Published: 12th July, 2024
Contents
Antibiotics prescribing data: Have you accessed your personalised report yet?
The Publications team at bpacnz recently released a report into antibiotic use in New Zealand between 2019 and 2023, encompassing the lead up and initial stages of the COVID-19 pandemic. Our analysis shows that despite a notable decrease in overall antibiotic use between 2019 and 2020, dispensing of oral antibiotics has trended back upwards again. As of 2023, oral antibiotic use was only slightly lower than 2019 levels, and it is unclear whether this will continue to increase, stabilise or decline moving forward. This is an opportunity to work collectively to make a change.
Subgroup analysis paints a diverse picture, including significant variation in oral antibiotic dispensings between New Zealand regions. Oral antibiotic dispensing decreased in most regions between 2019 and 2023, however, increases occurred in the Hutt Valley (+1.7%), Wairarapa (+3.6%) and West Coast (+8.6%). The highest rates of use occurred in Counties Manukau, likely reflecting their higher risk population, e.g. increased proportions of Pacific peoples, Māori and socioeconomic deprivation.
Check out your antibiotic prescribing snapshot: If you are a primary care prescriber and have a Mybpac account, you can log in to see your personalised 2023 antibiotics prescribing report. This includes assessment on how your prescribing compared against a matched comparator group and national trends. So... how do you compare?
To view the full antibiotics report and national trends, click here
To go straight to the personalised report section, click here
Patient information sheets available from bpacnz
We generally do not produce patient information, as our focus is on education for clinicians. However, from time to time, when writing a particular resource, we think: wouldn’t it be easier if you had something to hand out to the patient to explain all of this?
The following information sheets are especially designed to support primary care consultations, and can be downloaded and printed, or the link sent to patients via text or email.
Medicine supply news: Insulin, oestradiol patches, methylphenidate
The following news relating to medicine supply, of particular interest to primary care, has recently been announced. Medicine supply information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Novo Nordisk brands of biphasic insulin isophane (Mixtard 30, Penmix 30, Penmix 50) to be discontinued
Pharmac has announced that the following brands of biphasic insulin isophane with insulin neutral injections are being discontinued by the supplier (Novo Nordisk): Mixtard 30, PenMix30, PenMix 50. These brands will continue to be listed on the Pharmaceutical Schedule until stock is exhausted (final shipment due by 30th September, 2024). Patients taking these products will need to be prescribed a funded alternative; see the NZF for alternative treatment options.
Humulin 30/70 vials (equivalent to Mixtard 30, used with injection syringes) and Humulin 30/70 cartridges (equivalent to PenMix 30, but used with HumaPen injection devices) will continue to be available, but there is no funded equivalent to PenMix 50 cartridges; Humalog Mix50 (biphasic insulin lispro – used with HumaPen injection devices) may be an alternative as it has a similar mix of insulins but note that insulin lispro has a relatively more rapid onset and shorter duration of action than neutral human insulin.
For further information on prescribing insulin, see:
New brand of oestradiol patches available
A new brand of oestradiol patches (Lyllana; 25, 50, 75 and 100 micrograms) has been funded since 1st July, 2024, to help ease ongoing pressures on the supply of oestradiol patches. Lyllana patches are not approved by Medsafe and need to be prescribed for supply under Section 29 of the Medicines Act 1981. Pharmac expects stock of the 25 microgram (Lyllana) patches to be available from late July and the 50 microgram strength to be available from late August/early September. Lyllana 75 microgram and 100 microgram patches are also funded and listed in the Pharmaceutical Schedule – there is currently no specific information on when these will be available but Pharmac state that “monthly deliveries of all strengths of Lyllana patches until the end of the year to start in late September”.
Pharmac has also called for proposals from suppliers of oestradiol gel to further address availability of oestrogen products (as reported in Bulletin 97).
Methylphenidate (Concerta) expected shortage
Pharmac has announced that they are expecting an upcoming shortage of the Concerta brand of methylphenidate extended-release 18 mg (early-August – October) and 36 mg (mid-July – early-August) tablets. Other strengths are not expected to be affected. All strengths of methylphenidate (Teva) are currently available (however, supply may be constrained until August).
Patients prescribed methylphenidate (Concerta) may be dispensed methylphenidate (Teva) during the supply issue; a new prescription will not be required, but the patient must have Special Authority approval. Pharmac is asking prescribers to check patients Special Authority to ensure it is valid. Due to ongoing supply issues affecting methylphenidate in 2023, patients with a Special Authority for Teva were automatically provided with Special Authority approval for Concerta (and vice versa), however, this has now ended. Special Authority renewal or a new application will need to be made for patients if their Special Authority for Teva has lapsed (or if they only had approval for Concerta).
Pharmac is advising pharmacists not to dispense two 18 mg methylphenidate (Concerta) tablets to make up the 36 mg strength due to supply constraints affecting the 18 mg tablets. A brand switch fee is available until 1st August, 2024.
Proposal to widen access to immunotherapies for cancer
Pharmac has released a proposal to widen access to pembrolizumab (Keytruda) and nivolumab (Opdivo) for six types of cancer from October and November, 2024. Submissions are due by 4pm, Friday 26th July.
Pembrolizumab is currently funded for people with advanced non-small cell lung cancer and metastatic melanoma. It is proposed that from 1st October, 2024, funded access will be widened to include eligible people with:
It is also proposed that from 1st November, 2024, nivolumab will be funded as a second-line treatment for eligible people with advanced renal cell carcinoma cancer; it is currently only funded for people with unresectable or metastatic melanoma.
A summary of the proposal is available here. An associated news release is also available.
N.B. This consultation also includes a proposal to widen access to posaconazole and voriconazole from 1st October, 2024, for invasive fungal infection prophylaxis in people at high risk of severe fungal infections.
An additional proposal to fund further cancer medicines was released today by Pharmac. Click here for further information.
Proposal to widen access to ferric carboxymaltose and aripiprazole injections
Pharmac has released a series of proposals to widen access to medicines for schizophrenia, anaemia, opioid-induced constipation (hospital) and flexural or genital psoriasis. If these proposals are accepted, changes would take place from 1st November, 2024. Consultations close 4pm, Tuesday 30th July. The following proposals may be of particular interest to primary care:
Ferric carboxymaltose
Pharmac is seeking feedback on a proposal to widen access to ferric carboxymaltose (administered via intravenous infusion or injection) to include people with chronic inflammatory diseases and anaemia as diagnosing iron deficiency in the presence of inflammation can be challenging. It is proposed that the current Special Authority criteria for “serum ferritin ≤ 20 micrograms/L” would be changed and replaced with new Special Authority criteria entitled “anaemia”. The new criteria would still include people with anaemia who have a serum ferritin level of 20 micrograms/L or less but would also allow people with anaemia to access funded ferric carboxymaltose if they have both low-normal ferritin levels and an elevated CRP. A third option means that people who have a chronic inflammatory disease and symptoms of anaemia despite normal iron levels would now also qualify for funded treatment. Click here for details.
Aripiprazole depot injections
Pharmac is seeking feedback on a proposal to widen access to aripiprazole depot injections for people with schizophrenia. Aripiprazole depot injections have been funded with Special Authority approval for a small group of people since January, 2024, in response to ongoing supply issues affecting stock of olanzapine depot injections (as reported in Bulletin 90).
It is proposed that Special Authority criteria will be widened to include people with schizophrenia who have or who are at risk of developing metabolic syndrome. Criteria will remain for those who have already trialled a funded atypical antipsychotic depot injection (olanzapine, paliperidone or risperidone) but experienced an inadequate response, intolerable adverse effects or who cannot access olanzapine due to the supply issues (or would have been initiated on olanzapine but has been unable to). Renewal criteria would be removed as part of this proposal. Click here for further details
Cervical screening funding for priority groups to continue
HPV testing has been the primary cervical screening test in New Zealand since September, 2023, replacing the cytology-based test. Initial feedback about HPV primary screening is said to be encouraging, and increased participation has been reported in people who were previously unscreened or under-screened. Funding for priority groups was introduced to support the launch of HPV primary screening last year and was due to end on 30th June, 2024, however, it has now been extended until 30th June, 2025.
Cervical screening remains funded for:
- People with a cervix aged ≥ 30 years who are unscreened (never had cervical screening) or under-screened (click here for definitions). This includes people aged 70 – 74 years who are unscreened or under-screened.
- People with a cervix aged 25 – 69 years who are of Māori or Pacific ethnicity
- People with a cervix aged 25 – 69 years who are a Community Services Card holder
- Anyone requiring follow-up or surveillance (even if they were not eligible for funded screening for their initial test)
Click here for further information on who is eligible for funding screening
This is a timely reminder to opportunistically check whether eligible patients are up to date with cervical screening. A clinical audit is available for identifying patients who are not participating in regular cervical screening.
For further information on HPV primary screening, see: https://www.tewhatuora.govt.nz/health-services-and-programmes/ncsp-hpv-screening/understand-hpv-primary-screening/
A brief guide to HPV testing is also available from bpacnz, here
Immunisation reminders: Influenza and pertussis
Influenza vaccination has been a focus in general practice over the last couple of months. Community Influenza-like Illness (ILI) activity (reported by ESR) shows that levels of illness have been trending upwards in recent weeks (nationally). The national immunisation target is for at least 75% of all people aged 65 years and over to be vaccinated this influenza season. As of 7th July, the overall vaccination rate in this group is 59%.
Ensure patients who meet eligibility criteria for funded vaccination are aware that they can receive a flu vaccine for free.
Reported cases of pertussis continued to increase across New Zealand in June. According to data from ESR, there have been 227 cases of pertussis reported (confirmed, probable and suspected) in 2024 (data up to 5th July); an increase of 102 cases since we last reported on pertussis in Bulletin 100 (31st May). The total number of cases so far in 2024 now surpasses the total number of cases reported for the whole of 2023 (141).
Vaccination (with diphtheria, tetanus and pertussis vaccine, Boostrix) is recommended and funded for certain groups, including pregnant women during every pregnancy and as a booster dose for children aged 11 years. Click here for full eligibility criteria. Vaccination is also recommended, but not funded, for some groups, including close contacts of young infants;* read more here.
* It is reported that Boostrix is temporarily unavailable for private purchase; Adacel should be used in these groups. Boostrix remains available for those who meet eligibility criteria for funded vaccination.
Ensure patients (particularly children) have completed their course of Boostrix and offer vaccination where appropriate.
Medsafe clozapine survey 2023 results published
In 2023, Medsafe conducted an online survey, following recommendation by the Medicines Adverse Reactions Committee (MARC), to better understand the impact of clozapine on patients (as reported in Bulletin 81). The findings from the survey have now been released. A total of 187 responses were received (the majority of which were healthcare professionals); some of the responses can be found here.
Clozapine can be an effective treatment for some patients with schizophrenia, however, it is associated with a number of significant adverse effects, such as constipation, neutropenia and cardiac toxicity, that require close monitoring as adverse outcomes can quickly escalate. Co-ordinated care between the patient, caregivers, mental health and primary care teams is essential.
Key responses from healthcare professionals
The majority of healthcare professionals (n = 160) reported that:
- They asked patients about clozapine adverse effects every one to three months; constipation was the most frequently asked about adverse effect, followed by hypersalivation and sedation
- In general, patients were less likely to proactively inform clinicians about adverse effects compared to the clinician asking directly or via routine monitoring
- More than half of their current patients experience constipation with clozapine and that they recommend, prescribe and/or administer a regular laxative to be taken at least daily. Some healthcare professionals noted that constipation is common despite use of laxatives.
- Most of their patients taking clozapine were on a four-weekly haematological monitoring frequency; only a small number (up to 10%) had to interrupt or discontinue clozapine because of an abnormal result
Healthcare professionals also reported on some of the benefits of compulsory haematological monitoring (e.g. providing an opportunity for follow up, reduces neutropenia-associated complications) and the challenges (e.g. discourages clozapine use by patients, logistical issues for example if patients live rurally, increased workload). Some respondents suggested changes to current testing requirements are needed, e.g. reduced testing frequency, faster result reporting, increased education and awareness.
Further information on responses made by healthcare professionals is available here.
A summary of the findings can be found here. As part of a review on clozapine safety and monitoring requirements, Medsafe advise that the report will be now presented to MARC.
To refresh your knowledge on the safe prescribing of clozapine, see: https://bpac.org.nz/2017/clozapine.aspx
Advance care planning resource now available in Samoan
The Health Quality and Safety Commission provides a dedicated website for assisting people in creating an advance care plan: tō tātou reo. Resources are available in English and te reo Māori and now a new resource has been produced for the Samoan community: Tōfā Fetāla’i – advance care planning.
Advance care planning helps to establish a person's preferences and goals of care according to their beliefs, values and lived experience. This approach aims to reduce the burden of decision making, uncertainty and the likelihood of unwanted interventions at the end of life.
Information for clinicians about advance care planning is also provided here.
DermNet PRO coming later this year
DermNet is establishing a new platform for healthcare professionals: DermNet PRO, which is expected to launch later this year. The core service will be free, but there are optional features that can be purchased. It is reported that the new platform will include additional tools and resources for a range of healthcare professionals, compared to the public site, including patient information sheets (which can be branded with your practice logo), the ability to integrate with practice software and a mobile app.
Join the waiting list here (access will initially be restricted to those signed up to the waiting list)
Vapes now restricted to pharmacies in Australia
Australia has become the first country to restrict the sale of vapes to pharmacies, ending retail supply. From 1st July, 2024, only regulated therapeutic vapes are available on prescription from a medical or nurse practitioner for purchase in a pharmacy. From 1st October, 2024, vapes with a nicotine concentration of ≤ 20 mg/mL will become pharmacist-only products for people aged 18 years and over. However, a prescription will still be required for people aged under 18 years or if the nicotine concentration is > 20 mg/mL. Vape products are now subject to regulatory control in terms of nicotine concentration, packaging (plain, pharmaceutical style), flavour (tobacco, menthol or mint) and dispensing quantities. Further information is available here.
At this stage, it is not known if similar restrictions will be introduced in New Zealand. Current restrictions on vaping products are detailed by the Ministry of Health, Manatū Hauora, here, including a requirement that products contain ≤ 20 mg/mL nicotine (or ≤ 28.5 mg/mL in a reusable nicotine-only device) and do not display toy or cartoon images. A ban on disposable vapes is planned, but no timeframe has been announced.
For information on the role of vaping in cigarette smoking cessation, see: https://bpac.org.nz/2018/vaping.aspx
NZF updates for July
Significant changes to the NZF in the July, 2024, release include:
You can read about all the changes in the July release here . Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Let’s just run a few tests...
Laboratory testing is often a fundamental component of a patient’s clinical work up, to confirm diagnoses or exclude other potential causes of symptoms. However, as with any medical intervention, there are risks. A single unexpected abnormal result almost always requires follow up, and in some cases, more invasive investigations and referrals, i.e. a cascade effect. This can be associated with negative effects for the patient, e.g. health-related anxiety, and healthcare resources, e.g. increased clinician workload. In some situations, a pause to consider whether a specific test is necessary may be beneficial for overall patient outcomes.
A study published in the British Journal of General Practice examined the use of laboratory testing by primary care practices in the United Kingdom (UK). Laboratory tests were most requested for investigation of symptoms, followed by monitoring of existing disease or prescribed medicines and follow up of previous abnormal results. Notably, only approximately 6% of total laboratory tests requested led to a new diagnosis (or confirmation of diagnosis); doctor or patient reassurance was reported (as an outcome) in 7.5% of tests whereas almost half of the test results did not affect patient outcomes. These results suggest there is room for further optimisation in current testing practices in UK primary care, and it is likely that these findings are also applicable to New Zealand.
Is optimal use of laboratory investigations a consideration in your practice? Are there specific tests that you think are over-requested? What strategies do you use when a patient presents in your clinic asking for laboratory tests that are not clinically indicated?
Read more
- The study involved 57 clinicians from primary care clinics across the UK. Almost two-thirds were general practitioner registrars (n = 32) or general practitioners in the first five years of their career (n = 5). The rest of the study participants included general practitioners with more than five years’ experience (15), nurse practitioners (n = 2), practice pharmacists (n = 2) and a physician associate (n = 1).
- Participants used a pre-defined search strategy to each identify 50 patients’ health records for review from the practice they were working at. Eligible patients were aged 18 years and over, had attended the participant’s medical clinic during April, 2021, and laboratory tests had been requested (during this period). Pregnant patients were excluded.
- Data from more than 2,500 patients were collected, of which 58% were female and an average of 4.5 tests were requested at one time per patient
- Test results were reviewed and classified as normal (all test results within reference ranges), borderline (at least one test result slightly outside reference range) or abnormal (at least one test result clearly outside of the reference range)
- Participants were asked to comment if they considered all, some or none of the tests to be necessary, based on their clinical judgement
- The most requested laboratory tests were urea and electrolytes, full blood count, liver function tests and HbA1c
- Full blood count, lipid profile and vitamin D results were most likely to be borderline or abnormal. Given that tests for full blood count and lipids have multiple parameters, it is unsurprising that these rated highly as tests with abnormal results. Also note that vitamin D testing is not routinely requested in New Zealand.
- Investigation of symptoms was the most common reason for requesting laboratory tests (43.2%). In these patients, the most frequently coded symptoms were “general and unspecified” (20.1%), “digestive” (17.0%) and “musculoskeletal” (12.2%). Other reasons for testing included monitoring of a previously diagnosed condition (30.1%), medicines monitoring (10.1%) or following up on previously abnormal results (6.8%).
- Abnormal results were reported in more than half (56.4%) of laboratory tests requested to monitor a previously diagnosed condition
- Around half of laboratory tests requested in primary care were made by general practitioners (increasing to nearly 60% when including locums and registrars). Approximately 20% of tests were requested according to practice protocols (this was testing not requested by a clinician, i.e. routine monitoring ordered automatically using protocols set up in UK patient management systems).
- Changing a medicine or initiating a new medicine occurred based on the results of 15.9% of tests and further (or repeat) laboratory testing was requested following 13.4% of tests. However, only 6% of laboratory tests in this study led to a new diagnosis and approximately half (48.8%) of laboratory tests requested did not affect patient outcomes.
- Normal results (i.e. within the laboratory specified reference range) accounted for 26.6% of all test results
- Potential overuse of laboratory testing is one factor to address when considering the ever-increasing primary care workload; in this study up to one-quarter of tests may have been fully (4.2%) or partially unnecessary (20.9%)
- Participants were reviewing patient health records from their own clinic. This is likely to have included patients whom they had consulted on (including requesting laboratory testing) and may have influenced how they judged the testing.
- This study was conducted late in the COVID-19 pandemic, and associated flow on effects may still have impacted primary care services. As such, data may not necessarily reflect normal or “best” practice.
- The authors acknowledge that “patients tend to have high expectations of blood tests, hoping they will provide answers and solutions to their symptoms”. A discussion regarding the reasons for requesting a specific test and what they can and cannot show beforehand may be beneficial to prevent frustration and unnecessary anxiety while awaiting results.
Watson J, Burrell A, Duncan P, et al. Exploration of reasons for primary care testing (the Why Test study): a UK-wide audit using the Primary care Academic CollaboraTive. Br J Gen Pract 2023;:BJGP.2023.0191. doi:10.3399/BJGP.2023.0191.
A podcast discussing the results of this study with the lead author (general practitioner and researcher), is available here.
This Bulletin is supported by the South Link Education Trust
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