption of legumes resulted in a greater reduction in relative risk of diabetic nephropathy in participants with type 2 diabetes compared to other components of the diet
• A protective effect of a higher aMED score was not observed for diabetic neuropathy or retinopathy
• Study limitations include the use of a single dietary assessment at one point in time as evidence of an individual’s long-term dietary pattern and relying on hospital records and death registries for outcome data potentially resulting in an underestimation of microvascular complications (as primary care data was not included). There is also no information on ongoing management over the follow-up period that may influence disease progression, e.g. adding more diabetes medicines, medicine adherence, lifestyle modifications.
  • The UK Biobank population may not be generalisable to other populations as this cohort are more commonly older, female and living with less social deprivation than the general population
• The authors concluded that people with hyperglycaemia may reduce their risk of developing diabetic nephropathy by closely following a Mediterranean diet. They attribute the effect of this diet to the various components, e.g. vitamins and nutrients in fruit, vegetables and nuts reduce oxidative damage associated with hyperfiltration, omega-3 and fatty acids in fish and favouring monounsaturated fats may improve hyperlipidaemia and endothelial function.
• The importance of legumes in the Mediterranean diet was also highlighted with the authors suggesting dietary fibre may slow rapid elevations in blood sugar after meals, reducing risk factors for diabetic nephropathy, e.g. hyperlipidaemia, hypertension and low-grade inflammation

^* UK Biobank is a longitudinal population study in the UK investigating the effects of genetics and environmental exposures on the development of disease. The study recruited approximately 500,000 volunteers aged 37 - 73 years between 2006 and 2010.

^† Participants underwent a dietary assessment and completed lifestyle questionnaires as part of baseline testing

Qu C, Zhao J, Lai J, et al. Adherence to a Mediterranean diet is associated with a lower risk of diabetic kidney disease among individuals with hyperglycemia: a prospective cohort study. BMC Med 2024;22:224. doi:10.1186/s12916-024-03455-3

For further information on a Mediterranean diet, see: https://bpac.org.nz/2022/weight-loss.aspx#tab1

• More than 215,000 participants were included in the study using information from the UK Biobank* (54% female, average age = 57 years)
  • Notably, the study cohort was 95% Caucasian
• An estimate of a participant’s 24-hour urinary sodium excretion was calculated using the International Cooperative Study on Salt, Other Factors, and Blood Pressure (INTERSALT) equation that accounts for age, sex, body mass index and electrolyte concentrations in urine^†
  • It was assumed that 24-hour urinary sodium excretion is equivalent to 90% of 24-hour dietary sodium intake and the results of a single baseline measure were indicative of an individual’s long-term daily dietary sodium intake
• The primary outcomes were a history of atopic dermatitis or active atopic dermatitis at the time of urine sampling (determined by medical records and prescription history). Atopic dermatitis severity grading was based on the type of medicines prescribed, e.g. potent corticosteroids and topical calcineurin inhibitor use indicated moderate disease, whereas systemic immunotherapy indicated severe disease.
• The overall mean estimated 24-hour urine sodium excretion was 3 g per day. Only 11% (23,643) of participants had an estimated 24-hour urine sodium excretion at or below the recommended maximum daily sodium intake (2.3 g per day in the UK, or 2.1 g using 24-hour urinary sodium excretion and INTERSALT equation).
  • N.B. The New Zealand recommended dietary target for sodium is 2.0 g (equivalent to just under one teaspoon of table salt).
• Atopic dermatitis was identified in 5% of participants (10,839), of which 12% were considered to have active disease (1,282)
• Excess sodium consumption (1 g greater than recommendations) results in 11% higher odds of having atopic dermatitis, 16% higher odds of having active disease and 11% higher odds of more severe disease. Consuming sodium at recommended levels does not alter the risk of atopic dermatitis.
• This study has several limitations:
  • A single 24-hour urinary sodium excretion only captures the dietary sodium intake over the previous 24 hours and may not accurately represent a person’s long-term sodium intake
  • Sodium may not be the problem; processed foods contain high levels of sodium (along with other additives). Elevated sodium may indicate higher consumption of processed foods which are influencing atopic dermatitis.
  • The UK Biobank population may not be generalisable to other populations as this cohort are more commonly older, female and living with less social deprivation than the general population
• These findings indicate there may be an association between dietary sodium intake and atopic dermatitis. Given the overconsumption of dietary sodium in most populations and established benefits of reducing sodium intake for other medical conditions, e.g. hypertension, suggesting patients trial a reduced sodium diet to reduce their atopic dermatitis symptoms appears to be a reasonable option (along with standard management).

^* UK Biobank is a longitudinal population study in the UK investigating the effects of genetics and environmental exposures on the development of disease. The study recruited approximately 500,000 volunteers aged 37 - 73 years between 2006 and 2010.

^† Participants provided urine samples as part of baseline testing

Chiang BM, Ye M, Chattopadhyay A, et al. Sodium intake and atopic dermatitis. JAMA Dermatol 2024; [Epub ahead of print]. doi:10.1001/jamadermatol.2024.1544