Published: 27th October, 2023
Contents
New article: Cough medicines: do they make a difference?
Over-the-counter (OTC) cough medicines, although widely used, are not particularly effective at reducing the severity or duration of acute cough associated with a viral upper respiratory tract infection. Most cough preparations contain medicines that are not recommended for children aged under six years. Pharmacists and other staff working in community pharmacies are often tasked with guiding people who present with cough on appropriate management strategies. However, as there are a myriad of products available, with differing claims and extent of effectiveness, knowing which product(s) to recommend can sometimes be difficult. Click here to read more.
Pholcodine products will soon be unavailable
The management of dry cough is particularly challenging as products containing dextromethorphan are no longer being supplied to the New Zealand market, and pholcodine, one of the commonly used antitussive medicines in OTC products will no longer be available in New Zealand from early 2024; as reported in Bulletin 84, read more here. Besides antitussives (for which the effect on cough is minimal), there are currently no other medicines that benefit people with dry cough. However, there are complementary and alternative treatments available that have demonstrated some benefit in either reducing cough frequency or severity, e.g. honey, glycerol syrups, aromatic rubs, ivy leaf extract and zinc.
Read the full article here
#MedSafetyWeek coming up – updated bpacnz opioid report now available
The eighth annual #MedSafetyWeek is coming up on 6th – 12th November, 2023. This initiative aims to raise awareness of adverse medicine reactions, with the theme this year being 'Who can report?': how patients, doctors, pharmacists and other health professionals can contribute to pharmacovigilance. A media campaign will occur in that week so look out for it; we will be joining in so follow, like and share!
bpacnz has a strong history of advocating for appropriate and safe medicine use, and we have found that reflecting on dispensing data can be an effective way to achieve this goal. Last year, we published a report on national opioid use between 2017 and 2021, highlighting that while overall dispensing had declined over time, there was a small increase in the use of both weak and strong opioids at the end of this period that warranted closer monitoring. This report also included a personalised section for primary care prescribers to review their data from 2021, and editable resources to support safe opioid use, including a pain management plan and an example opioid contract.
We have now updated this opioid report with dispensing data from 2022, demonstrating that national use continues to trend upwards during the “COVID-19 era”. In particular, the relative increase in oxycodone prescribing is a concern, given that morphine is the preferred first-line option if a strong opioid is required. A new-look interactive graph format also allows for comparison between New Zealand regions in 2020 and 2022, and the personalised data section has been updated to also include 2022 statistics.
Is the overlap between increased national opioid use and the “COVID-19 era” causal or coincidental? What explains the significant variation between regions? Has your prescribing changed over time, and how does it compare against your peers?
Click here to explore the updated opioid resource
Dulaglutide/liraglutide Special Authority changes + other Pharmaceutical Schedule updates
The following changes to the Pharmaceutical Schedule of particular interest to primary care, have recently been announced and will be effective from 1st November, 2023:
Dulaglutide and liraglutide Special Authority criteria to be amended
The Special Authority criteria for dulaglutide and liraglutide are being amended due to ongoing supply shortages to ensure that people currently taking either of these medicines can continue to do so. Key changes include:
- Prior Special Authority approval for either a SGLT-2 inhibitor or GLP-1 receptor agonist is no longer part of the criteria
- At least six months of prior treatment with all funded blood-glucose lowering agents, i.e. empagliflozin, metformin and vildagliptin, is required where clinically appropriate (previously only three months of treatment with one blood-glucose lowering agent was a requirement)
- Note added: “Due to the ongoing supply issues with GLP-1 agonists, we strongly urge all prescribers to consider initiating patients on other hypoglycaemic agents, provided they are not contraindicated. Please also consider discontinuing GLP-1 agonist treatment where the patient is not receiving clinically meaningful benefit.”
Ezetimibe Special Authority criteria to be removed
The requirement for Special Authority approval for funded access to ezetimibe and ezetimibe with simvastatin is being removed. All patients will therefore be eligible for funded lipid-lowering treatment with ezetimibe without restriction. Ezetimibe is usually prescribed in combination with a statin for a patient if their target LDL is not reached despite optimal statin treatment, or as monotherapy if a statin is intolerable or contraindicated.
For further information on the role of ezetimibe in lipid-lowering treatment, see: https://bpac.org.nz/2021/statins.aspx
Pharmaceutical Schedule Rules to align with changes to Misuse of Drugs Amendment Regulations
Pharmac has announced that the General Rules of the Pharmaceutical Schedule will be amended to align funding with the Misuse of Drugs Amendment Regulations (No 2) 2023 that came into effect on 5th October, 2023. As reported in Bulletins 83 and 80, the maximum limit for all opioid prescriptions has reduced from three months to one month (excluding opioid substitution treatment) for all prescribers.
N.B. This includes codeine and tramadol.
A FAQ sheet about the Misuse of Drugs Amendment Regulations (No 2) 2023 is available here.
Lamictal (lamotrigine): new look
GSK has advised of a change in packaging of the Lamictal brand of lamotrigine 25 mg, 50 mg and 100 mg tablets (not funded, unless under an exceptional circumstances approval). This change is due to the introduction of new child-resistant foil blister packaging. The 2 mg and 5 mg tablets are unaffected as they are packaged in a bottle.
Patients taking these tablets should be advised that the packaging will look slightly different but be reassured that there has been no change to the formulation, manufacturer or manufacturing method. An information sheet is available to give to patients here.
Low-dose cannabidiol products reclassified + other recent reclassifications
Medsafe has reclassified low-dose cannabidiol (CBD) from a prescription-only to pharmacist-only medicine. There are currently no approved low-dose CBD products available in New Zealand, but the reclassification means that if such a product becomes approved in the future, registered pharmacists will be able to supply it without a prescription for people aged 18 years and older under certain conditions.
CBD is now classified as:
- Prescription: “except when elsewhere in the schedule”
- Pharmacist-only (restricted): “when supplied, in medicines with dosing instructions for 150 milligrams or less per day and containing not more than 4.5 grams, when sold in the manufacturer’s original pack that has received consent from the Minister or Director-General, for adults aged 18 years and over, by a registered pharmacist”
N.B. The reclassification of low-dose CBD only applies to medicines approved under the Medicines Act 1981. Medicinal cannabis products may also be supplied (if prescribed by a medical practitioner) if they meet the minimum quality standards of the Misuse of Drugs (Medicinal Cannabis) Regulations 2019.
For an overview of medicinal cannabis for health practitioners, see: https://bpac.org.nz/2022/medicinal-cannabis.aspx. A medicinal cannabis guide for pharmacists is also available here: https://bpac.org.nz/2022/medicinal-cannabis-guide.aspx.
Other recent reclassifications
From 1st October, 2024, some medicines containing naproxen will be reclassified as pharmacist-only and can be supplied with a higher recommended daily dose (> 750 mg/day) than pharmacy-only products (≤ 750 mg/day).
From 1st October, 2024, paracetamol liquid in packs containing ≤ 10 g will be reclassified as pharmacy-only and packs containing > 10 – 50 g will be reclassified as pharmacist-only. N.B. A 200 mL bottle containing 250 mg/5 mL contains 10 g of paracetamol.
From 1st December, 2023, methenamine hippurate (Hiprex, U-Tract) will be reclassified as a pharmacist-only medicine. Currently, methenamine hippurate is unscheduled, i.e. it can be purchased from a supermarket, pharmacy or prescribed (funded) for antimicrobial prophylaxis in those with a history of recurrent urinary tract infections. For further information on the management of lower urinary tract infections, click here.
International Lead Poisoning Prevention Week 2023: 22nd – 28th October
This week is International Lead Poisoning Prevention Week, an initiative from the World Health Organization (WHO) highlighting the negative health impacts of lead exposure. This year, the focus is to “End Childhood Lead Poisoning” and the WHO are calling for a combined effort from governments, health care groups and industry to support this campaign. The removal of lead from petrol and restricting the use of lead paint has reduced lead exposure in many countries, however, more can be done to raise awareness of the dangers of lead exposure and to prevent it occurring, especially in children. Paintwork on older homes and buildings, cots, toys, some painted items manufactured overseas, rainwater tanks with runoff from lead roofs or piping, and contaminated soil are examples of environmental sources of lead in New Zealand.
Resources for Lead Poisoning Prevention Week including training modules for health care providers, posters and patient education material are available from the WHO website.
Notifiable blood lead levels
In New Zealand, the notifiable blood lead level was reduced from 0.48 micromol/L to 0.24 micromol/L in April, 2021. This was in response to findings from the Dunedin Multidisciplinary Health & Development Study that suggest long-term neurological and behavioural health effects may occur at lower blood lead levels than previously thought. The new level also aligns with reference values from the Centers for Disease Control and Prevention (CDC) in the United States and the Australian National Health and Medical Research Council.
Electronic reporting is available for lead exposures in your practice management system via the Hazardous Substances Disease and Injury Reporting Tool (HSDIRT), developed by BPAC Clinical Solutions, in association with Environmental Health Intelligence New Zealand, and sponsored by the Ministry of Health.
For further information on lead exposure and reporting notifiable lead levels in New Zealand, see: https://bpac.org.nz/2021/lead.aspx
National Polio Response Framework released
Manatū Hauora, Ministry of Health, has released the National Polio Outbreak Preparedness and Response Framework for Aotearoa New Zealand, in response to the increase in poliomyelitis activity in countries where polio was considered to be eradicated, e.g. detection in wastewater in the UK, USA and Canada (reported in Bulletin 66). There are currently no cases of poliomyelitis reported in New Zealand (with the last being in 1977), however, this framework has been introduced to provide technical guidance and direction for decision makers and health care professionals in the event of a polio outbreak. The framework also covers the escalation of surveillance measures, if required.
What can primary care providers do?
Immunisation remains an effective intervention to reduce the risk of poliomyelitis in New Zealand. Primary care clinicians should review patient’s polio vaccination status and recommend vaccination with IPV if required (and other missed vaccines). Up to three doses of the polio vaccine are funded for people who are unvaccinated or partly vaccinated (outside the childhood immunisation schedule), or for re-vaccination in people following immunosuppression. Also, ensure that patients who are travelling overseas are fully vaccinated against polio (and MMR).
Although many people are initially symptomatic, consider poliomyelitis in a patient with “flu-like” symptoms and a history of recent overseas travel to an outbreak country/area. Rapidly evolving muscle weakness and difficulties with swallowing or breathing can indicate the development of acute flaccid paralysis, which requires urgent notification and hospital assessment.
For further information on poliomyelitis, see: https://www.health.govt.nz/our-work/immunisation-handbook-2020/17-poliomyelitis
bpacnz focus: Ask about menopause
Menopausal symptoms are experienced by most women, but only some seek treatment, or are aware that treatment is available. Potentially even fewer women are regularly asked by their health care professional about their experience of menopause and proactively offered support or advice about their symptoms. Cultural and ethnic differences, societal barriers and level of engagement in health services can all contribute to women missing out on treatment, if required, which can lead to a reduced quality of life. A lack of knowledge or confidence about the safety of prescribing menopausal hormone therapy among healthcare professionals may also be contributing to this issue.
The challenge: Where appropriate, ask every female patient you see, aged 40 – 60 years, if they have any questions about menopause: what to expect if it hasn’t happened yet, and what they are experiencing if it has. You may be able to offer some quick, simple advice, or invite them to come back to see you, or a colleague, for a dedicated appointment. The objective is to ensure that women understand that menopause is a legitimate reason to seek medical advice and treatment, it is not something to be ashamed about or trivialised, and symptoms can be managed or reduced, they don’t need to just live with it.
Read more about menopause:
Menopause, and perimenopause, is associated with a range of symptoms, including hot flushes and night sweats (vasomotor symptoms), vaginal dryness, itching or pain during intercourse and changes in mood or sleep patterns. Some women may find their symptoms tolerable, or manageable with lifestyle adjustments, however, some will have symptoms that significantly affect their quality of life, in some cases severely. Primary care clinicians should take a proactive approach by regularly asking women early about any menopausal symptoms and ensuring they know what to expect. If a woman experiences symptoms, discuss the available treatment options, as well as the risks (including any cautions and contraindications) and benefits of menopausal hormone therapy (MHT).
There may be some reluctance by patients to take MHT, or clinicians to prescribe it, due to historical safety concerns, e.g. from the early stages of the Women’s Health Initiative trials. However, more recent evidence suggests that for women aged < 60 years or within ten years of menopause, the benefits of MHT are likely to outweigh the risks (which include breast cancer, stroke and venous thromboembolism).
Wellspring is a tool developed in the UK to support women deciding about MHT (or hormone replacement therapy, HRT, as it is referred to in the tool). The tool displays graphical representations of the risks and benefits of MHT, depending on specific patient factors, and would be a useful prompt for patient discussions. The treatment options are based on NICE guidance and not all medicines or presentations will be available/funded in New Zealand.
Transdermal oestradiol patches are usually considered the most appropriate MHT option and are associated with the lowest risk of adverse effects, e.g. cardiovascular events. However, ongoing supply issues for oestradiol patches resulting from increased global demand over the last two years has made it difficult to access this form of MHT in New Zealand. The availability of specific brands of patches changes often; refer to the Pharmac website for up-to-date supply information or speak to your local pharmacist. Oral oestradiol (fully funded and partly funded options available) can be considered as an alternative treatment, but may be impractical due to the difficulty of dividing tablets to achieve low recommended doses.
Key management points:
- When deciding whether to prescribe MHT and what regimen to use, consider the patient’s age or time since final menstrual period, any contraindications or cautions to MHT use and whether the uterus is intact
- Combined oestrogen and progesterone therapy should be prescribed to women with an intact uterus as oestrogen alone can cause endometrial hyperplasia and increase the risk of endometrial cancer
- Consider changing the dose or formulation of MHT if a patient experiences adverse effects that impact their quality of life, e.g. bloating, breast tenderness, increased blood pressure, headaches, fluid retention and urinary incontinence
- Sexually active women receiving MHT still require contraception for at least 12 to 24 months after their last menstrual period or up to age 55 years (when a natural loss of fertility can be assumed)
- A levonorgestrel intrauterine device (Mirena) can be used as both a contraceptive and to provide protection from oestrogen-induced endometrial hyperplasia, and can be left in place until the age of 55 years (if inserted from age 45 years or older)
- There is no specific recommended duration for MHT. The decision to continue treatment should be reviewed on an annual basis, considering any changes in the patient's risk factors, adverse effects and extent of benefit.
- If women primarily seek assistance for urogenital symptoms of menopause, vaginal products are recommended instead of systemic MHT. This includes moisturisers, lubricants or a vaginal oestrogen cream or pessary.
For further information on menopausal hormone therapy, including a prescribing algorithm, see: https://bpac.org.nz/2019/mht.aspx
Paper of the Week: Atopic dermatitis in children with melanin-rich skin
Atopic dermatitis (eczema) is a common dermatological condition in childhood, usually managed in primary care. New Zealand is a multicultural country and primary care clinicians assess and treat dermatological conditions in patients with a spectrum of skin tones. Conventionally, resources used in medical training often focus on symptomology and diagnosis of dermatological conditions in people of European ethnicity. This can lead to an underestimation of symptom severity, misdiagnosis, inappropriate or under-treatment of dermatological conditions in children with melanin-rich skin, in which dermatological conditions may present “outside of the textbook”. An article published in the Australian Journal of General Practice provides an overview of the diagnosis and management of atopic dermatitis in children with skin of colour, including Indigenous Oceanic ethnicities (e.g. Māori and Pacific Peoples), as well as people of Asian, African and Middle Eastern ethnicity.
How confident are you at diagnosing and managing atopic dermatitis (eczema) in children with melanin-rich skin? Are there specific situations that make diagnosing atopic dermatitis more difficult? What have you done to improve your clinical skills when treating atopic dermatitis?
Read more
Assessment
- Features of atopic dermatitis that are more commonly seen in children with melanin-rich skin include clearly defined and scaly plaques, areas of violet, grey or dark brown coloured skin (or dyspigmentation after a flare has settled), lichenification, presence of papillae and follicles, psoriasiform or lichenoid patterns. These manifestations are often located on extensor skin.
- Secondary manifestations of atopic dermatitis that occur more often in children with melanin-rich skin include prurigo nodularis (itchy, firm lumps), lichen amyloidosis (scaly areas of protein deposition), labial melanocytic macules (dark patches on the lips), palmar hyperlinearity (an increase and accentuation of fine lines on the palms) and Dennie-Morgan folds (a fold or crease in the skin below the lower eyelid); for further information about these conditions and images, see DermNet
- Rule out other dermatological conditions (e.g. psoriasis, tinea corporis, lichen planus and lichen nitidus) before a diagnosis of atopic dermatitis is confirmed in children with melanin-rich skin
- Erythema can be difficult to identify in children with melanin-rich skin reducing the clinical accuracy of conventional assessment tools. For example, the Eczema Area and Severity Index (EASI) includes “intensity of redness” as a measure of severity and may lead to undertreatment in children with moderate to severe conditions. To improve assessment in children with skin of colour, the study authors suggest:
- Add one measure to any assessment of erythema when using clinical assessment tools to prevent underestimation of clinical severity; or
- Assess the “intensity of greyness” as this may be more appropriate in children with darker skin
- Consider the psychosocial impacts of atopic dermatitis in children, e.g. anxiety, depression, bullying, school absenteeism. Regularly re-evaluate psychosocial impacts during follow-up. Consider referral to a psychologist or other relevant health professional.
Management
Management of atopic dermatitis is generally the same for all children, i.e. appropriate emollient and topical corticosteroid use, identifying and avoiding triggers, skin care and bathing advice, hot washing/ironing clothes and linen if possible. Potential additional considerations in children with melanin-rich skin are the development of:
- Post inflammatory hyper- or hypopigmentation - localised changes in skin can occur in children with melanin-rich skin, following topical corticosteroid treatment for atopic dermatitis. While this will likely resolve spontaneously, it is important to discuss dyspigmentation with children and their caregivers to prevent unnecessary worry or overtreatment. Short periods of sun exposure may be beneficial.
- If dyspigmentation persists or is particularly distressing, possible treatment options include hydroquinone (which can cause discolouration itself), retinoids or azelaic acid
- Pityriasis alba - a less severe form of dermatitis that is more commonly seen in children with melanin-rich skin. It is characterised by small scaly patches of hypopigmentation on the face. Pimecrolimus cream (available with Special Authority approval following recommendation from a dermatologist, paediatrician or ophthalmologist) can be used if mild topical corticosteroids are not appropriate.
Gan C, Brand R, Foster RS, et al. Diagnosis, assessment and management of atopic dermatitis in children with skin of colour. Aust J Gen Pract 2023;52:673–9. https://doi.org/10.31128/AJGP-01-23-6684
For further information on the management of childhood eczema in primary care, see: https://bpac.org.nz/2021/childhood-eczema.aspx
DermNet contains an index of pages about dermatological conditions that tend to affect, or have special characteristics in, people with skin of colour: Skin of colour | DermNet
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