Published: 22nd March, 2024
Contents
New article – Anticholinergic burden in older people
Medicines with anticholinergic activity are widely prescribed in primary care and commonly associated with adverse effects. Examples include antidepressants (e.g. amitriptyline), antiemetics (e.g. cyclizine), antipsychotics (e.g. chlorpromazine) and oxybutynin (for urinary urgency and incontinence). Anticholinergic burden refers to the cumulative effect of taking anticholinergic medicines, further increasing the risk of developing adverse effects.
Older people, particularly those who are frail and with multiple morbidities, are most susceptible to the cumulative effects of anticholinergic medicines, leading to adverse effects such as cognitive impairment and falls. Prescribers should be aware of which medicines are most likely to increase anticholinergic burden, and how to recognise and manage this if it occurs.
The full article can be accessed here. A B-QuiCK summary is also available here.
Decision made for childhood immunisations to be offered at pharmacies
Pharmacists can administer many childhood vaccines from April
A decision has been made following consultation on the joint proposal between Pharmac and Health New Zealand, Te Whatu Ora (as reported in Bulletin 91), to allow pharmacists to administer selected childhood vaccines. From 1st April, 2024, the Xpharm restriction will be removed in the Pharmaceutical Schedule from the following vaccines:
- Diphtheria, tetanus, pertussis and polio vaccine (Infanrix IPV)
- Diphtheria, tetanus, pertussis, polio, hepatitis B and haemophilus influenzae type B vaccine (Infanrix-hexa)
- Haemophilus influenzae type B vaccine (Hiberix)
- Pneumococcal (PCV13) conjugate vaccine (Prevenar 13)
- Rotavirus oral vaccine (Rotarix)
- Varicella (chickenpox) vaccine (Varivax)
Changes have also been made to allow for direct provision of funded paracetamol oral liquid by pharmacies when vaccinating children under the age of two years with the meningococcal B vaccine (Bexsero).
Read more
Community pharmacies will be able to claim reimbursement on all vaccines given as part of the routine childhood immunisation programme up to the age of 12 years. These changes have been made with the intention of reducing barriers for whānau accessing free immunisation in their communities, particularly those not enrolled with a general practice or with access difficulties. Pharmacies offering childhood vaccines will need robust processes in place to avoid gaps in care, including facilitating referral to general practice if there are any concerns and logging of data in the Aotearoa Immunisation Register (AIR). Health New Zealand has advised that practices will receive a notification via their patient management system when a vaccine is entered via AIR.
Read more about the changes here (Pharmac) and here (Health New Zealand, Te Whatu Ora)
Additional funding available for general practices to support immunisation work
The Royal New Zealand College of General Practitioners (RNZCGP) reports that from 1st April, 2024, funding will be available for general practices from Health New Zealand, Te Whatu Ora, to support the pre-call and recall work required to ensure children receive their immunisations on time. This includes:
- A $40 base payment to the practice where the infant is enrolled for any completed six-week immunisation, regardless of the location where vaccinations are administered
- An additional $40 payment for priority groups, including high-needs, Māori, Pacific peoples, rural, community service card holders and Quintile 5 (most socioeconomically deprived areas)
Advice from the RNZCGP is that six-week immunisations (Infanrix-hexa, Prevenar 13 and Rotarix) should ideally occur at the general practice, along with the six-week medical check. This represents an important opportunity to evaluate the health and well-being of the baby, mother and whānau.
Read more about the changes here (RNZCGP)
Upcoming influenza webinar
The Immunisation Advisory Centre (IMAC) and Health New Zealand, Te Whatu Ora, are hosting a webinar on Tuesday, 26th March, 5.30 – 6.30 pm, about the upcoming 2024 Influenza Immunisation Programme (starting on 2nd April). This webinar aims to provide vaccinators with essential information regarding the programme, including vaccine details, administration advice and eligibility criteria for funded vaccination. A FLU2024 information resource is also available, including a summary and quick reference guide.
Read more about the webinar here or click here to register
Health New Zealand, Te Whatu Ora, is also hosting a series of webinars for the wider healthcare workforce focusing on influenza immunisation in priority groups, e.g. Māori and Pacific communities, pregnancy, pēpi and tamariki (infants and children), mental health and addictions and people aged ≥ 65 years. Discussion topics include clinical rationale for eligibility criteria, effective communication, available resources and concomitant vaccination. The first webinar on Māori and Pacific communities is being held on Tuesday, 26th March, 12.15 – 1.15 pm. Webinars will be recorded for later viewing.
New version of the Immunisation Handbook released
The updated Immunisation Handbook 2024 (Version 1) is now available, providing recommendations for healthcare professionals on the safe and effective use of vaccines. Key updates include changes to the COVID-19 chapter (e.g. replacing information on the original and bivalent mRNA-CV [30 mcg] with the new XBB.1.5 mRNA-CV vaccine [reported in Bulletin 94] which includes a one dose primary course, updated recommendations regarding additional doses), changes to antimicrobial prophylaxis guidance and exclusion of contacts for diphtheria, updates relating to the 2024 influenza programme, removal of information about the meningococcal B vaccine catch-up programme for people aged 13 – 25 years (this ended on 28th February, 2024, as reported in Bulletin 93).
Medicine supply news: morphine oral liquid, clobetasone butyrate (Eumovate) cream
The following news relating to medicine supply, of particular interest to primary care, has recently been announced. This information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Morphine oral liquid supply issue ongoing
Pharmac has announced there is a nationwide shortage of morphine oral liquid. This supply issue comes after a change in the manufacturer of the original funded product, RA-Morph, as reported in Bulletin 88. Currently, stock of morphine oral liquid varies throughout the country and supply interruptions are expected throughout April.
Any remaining stock of morphine hydrochloride liquid (RA-Morph) 2 mg/mL and 5 mg/mL will expire at the end of this month. Stock of morphine sulphate liquid (Wockhardt) 10 mg/5 mL (2 mg/mL), an alternative product listed on the Pharmaceutical Schedule last year, is also low. A second alternative product, morphine sulphate liquid (Oramorph) 10 mg/5 mL (2 mg/mL)*, has been listed on the Pharmaceutical Schedule since 1st March, 2024. Stock of Oramorph was expected to be available later this month, but delivery may be delayed.
The alternative products are not approved by Medsafe and need to be prescribed for supply under Section 29 of the Medicines Act 1981. Clinicians are being asked to use discretion when prescribing morphine oral liquid to conserve stock for those who need it most. Other morphine formulations, e.g. Sevredol immediate release tablets, should be prescribed where possible. The different morphine salts are considered interchangeable, however, care needs to be taken when prescribing, dispensing and administering this medicine due to the difference in strength. The period in which a brand switch fee can be claimed by pharmacists has been extended to 1st June, 2024.
*Morphine sulphate liquid (Oramorph) 10 mg/5 mL (2 mg/mL) contains ethanol 10% v/v and may not be suitable for children, people who are pregnant or breastfeeding or people with or recovering from alcohol use disorder or dependency.
Supply of oxycodone oral liquid and immediate release capsules is also limited; prescribing these products as alternatives to morphine oral liquid should be avoided if possible. N.B. Oral oxycodone is one and a half to two times more potent than oral morphine, so caution should be taken when determining dose if it needs to be prescribed.
Clobetasone butyrate (Eumovate) cream supply issue
There is a supply issue affecting stock of clobetasone butyrate (Eumovate) cream. Both prescription (partly funded) and over-the-counter clobetasone butyrate (Eumovate) 0.05% cream are out of stock. Re-supply is not expected until late April, 2024.
Clinicians could consider prescribing an equivalent potency topical corticosteroid, if required, e.g. triamcinolone acetonide (Aristocort).
For further information on topical corticosteroid potency and appropriate alternatives, see Topical corticosteroids for childhood eczema: clearing up the confusion bpacnz, 2021
New ACC programme for people with musculoskeletal injuries
ACC is rolling out a new service called the Integrated Care Pathways Musculoskeletal (ICPMSK), intended for patients with musculoskeletal injuries such as fractures, dislocations and high-grade tears. ICPMSK has been developed by ACC to support patients who are likely to require engagement with multiple rehabilitation services (e.g. physiotherapy, assistance with return to work, specialist opinion, surgery) with the aim of more effectively co-ordinating decisions and care delivery.
To be eligible, patients must:
- Have accepted cover for a non-permanent musculoskeletal injury to their lower back, shoulder and/or knee; that
- Occurred within the last 12 months at the time of referral (with the exception of selected diagnoses listed in the operational guidelines); that
- Carries a high probability of needing surgery; and
- Patients must intend to reside in New Zealand for the duration of the programme
Read more about ICPMSK here
Referral to ICPMSK. Patients can be referred for an ICPMSK pre-screen via their general practice or other healthcare provider (e.g. Rongoā Māori practitioner, Kaupapa Māori health provider, allied health provider), employer or directly via ACC. There are currently eight ICPMSK suppliers contracted nationally, with more scheduled to be added throughout the year.
A referral guide for ICPMSK is available here
More cryptosporidium cases than expected so far this year
Health New Zealand, Te Whatu Ora, has announced a surge in cryptosporidium cases across New Zealand over the past summer, with 262 cases notified to public health services between 1st January and 8th March. This is more than three times the average for the same time period over the past five years (81 cases).
The rise in cases is not thought to represent a concentrated outbreak linked to drinking contaminated water sources, as seen in Queenstown last year (reported in Bulletin 84). However, approximately one in two cases are thought to involve people becoming unwell after undertaking swimming-related activities. Most instances occurred within urban areas, particularly in the Auckland, Canterbury and Waikato regions. A similar increase has been reported recently in several Australian States, with warmer weather and swimming in recreational water being identified as likely contributing factors.
Patients reporting cryptosporidium symptoms such as diarrhoea and abdominal pain should be advised to avoid using swimming pools, splash pads, rivers, lakes and beaches for at least 14 days, and apply good hygiene practices to prevent further spread. Information on local water quality can be found on the Land Air Water Aotearoa (National) or Safeswim (Northern region only) websites.
Clinicians or laboratories must immediately notify any suspected cases of cryptosporidium to the local Medical Officer of Health through ERMS. Do not wait for laboratory confirmation before notifying.
Suite of tools available for the holistic assessment of dementia in Māori
In late 2023, the New Zealand Dementia Foundation released Māori Assessment of Neuropsychological Abilities (MANA), a suite of diagnostic tools for evaluating mate wareware (dementia) in Māori. MANA is intended to facilitate comprehensive assessment that is sensitive to Māori cultural needs, and is thought to be the first dementia assessment in the world incorporating a wairua (spiritual) evaluation. It is encouraged that these resources are considered when assessing dementia in Māori, and they may be particularly useful for clinicians wanting to increase their cultural competency skills and knowledge.
Read more about MANA here or click here to access the assessment tools
Read more
- MANA was developed by researchers in collaboration with over 400 kaumātua (respected elders) and validated in 92 Māori participants. It addresses concerns that conventional cognitive assessment tools do not incorporate aspects that Māori consider to be important or significant when experiencing or evaluating dementia.
- Assessment with MANA can be offered to Māori aged ≥ 55 years as an alternative to conventional cognitive assessment tools. It can be delivered in English or te reo Māori (however, an interpreter may be required if the clinician is not confident communicating using te reo Māori).
- MANA includes four key components: (1) A guided history taking tool, (2) a wairua and wellbeing tool, (3) a cognitive assessment tool and (4) a whānau/family tool. Clinicians may find it useful to have the family complete the whānau tool while they are undertaking the cognitive assessment tool with the patient.
- The developers recommend following the Hui Process when conducting MANA assessments, involving mihimihi (initial greeting/engagement), whakawhanaungatanga (connecting at a personal level with the patient/whānau), kaupapa (performing the history/assessment) followed by poroporoaki (concluding the encounter and providing clarity about the next steps)
- The entire MANA assessment process may take up to an hour to complete; it is acknowledged that this may be challenging to carry out in a conventional primary care setting. Instead, the developers suggest it may be more practical to work through the assessment in stages, and if possible, involve another member of the primary care team.
For general information on diagnosing dementia, including special considerations for Māori, see: “Recognising and managing early dementia” bpacnz, 2020.
Inaugural Rongoā Māori conference
Registrations are now open for the ACC Rongoā Māori Conference 2024, taking place in Rotorua on 22nd – 23rd May, 2024. This is the first national conference of its kind. Rongoā Māori encompasses a range of techniques related to the traditional Māori approach to care and healing, including mirimiri (bodywork), rākau rongoā (native flora herbal preparations) and karakia (spirituality and prayer).
ACC has funded Rongoā Māori services for injury-related claims since 2020 in conjunction with other treatment or rehabilitation approaches, depending on a patient’s needs. Demand for this type of service has increased substantially since being introduced; in the 12 months leading up to January, 2024, there were 6,016 claims involving the use of Rongoā Māori (41% were for non-Māori patients).
Due to high demand, registrations specifically for Rongoā Māori practitioners are now closed. However, places still remain for clinicians and other health providers. Read more about the event here or click here to register.
Drum roll please… Your 2024 “Allergen of the year”: Sulphites
The American Contact Dermatitis Society (ACDS) has named sulphites (sulfites) the “Allergen of the year” for 2024. Sulphites are compounds containing the sulphite ion, SO32-, and are commonly used as preservatives in food and beverages, personal care products and medicines. The Society is aiming to raise awareness of sulphite allergy as an overlooked cause of skin rash. Given that many of the same foods and products consumed in the United States are available in New Zealand, sulphites should be considered when assessing potential causes of allergic reactions. Avoidance of sulphite-containing products is recommended in patients with a confirmed sulphite allergy; however, pre-emptively removing sulphites without a diagnosis is unnecessary. It is also important to consider the difference between true allergy, e.g. hypersensitivity topical reaction, and intolerance, e.g. gastrointestinal effects after consuming a food item.
Read more
Sulphites are found in high concentrations (> 100 ppm) in many dried fruits (but not prunes or raisins), bottled lemon and lime juices, wine and grape juices, pickled onions, sweeteners and many processed foods. These compounds are sometimes added to wine at a certain stage to halt fermentation, or later in the production process for both wine and beer as a preservative (i.e. to prevent oxidation and bacterial growth). Sulphites are recognised as a potential food allergen in New Zealand and should be listed on product labels if their concentration is > 10 mg/kg (or mg/L). Occupational sources of sulphites include the manufacturing processes of chemicals, pharmaceuticals, rubber and textiles. Sulphites can also be found in several medicines, e.g. nasal preparations, topical antifungals and topical corticosteroids, and personal care products, e.g. haircare products, makeup and sunscreens.
Sulphite exposure in sensitive individuals results in a delayed or type IV hypersensitivity reaction and topical symptoms include a macular or papulovesicular rash with pruritis, erythema and scaling. Common locations of cutaneous symptoms include the face, lips and hands, depending on the route of exposure, e.g. eating or drinking, applying personal care products to the face, hair care products dripping on the face. Sulphites may also trigger bronchoconstriction and breathing difficulties in people with asthma. Anaphylaxis from sulphite exposure is rare.
Sulphite allergy is different from sulphate or sulfonamide allergy
Sulphites (SO32-) should not be confused with sulphates (sulfates) and sulfonamides. Cross-reactivity is not expected to occur between these different compounds and the generic term “sulphur allergy” should be avoided (allergy to the element sulphur alone does not occur).
Sulphates (SO42-) are commonly present in substances such as soaps, detergents and cosmetics (e.g. sodium lauryl sulphate), and may also be present in certain medicines, e.g. morphine sulphate, heparin sulphate. Sulfonamide groups can be present in antibiotics (e.g. sulfamethoxazole) and non-antibiotic medicines (e.g. gliclazide, furosemide, azetazolamide). Evidence suggests cross-reactivity does not occur between antibiotic sulfonamides and non-antibiotic sulfonamides. For further information, click here.
Practice point: Patients who are diagnosed with a sulphite allergy should be advised to avoid foods and products containing high concentrations of sulphites, where possible. Clinicians should also avoid prescribing medicines containing sulphites to such patients, especially topical preparations (corticosteroids or antifungals) and eye drops. An information sheet on sulphite sensitivity from the Australasian Society of Clinical Immunology and Allergy is available here.
The full article is available here (not open access) and a Medscape commentary is available here
Further information on allergy testing in primary care is available here
Widened eligibility for health professional work placement scheme
Registrations of interest for the 2024 Voluntary Bonding Scheme intake opened on 6th March and will remain open for six weeks until 16th April. This initiative is designed to encourage newly qualified health professionals to work in hard-to-staff communities and specialties. Health New Zealand, Te Whatu Ora, has announced widening of the Scheme eligibility criteria to include all new and recent anaesthetic technician and midwifery graduates nationwide. New or recent pharmacist graduates are now included in the scheme if they intend on working in rural and regional areas (i.e. excluding Auckland, Tauranga, Hamilton, Wellington, Christchurch and Dunedin). The Scheme has also been expanded to provide additional places for rural and regional general practice trainees, and graduate nurses working in eligible specialties, e.g. mental health, aged care.
Read more about the Scheme here or to register your interest for the 2024 intake click here
Paper of the Week: Rx exercise
Regular exercise is an essential component for all aspects of health and wellbeing. The most recent New Zealand physical activity guidelines for adults recommends two and a half hours of moderate intensity activity or one and a quarter hours of vigorous intensity activity spread across the week. However, last year, more than half of adults in New Zealand did not meet these recommended levels. Reduced physical activity is associated with an increased risk of arthritis, cancer, cardiovascular disease (CVD), chronic obstructive pulmonary disease, type 2 diabetes and poor mental health. While there is no doubt discussions regarding the need to increase physical activity are a daily occurrence in primary care, motivating patients to actually make meaningful long-term changes can be challenging.
An article published in the Australian Journal of General Practice provides an overview and example action plan on how primary care providers can incorporate exercise as a component of the management of adults living with chronic disease. Suggested approaches to increase exercise engagement include treating physical activity as a clinical “vital sign” that should be routinely evaluated, incorporating smart phone apps and wearable technology for monitoring progress, and considering innovative exercise regimens (e.g. vigorous intermittent lifestyle physical activity and “exercise snacks”) as tools when conventional exercise does not appeal. The authors challenge primary care providers to take a more active role in enabling patients to increase the amount of exercise they do.
“If we had a pill that conferred the proven health benefits of exercise, doctors would prescribe it to every patient” - Dr Bob Sallis, founder of the Exercise Medicine Initiative
Do you regularly assess physical activity as a “vital sign” in patients with chronic disease? Do you feel confident in recommending specific exercises or routines? Are you familiar with referral criteria for physical activity support in your area?
Read more
- A lower level of cardiorespiratory fitness is a strong predictor of CVD and all-cause mortality. As regular exercise increases cardiovascular fitness, there is a rationale to considering exercise as a “vital sign” in clinical practice and routinely assessing it as part of patient evaluation.
- Patients with chronic conditions may benefit from an annual assessment of their physical activity levels. The results of these assessments can be used as the basis for exercise prescriptions (i.e. green prescriptions) or referrals to exercise programmes or appropriate health professionals.
- Primary care clinicians should incorporate health coaching theory and motivating techniques when discussing health goals and exercise with patients. These may include active listening, non-judgemental communication, goal setting and action planning.
- The overall goal is to support patients in identifying what is meaningful to them, so they can use it as self-motivation to make long-term behavioural changes regarding exercise. Often, the most effective activities for patients to focus on is the ones they enjoy doing, e.g. some people may prefer gardening to conventional exercise (if strenuous enough).
- Conversations can be initiated in primary care and appropriate resources provided, however, patients who are referred to a specialist service are more likely to receive individualised management which may increase exercise adherence. See local HealthPathways for referral options for physical activity support.
- The social aspect of group programmes can increase accountability (which in turn motivates change) and make exercise more enjoyable, e.g. walking groups
- Patients who do not meet eligibility criteria for physical activity support but would benefit from more individualised management could be referred to a local exercise group or sports club, if appropriate
- The ability to manage and self-monitor progress through smart phone apps and wearable technology may encourage and motivate people to increase their physical activity and adhere to exercise programmes, e.g. daily step counters, reminders and social media functions
- A progressive approach, focusing on small daily increases in physical activity duration is recommended until a goal level of exercise is achieved
- Introducing low-volume high intensity interval training (HIIT) may be useful for some patients. This approach involves a repeated pattern of short bursts of high intensity exercise followed by low intensity recovery periods. Even shorter duration HIIT (< 15 min) has been shown to be beneficial for cardiorespiratory fitness, cardiovascular health and glycaemic control.
- HIIT may not be appropriate for all people with chronic health conditions; medical screening, professional supervision and regular cardiopulmonary monitoring may be required for some patients
- Novel exercise strategies for people with limited time include vigorous intermittent lifestyle physical activity (VILPA) and exercise snacks. Both methods involve small bursts of vigorous exercise throughout the day. VILPA can be incorporated into normal daily activities (e.g. running for the bus, choosing the stairs over the lift) whereas “exercise snacks” involve planned periods of brief physical exercise (e.g. 1 – 5 mins) at set times throughout the day. “Exercise snacks” have also been shown to improve glycaemic control when planned before mealtimes.
- A selection of resources are listed to aid healthcare providers when discussing and guiding patients to increase their physical activity, including appropriate modifications to exercising programmes for patients with chronic medical conditions. Some of these resources are specific to the Australian healthcare system but may still be a useful starting point for discussions with patients in New Zealand primary care.
Keating SE, Brown RCC, Sullivan V, et al. Exercise care by general practitioners: providing sustainable solutions for patients living with chronic disease. Aust J Gen Pract 2024;53:99–107. doi:10.31128/AJGP-05-23-6846
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