Published: 8th March, 2024
Contents
What’s trending at bpacnz this week
The most popular resource on the bpacnz website this week is the Antibiotics Guide. Over the past seven days, thousands of website users in New Zealand clicked on the Guide to check which antibiotic to prescribe, at what dose and duration, and perhaps most importantly, when. For example, antibiotic treatment is usually not necessary in people with sore throats, unless they are at high risk of rheumatic fever as a consequence of group A streptococcus infection.
Other popular resources this week include the Contraception series, in which you can find information and prescribing guidance for all available contraception options; our recently updated article on Melatonin: is it worthwhile for sleep, in which the evidence remains equivocal; and Hypertension in adults: the silent killer, where you can update yourself on the latest guidelines for treating this commonly seen condition in primary care: if your patients are not on dual antihypertensive treatment yet, consider if they should be.
Find the answers to all your clinical questions here, or just stay awhile to browse and perhaps learn something new.
*Sneak peek*
Coming soon: A podcast on navigating the last days of life - a general practice perspective
This is the conversation every health care professional should be part of – how do we talk about dying?
“Whenever we're discussing dying, it brings us close to our own mortality. It brings up all kinds of emotions in ourselves. And until we kind of wrestle with those a little bit and get comfortable with it and manage our own demons around that, I don't think we can really move forward. We've got to get comfortable with using the words in getting close to it.”
Dr Helen Atkinson, GP and Medical Officer, Harbour Hospice
Influenza vaccine eligibility criteria for 2024
The 2024 influenza immunisation programme commences on 2nd April. Pharmac has announced eligibility criteria for funded vaccination this year. Funded access remains for people aged 65 years and older, people aged under 65 years with long-term conditions or specific mental health conditions or addictions, people who are pregnant and children aged ≤ 4 years who have been hospitalised for, or have a history of, significant respiratory illness. However, people aged 55 – 64 years of Māori or Pacific ethnicity and children aged 3 – 12 years are no longer eligible for funded influenza vaccination this year. Click here for the full list of funded access criteria.
The following quadrivalent flu vaccines are available for 2024
Funded vaccine
INFLUVAC TETRA: for use in children aged six months and over and adults. Funded for children and adults who meet eligibility criteria and available for purchase for those not eligible.
Non-funded vaccines (available for purchase)
FLUCELVAX QUAD: for use in children aged six months and over and adults.
N.B. This is a cell-based culture vaccine, other vaccines are egg-based (but can be administered to people with a history of egg allergy or egg anaphylaxis).
FLUAD QUAD: for use in adults aged 65 years and over.
FLUQUADRI: for use in children aged six months and over and adults.
ALFURIA QUAD: for use in children aged three years and over and adults.
Included strains
Two new strains are included in this year’s influenza vaccines:
- INFLUVAC TETRA, FLUAD QUAD, FLUQUADRI, ALFURIA QUAD
- A/Victoria/4897/2022 (H1N1) pdm09-like virus
- A/Thailand/8/2023 (H3N2)-like virus
- FLUCELVAX QUAD
- A/Wisconsin/67/2022 (H1N1) pdm09-like virus
- A/Massachusetts/18/2022 (H3N2)-like virus
Two strains are retained from last year (ALL VACCINES):
- B/Austria/1359417/2021-like virus
- B/Phuket/3073/2013-like virus
Dosing
One dose is given for all vaccines. A second dose is recommended for children aged < 9 years at least four weeks after their first dose if they have not previously been vaccinated. Any of the influenza vaccines may be administered at the same time as a COVID-19 vaccine.
The 2024 Flu kit booklet for health professionals is available here.
New COVID-19 vaccine (XBB.1.5) now available
The Comirnaty 30 microgram XBB.1.5 COVID-19 vaccine is now available for people aged 12 years and older. This vaccine replaces the Comirnaty 30 microgram and Comirnaty BA.4/5 (15/15 mcg) vaccines for both primary and additional doses in people aged ≥12 years. A factsheet is available here.
People aged 30 years and older, people aged 16 – 29 years who are pregnant and people aged 12 – 29 years who are at higher risk of severe illness from COVID-19 remain eligible to receive funded additional doses (previously called booster doses). It is recommended that additional doses are given at least six months apart, or six months after a positive COVID-19 test. Clinical discretion, however, can be applied for some patients, e.g. an interval of three months may be appropriate for patients at high risk of severe disease from COVID-19.
For further information on COVID-19 vaccines, including eligibility criteria, see: https://info.health.nz/immunisations/vaccines-aotearoa/covid-19-vaccines/getting-covid-19-vaccines/ or the Immunisation Handbook, here.
The Immunisation Advisory Centre recently hosted a webinar discussing the new vaccine. For those who missed it, the recording can be found here.
New guidance for household contacts: It was announced earlier this week that asymptomatic household contacts of a person with COVID-19 are no longer recommended to test (with a RAT) each day. Contacts need only test for COVID-19 if they develop symptoms. RAT home testing kits are currently free until 30th June, 2024.
Empagliflozin: new indications, updated guidance on use in renal impairment
Boehringer Ingelheim and Eli Lilly have announced some key updates to the approved therapeutic indications and prescribing guidance for empagliflozin (Jardiance). It should be noted, however, that there has been no change to funding restrictions and empagliflozin remains funded only for patients with type 2 diabetes who meet criteria for Special Authority approval. The changes include:
- New indication for the treatment of adults with chronic kidney disease (where it is used for its dual kidney- and cardio-protective properties)
- New indication for use in children aged ≥ 10 years with type 2 diabetes as monotherapy if metformin is not tolerated or in combination with other glucose-lowering medicines (under specialist supervision) if glycaemic control remains poor (previously only indicated in those aged ≥ 18 years)
- The recommendation that empagliflozin should not be used in people aged ≥ 85 years has been removed, however, caution is still advised for those aged ≥ 75 years who may be more at risk of volume depletion
- Updated recommendations for use in people with renal impairment
- People with an eGFR < 30 mL/min/1.73 m2 can take a maximum dose of empagliflozin of 10 mg, however, it is not recommended for use in people undergoing dialysis
- Empagliflozin may be ineffective at reducing glucose levels in people with this degree of renal impairment, therefore additional glucose-lowering medicines may be required
- Empagliflozin was previously contraindicated for people with an eGFR < 30 mL/min/1.73 m2
- An expanded warning on ketoacidosis as this is considered a risk in people with, or without, diabetes. N.B. Fournier’s gangrene is also a rare adverse effect associated with empagliflozin; see Bulletin 64.
For a full list of indications for empagliflozin see the New Zealand Formulary
For further information on the management of CKD, see: https://bpac.org.nz/2022/ckd.aspx
For further information on empagliflozin, and type 2 diabetes in young people, see: https://bpac.org.nz/2021/diabetes.aspx and https://bpac.org.nz/2021/diabetes-younger.aspx
Position statement on the management of heart failure in New Zealand released
A position statement from a collective of New Zealand cardiology experts (the Heart Failure Working Group), endorsed by the Cardiac Society of Australia and New Zealand (NZ Region), and the New Zealand Heart Foundation, has recently been published in the New Zealand Medical Journal. This statement comes in response to developing perspectives around optimal heart failure management in local and international guidelines, as well as evidence that health inequities relating to heart failure continue to widen in New Zealand.
Read more
The position statement recommends use of “the four pillars of heart failure treatment” – also known as guideline-directed medical therapy (GDMT) – as early as possible in all patients with heart failure with reduced ejection fraction (HFrEF) to improve clinical outcomes, i.e. an angiotensin receptor-neprilysin inhibitor (ARNI, i.e. sacubitril + valsartan), beta blocker (e.g. carvedilol, bisoprolol, metoprolol succinate), mineralocorticoid receptor antagonist (MRA, e.g. spironolactone, eplerenone) and SGLT-2 inhibitor (i.e. empagliflozin). To better enable this approach, the Group recommends that sacubitril + valsartan, empagliflozin and eplerenone treatment should be fully funded without the need for Special Authority approval in patients with HFrEF. The statement also emphasises that while combined GDMT has not been associated with the same efficacy in randomised controlled trials involving patients with heart failure with preserved ejection fraction (HFpEF), the potential benefits and recommendations for SGLT-2 inhibitor treatment should apply regardless of left ventricular ejection fraction (LVEF) status.
Click here to view the full position statement (N.B. Individuals must subscribe and log in to view this resource, however there is no subscription fee.)
The bpacnz heart failure article has been updated to include this statement, see: https://bpac.org.nz/2022/heart-failure-part-2.aspx
Medsafe Alert Communication: lead poisoning with Ayurvedic products
Medsafe has issued an Alert Communication about lead poisoning associated with the use of Ayurvedic products, which are a form of traditional Indian medicine, typically derived from plants, but they may also contain mineral, metal or animal substances. In recent months, there have been eight notifications of people with lead poisoning with exposure suspected to be from Ayurvedic products. We previously reported on an increase in lead notifications from suspected Kamini use in Bulletin 92.
Medsafe is advising health care professionals to ask patients presenting with unexplained symptoms and signs (e.g. abdominal pain, nausea, vomiting, constipation) about their use of traditional remedies, including Ayurvedic products, and to consider the possibility of lead poisoning in patients taking these products. Contact the National Poisons Centre (0800 764 766) if a patient is suspected to have lead poisoning, and if possible, collect a sample of the implicated product so that it can be tested by Medsafe.
For further information on Kamini, see: https://bpac.org.nz/2020/kamini.aspx
For further information on lead poisoning, including notifying the local Medical Officer of Health, see: https://bpac.org.nz/2021/lead.aspx and https://www.tewhatuora.govt.nz/our-health-system/environmental-health/hazardous-substances/lead/lead-poisoning/
Latest edition of Prescriber Update released
The March edition of Prescriber Update has been published. Particular items of interest for primary care include:
The effect of pharmacokinetic changes in pregnancy on antiepileptic medicines
Plasma levels of antiepileptic medicines can be reduced during pregnancy due to pharmacokinetic changes. The extent of the reduction in serum concentration differs depending on the patient and the antiepileptic medicine; phenytoin has the highest decrease. Therapeutic drug monitoring with dose adjustments as indicated is recommended for patients who are pregnant who take phenytoin, carbamazepine or lamotrigine. Read more here.
For further information on prescribing antiepileptic medicines in women, see: https://bpac.org.nz/2018/antiepileptic.aspx
Unexplained changes in mood and behaviour could be medicine adverse effects?
Psychiatric adverse effects are not only associated with psychotropic medicines. Many non-psychotropic medicines frequently prescribed in primary care (e.g. metoprolol, enalapril, metronidazole, cetirizine) have been associated with psychiatric effects, e.g. agitation, hallucinations. People with, or who have a history of, a psychiatric disorder are at increased risk; higher doses and extremities of age are also risk factors. Medsafe is reminding clinicians to consider the possibility of medicine adverse effects as a cause of new or worsening psychiatric symptoms in patients. Read more here.
Medicine interactions with low-dose methotrexate
Methotrexate when taken with certain medicines, e.g. NSAIDs, penicillins, can be associated with an increase in adverse effects and toxicity. Consider the potential for interactions and toxicity when initiating or modifying the dose of medicines in patients taking low-dose methotrexate. Read more here.
Medicine safety reminder: unintentional poisoning in the home
Medsafe is reminding clinicians about avoiding unintentional childhood poisoning at home (and pets). The natural curiosity of young children and their surroundings can sometimes lead to unintentional exposures to hazardous substances around the home. Some medicines, e.g. tricyclic antidepressants, can cause significant toxicity in children in small quantities. Remind parent/caregivers to store medicines out of reach of children, in the original packing and to put them away immediately after use. Patients should also be advised not to share prescription medicines. Read more here.
For further information about hazardous substances around the home, see: https://bpac.org.nz/2022/hazardous.aspx
MARC’s remarks: December 2023 meeting
In the December, 2023, meeting, the Committee recommended updates to medicine data sheets including: oral anticoagulants (e.g. warfarin, dabigatran, rivaroxaban and apixaban) should be updated to include the risk of anticoagulant-related nephropathy (ARN); oestrogen-based menopausal hormone therapy (e.g. oestradiol valerate; excludes vaginal preparations) should be updated to include a potential interaction with lamotrigine (a reduction in plasma lamotrigine levels may occur which can increase seizure frequency and mood instability). Click here to read more.
View the full edition of Prescriber Update here
A focus on suicide prevention: latest suicide data released
Health New Zealand, Te Whatu Ora, has updated the suicide data web tool to include confirmed data from 2019 and suspected self-inflicted deaths up to 2022/23. There were 673 confirmed suicide deaths in New Zealand in 2019; 13% higher than the average rate over the past ten years. Age-standardised rates by ethnicity show that Māori die by suicide at approximately twice the rate of non-Māori. Young people are also over-represented in suicide statistics. There were 565 suspected self-inflicted deaths in New Zealand in 2022/23, with similar demographic trends as previous years; Māori males had the highest rates of death. Although the number of suspected suicides is lower in 2022/23 than the confirmed statistics from 2019, suicide rates are variable and the overall trend over time has not thought to have changed.
In 2017, bpacnz published an editorial on suicide prevention in primary care, with guest commentary from mental health experts in New Zealand. The following is an excerpt: Only a portion of the total number of people who die by suicide are seen in general practice, therefore it is crucial that any opportunity for intervention is acted on. If in the course of a consultation a patient expresses verbally or non-verbally that their mood is low, they should be assessed for suicide risk. This can be done in a formal manner, but it is often best approached as a conversation, using clinical judgement as to how far the questions go. There is no one right way to ask about suicide, and the only wrong way is not to ask at all. The manner and tone of asking is more important than the words used. Be empathic, sensitive and non-judgemental, in a way that invites the patient to share the depth of their concern and despair.
As individuals we cannot prevent every death, but if we can make a meaningful connection with one person, that may make a difference.
For further reading, see: "Suicide prevention: what can primary care do to make a difference".
Cilazapril delisting date moved to 2025
Pharmac has announced that the delisting date for cilazapril has been moved to 1st January, 2025. Stock of the 5 mg presentation is expected to run out by July, 2024; the 0.5 mg and 2.5 mg presentations will expire in October, 2024. Prescribers should be identifying any patients still taking cilazapril and moving them to another option.
For further information on selecting an ACE inhibitor or ARB, see: https://bpac.org.nz/2021/ace.aspx
News in brief: Family Planning is now Sexual Wellbeing Aotearoa
Sexual Wellbeing Aotearoa is the new name for Family Planning. The name change is intended to better represent the wide range of services offered, including clinical services, contraception, fertility and reproductive health advice, sexuality and relationships education, training and other related resources. Read more about the name change here.
NZF updates for March
Significant changes to the NZF in the March, 2024, release include:
- Contraindication removed (type 1 diabetes) from the dulaglutide and liraglutide monographs
- Chronic kidney disease added as a new indication for empagliflozin. Contraindications and advice in renal impairment have also been updated.
- Dosing regimen has been updated in the testosterone and esters monograph, including the addition of a transdermal gel (Testogel) which will be funded from 1st April, 2024.
- Contraindications, contraception and conception, pregnancy advice, pre-treatment screening and patient advice has been updated in the modafinil monograph (used in the treatment of narcolepsy, obstructive sleep apnoea and other sleep disorders)
- Pregnancy advice has been updated in the CNS stimulants monographs
You can read about all the changes in the March release here. Also read about any significant changes to the NZF for Children (NZFC), here, including the lowering of the approved age for use of empagliflozin.
Paper of the Week: Is orthostatic hypotension a problem in adults with hypertension?
Hypertension is a common clinical finding in general practice, and primary health care professionals are well versed in the importance of lowering blood pressure (BP) to reduce cardiovascular disease (CVD) risk. While the initial approach to treatment for hypertension is well defined, management can sometimes be complicated by the presence of orthostatic hypotension (postural hypotension), where a patient exhibits a sustained drop in systolic BP (> 20 mmHg) or diastolic BP (> 10 mmHg) a short time after standing. This can increase the risk of adverse clinical outcomes, e.g. falls, syncope, dementia, CVD, mortality. However, under-treated hypertension is also associated with adverse outcomes, so management decisions must be balanced.
The American Heart Association (AHA) has recently released a scientific statement on identifying and managing orthostatic hypotension in adults with hypertension. The recommended strategy is:
- Identify the pattern of orthostatic hypotension, triggers and any underlying causes
- Eliminate these triggers and causes where possible, e.g. withdrawing or reducing doses of medicines not related to hypertension treatment (e.g. amitriptyline), avoiding antihypertensive treatments that have an increased risk of orthostatic hypotension (e.g. alpha-blockers such as doxazosin, vasodilating beta blockers such as carvedilol), reducing aggravating factors (e.g. excessive alcohol intake, volume depletion)
- Optimise the antihypertensive regimen: there is no need to set a less stringent BP target as well controlled hypertension appears to be less associated with orthostatic hypotension
- Add a tailored treatment strategy for the patient that avoids exacerbating their hypertension (which will therefore reduce the risk of orthostatic hypotension), e.g. maintaining adequate fluid and salt intake, use of compression garments. Short-acting vasoactive medicines (e.g. pyridostigmine, fludrocortisone) may be considered in patients with severe symptoms.
Do you commonly assess for orthostatic hypotension in patients with hypertension or only investigate if they report symptoms such as light-headedness on standing? Are you confident in individualising the management of patients with both hypertension and orthostatic hypotension?
Read more
- Orthostatic hypotension is estimated to affect 10% of adults with hypertension and prevalence increases with age and burden of disease, e.g. comorbid diabetes, heart failure or chronic kidney disease
- It is uncertain who should be “screened”, as there is a need to avoid overtreatment in those without symptoms: AHA guidelines recommend assessing for orthostatic hypotension at the initial visit in all patients with hypertension and at follow-up visits in patients at higher risk, e.g. older people; NICE guidelines from the UK recommend checking for orthostatic hypotension in people with hypertension and type 2 diabetes or aged > 80 years.
- Measurements for orthostatic hypotension are most sensitive and consistent when taken early in the morning, and BP should be measured after the patient has spent 5 – 10 minutes in the supine position and then again within three minutes of standing upright. This method has limitations within the 10 – 15 minute general practice consultation, therefore a more pragmatic approach (NICE) is to measure BP while the patient is seated or lying on their back, then measure again one minute after standing; if systolic BP drops by > 20 mmHg or diastolic BP drops by > 10 mmHg, orthostatic hypotension is present. N.B. This will not capture all patterns of orthostatic hypotension but will find the most clinically significant cases.
- When orthostatic hypotension is diagnosed, the first step is to identify any obvious modifiable causes, any pattern that occurs throughout the day, and possible aggravating factors/triggers, and address these where possible.
- Often there will be multiple contributory factors; autonomic impairment is a well-defined cause of orthostatic hypotension
- Neurogenic orthostatic hypotension is secondary to neurodegeneration of central autonomic pathways or denervation of peripheral sympathetic nerves, e.g. as seen in neurodegenerative disorders, pure autonomic failure, diabetes
- Non-neurogenic orthostatic hypotension describes cases with some degree of autonomic dysfunction in addition to other aggravating factors, e.g. volume depletion, CVD, ageing, physical deconditioning, alcohol intake, the type and timing of medicine use (see below)
- The ratio between increase in heart rate and the drop in systolic BP can be used to distinguish between types of orthostatic hypotension; an increase of > 0.5 beats/min for every 1 mmHg drop in systolic BP (while the patient is standing) indicates non-neurogenic orthostatic hypotension. A ratio < 0.5 indicates neurogenic orthostatic hypotension.
- Common patterns that are associated with orthostatic hypotension in people with hypertension include: white-coat, nocturnal or non-dipping hypertension and morning hypotension
- Review use of contributory medicines after diagnosing orthostatic hypotension
- Various non-antihypertensive medicines can induce orthostatic hypotension including tricyclic antidepressants (particularly amitriptyline), dopaminergic receptor antagonists (e.g. anti-Parkinson’s medicines), antipsychotics (e.g. clozapine) and nitrates. Consider dose reduction, switching or stopping use, however, this may not be possible depending on the indication.
- Use of first-line antihypertensives should be optimised in most patients; there is no need to reduce doses. Orthostatic hypotension is more common in patients with uncontrolled hypertension and there is insufficient evidence that using more lenient treatment targets reduces the risk of associated symptoms.
- Avoid antihypertensives with an increased risk of orthostatic hypotension, such as alpha-1 blockers (particularly doxazosin), central alpha antagonists (clonidine), beta blockers (particularly vasodilating options, e.g. carvedilol, labetalol)
- Non-pharmacological approaches should underpin the management of orthostatic hypotension, regardless of the cause. However, data supporting these strategies is considered to be of low quality.
- Use of compression garments applied to the lower body or an abdominal binder (specifically for improving upright BP)
- Increasing sodium intake to 10 g sodium chloride daily is recommended by some experts but this must be balanced against the risk of worsening supine hypertension and pressure natriuresis. Small studies have shown that drinking approximately 500 mL of water within 15 minutes of standing can improve standing BP in patients with severe autonomic dysfunction (water bolus). Otherwise, encourage a healthy fluid intake (e.g. ≥ 2 L daily).
- There is limited evidence that sleeping in a head-up tilt position helps control nocturnal hypertension and morning orthostatic hypotension, but this likely requires tilt levels of at least 12° which is not practical, tolerable or safe
- Application of local passive heat (e.g. heated mattress) and continuous positive airway pressure (at levels used in sleep apnoea) may be useful in select cases
- After addressing contributory medicines and non-pharmacological interventions, use of short-acting vasoactive medicines such as midodrine, fludrocortisone (unapproved indication) or pyridostigmine (unapproved indication) can be considered in patients with significant symptoms, particularly in those with neurogenic orthostatic hypotension. In New Zealand, pharmacological treatment decisions are usually made under specialist guidance.
- The AHA statement recommends pyridostigmine as the safest option in patients with co-existing hypertension and orthostatic hypotension (but it may not be effective patients with the most severe symptoms)
Juraschek SP, Cortez MM, Flack JM, et al. Orthostatic hypotension in adults with hypertension: a scientific statement from the American Heart Association. Hypertension 2024;81. doi:10.1161/HYP.0000000000000236
This Bulletin is supported by the South Link Education Trust
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