Published: 19th April, 2024
Contents
bpacnz presents – Navigating the last days of life: the podcast
Helping patients navigate the last days of life in the community can be a significant challenge for primary healthcare professionals. Most clinicians in general practice will feel a strong moral or personal obligation to assist in the closing chapter of a patient’s journey, however, the reality is that much of this work is undertaken out-of-hours without any additional funding. So how do general practices navigate this challenge? What policies and practices relating to end of life care can be put in place that reflect the unique settings, demographics and resource constraints under which they operate?
We are pleased to announce the release of a new podcast, that is a conversation with three outstanding clinicians who champion efforts to improve the standards of end of life care within New Zealand: palliative medicine physician Dr Kate Grundy, hospice clinical specialist nurse and educator Vikki Telford and general practitioner and palliative care medical officer Dr Helen Atkinson. This informative and compelling conversation expands on many of the points covered in the last days of life resources and the real-life challenges that primary care faces. Meaningful improvements to end of life care in New Zealand require system-level differences that are beyond the control of individuals, but by taking part in the conversation, you are adding to the momentum of change.
"Most normal dying doesn't need to be in a facility looked after by specialists. It is normal, it is part of what society must do, and society is supported primarily by GP teams in the community setting…That's the bit that I feel bad about, that in doing this as general practices become more and more squeezed, is there's less and less opportunity for that to happen. I think that we should use our collective strength to highlight this, that if this is genuinely what we want to do and to keep normal dying and people who want to die in the community, that we have to look at how that's provided"
- Dr Kate Grundy, Palliative Medicine Physician, Christchurch Hospital
Tune in to the new podcast by clicking here
Read more about our other last days of life resources
In 2023, bpac published “Navigating the last days of life: a general practice perspective” with the support of Te Aho o Te Kahu, Cancer Control Agency. This resource outlines the essential components and considerations required to provide quality end of life care in the community. In addition, we also released a series of associated articles on managing common symptoms within this context, including:
Following the release of this work we published a peer group discussion, intended as a prompt for general practices to reflect on their approach to care delivery, and consider opportunities for improvement depending on their particular circumstances.
Got any thoughts regarding this topic? Contact us at [email protected]
New article – Seasonal influenza and COVID-19 vaccinations: 2024 edition
The Influenza Immunisation Programme has begun for the 2024 season. Influvac® Tetra is the sole funded influenza vaccine for 2024 for people who meet eligibility criteria. Since March, 2024, a new COVID-19 vaccine (XBB.1.5) has been available in New Zealand for people aged 12 years and over; a single dose is sufficient for a primary course. Eligible adults and children who have not yet received a primary COVID-19 vaccination, or are not up to date with additional (booster) doses, should be encouraged to do so.
Click here to read the full article
Medsafe Alert Communication: moisturiser containing high potency steroid
Medsafe has published an Alert Communication about NaturaCoco Moisturising Cream and Dark Apo Moisturise Soothing Cream as they contain a potent steroid not labelled on the packaging. These products contain fluocinonide, a prescription-only high potency steroid (0.01% and 0.008% respectively), that is not approved or available in New Zealand. The products are manufactured in the Philippines and may be brought into New Zealand or obtained online. Due to the potency of the steroid, use of these products can result in adverse effects, such as skin atrophy and hypothalamic-pituitary-adrenal (HPA) axis suppression.
Medsafe is advising healthcare professionals to ask patients who are not using steroid creams but who present with adverse effects consistent with potent steroids about their use of NaturaCoco Moisturising Cream and Dark Apo Moisturise Soothing Cream. Patients should be advised to stop applying the cream and to safely dispose of any product(s).
Monitoring Communication: calcium channel blockers may be associated with new-onset eczema
Medsafe has issued a Monitoring Communication to seek more information from clinicians on the risk of new-onset eczema with the use of calcium channel blockers, e.g. amlodipine, diltiazem. The safety communication has been made following six reports to the Centre for Adverse Reactions Monitoring (CARM) of adult-onset eczema suspected to be related to felodipine or diltiazem use. Responses can be submitted until 8th October, 2024 (at which time the risk will be assessed; any adverse effect reports should continue to be submitted after this date).
Healthcare professionals should be alert for this potential risk with calcium channel blockers and report any suspected cases of new-onset eczema to CARM.
For further information on the management of eczema, see: https://bpac.org.nz/2021/childhood-eczema.aspx and https://bpac.org.nz/2021/topical-corticosteroids.aspx
Medical Council seeking feedback on treating yourself and those close to you
The Medical Council of New Zealand is currently reviewing its official statement on “Treating yourself and those close to you” and has issued a consultation seeking feedback on proposed changes. In most cases, doctors should not treat themselves or people who are close to them. The statement recognises that there are, however, some exceptional circumstances where this is not possible, and provides guidance on how to maintain best practice in these situations. The consultation closes on Friday 24th May, 2024. This link contains an online form to complete or your submission can be emailed to [email protected].
Pharmac funding decisions: ICS/LAMA/LABA inhaler, shingles vaccine
A decision has been made following consultation on the proposal by Pharmac to fund a triple medicine inhaler (ICS/LAMA/LABA) for patients with moderate to severe COPD and to widen access to the varicella zoster virus vaccine (Shingrix) - as reported in Bulletin 93. Decisions have also been made on funding treatments for a range of other conditions, e.g. ovarian cancer, HIV, click here for further information. An associated news release can be found here.
ICS/LAMA/LABA combination inhaler to be funded
From 1st May, 2024, fluticasone furoate with umeclidinium and vilanterol (ICS/LAMA/LABA; Trelegy Ellipta), a triple medicine inhaler, will be funded with Special Authority approval for patients diagnosed with COPD* who are already taking either two or three medicines for COPD and who meet at least one of the following clinical criteria in the last 12 months: an eosinophil count ≥ 0.3 x 10x9 cells/L, two or more exacerbations or one exacerbation requiring hospitalisation, or a COPD Assessment Test (CAT) score > 10. Having the option of this novel funded triple combination will mean that patients only need to use one inhaler to achieve ICS/LABA/LAMA combination treatment (instead of two or three), which may improve treatment adherence. N.B. Trelegy Ellipta is also indicated for the maintenance treatment of asthma in adults, however, this is not included in the current funding decision.
*While diagnosis of COPD should be confirmed by spirometry for the Special Authority application, this may not always be practical in primary care. Patients in whom spirometry has been attempted but results are not technically acceptable will also meet Special Authority criteria.
Widened access to shingles vaccine
From 1st July, 2024, eligibility for vaccination with Shingrix will be widened to include people aged ≥ 18 years who are immunocompromised due to any of the following conditions:
- Pre- or post-haematopoietic stem cell transplant
- Solid organ transplant
- Haematological malignancy
- Poorly controlled HIV infection
- Planned or receiving disease modifying anti-rheumatic drugs (DMARDs) for polymyalgia rheumatica, systemic lupus erythematosus or rheumatoid arthritis
- End stage kidney disease (CKD 4 or 5)
- Primary immunodeficiency
Funded access will remain for people aged 65 years.
Pharmac considering funding oestradiol gel
Pharmac is considering funding oestradiol gel. Oestradiol is currently approved for menopausal hormone therapy and osteoporosis prophylaxis (oestradiol-based gender affirming hormone therapy is an unapproved indication), and is available in two formulations: patches and tablets. The availability of oestradiol gel will provide people who take oestradiol with another option if other oestradiol formulations are not suitable or available, particularly with the ongoing supply issues affecting stock of oestradiol patches. An associated news release is available here.
Pharmac recently funded testosterone gel (as reported in Bulletin 92) - watch this space for an upcoming bpacnz article update on the use of testosterone in ageing males.
For further information on menopausal hormone therapy, see: https://bpac.org.nz/2019/mht.aspx
Funding for community pharmacist education courses announced
Health New Zealand, Te Whatu Ora, in conjunction with the Pharmaceutical Society of New Zealand has announced that funding will be available for community pharmacists to undergo the following courses: clozapine dispensing, the community pharmacy anticoagulation management service (CPAMS) training programme and COVID-19 antiviral medicine training. The funding is intended to support community pharmacists by removing the financial barriers to accessing these training courses, encourage provider equity and increase the number of pharmacists with the skills needed to provide these services.
Rongoā Māori resources available from ACC
ACC has announced the establishment of a YouTube channel dedicated to Rongoā Māori. This channel hosts a collection of video resources explaining Rongoā Māori, including what it is, how it is used in the context of patients recovering from an injury and how to determine which techniques are best for a patient. View the channel here.
Further information about Rongoā Māori services that are offered by ACC is available from: https://www.acc.co.nz/about-us/rongoa-maori-services
Did you know about Nymbl? A falls prevention exercise app
Last year, ACC launched Nymbl, a free app (available through the Apple App Store or Google Play Store) to improve balance and mobility in older people. The app, which is part of the ACC Live Stronger for Longer programme and intended for use by patients, uses a combination of exercise and cognitive behavioural training to improve balance and decrease falls risk.
The app is intended to be used regularly for short durations, e.g. 10 minutes/day for a few days per week, by people aged over 50 years; consider whether there are any older patients in your practice who might benefit from using Nymbl. A weekly educational email programme is available (selected during the sign-up process) for those without a smartphone or tablet.
For further information on strength and balance activities for older people from ACC, see: https://www.acc.co.nz/preventing-injury/trips-falls/strength-and-balance
Paper of the Week: Age is not a barrier to efficacy of osteoporosis medicines
It is well established that bone mineral density declines progressively after early adulthood. This is likely related to physiological changes in bone remodelling, age-related reductions in sex hormones, malnutrition and reduced physical exercise. Over time, this reduction in bone mineral density may lead to the development of osteoporosis. Oral bisphosphonates are the first-line pharmacological treatment option for osteoporosis in New Zealand, e.g. alendronate, risedronate. Other available medicines include zoledronate (zoledronic acid; an intravenous bisphosphonate), denosumab, teriparatide and raloxifene. Some clinicians are hesitant to initiate these medicines in older people (e.g. > 70 years) based on the common belief that they may be less effective at increasing bone mineral density in this group. Given that deprescribing is increasingly considered in older patients due to the risks of treatment outweighing the intended benefits, is there still a place for pharmacological management options for osteoporosis in patients aged 70 years and over?
A recent review published in the Journal of Bone and Mineral Research has examined the influence of age on the efficacy of osteoporosis medicines. Contrary to popular belief, it was found that medicines used for osteoporosis reduced fracture risk to a similar extent regardless of whether participants were aged under or over 70 years. In some cases, a greater increase in hip and spine bone mineral density was observed after 24 months of treatment in participants aged 70 years and over, compared to younger participants. The authors suggest these results support the continued use of medicines for osteoporosis treatment in older patients.
In your experience, does age influence the decision to prescribe osteoporosis medicines? Do you think the results of this study will change your approach to prescribing medicines for osteoporosis in older people?
Key points
- Researchers from the United Kingdom (UK) and United States of America (USA) analysed a total of 23 randomised placebo-controlled trials (RCTs) investigating osteoporosis medicines, involving over 120,000 participants (~ 99% females)
- Of the 23 RCTs included in the study, 11 involved bisphosphonates (e.g. alendronate, ibandronate*, risedronate and zoledronate), four involved selective oestrogen receptor modulators, three involved anabolic agents (including abaloparatide* and teriparatide), two involved menopausal hormone treatments, and there were single studies involving odanacatib*, denosumab and romosozumab*
*Not currently available in New Zealand
- Participants were divided into two subgroups based on their age; < 70 years or ≥ 70 years. An age threshold of 70 years was used as this provided comparable fracture rates in both subgroups, however, only approximately 40% of the total participants were aged 70 years or over.
- Participants in the older subgroup were more likely to have previously experienced fractures and had a lower BMI at baseline, compared to the younger subgroup. Lower total hip and femoral neck bone mineral density was also initially reported in the older subgroup.
- For each age group, the treatment effect on fracture risk and bone mineral density was assessed. Five fracture endpoints were chosen for analysis; radiographic vertebral, non-vertebral, hip, all clinical and all fractures.
- Fractures with a pathological or traumatic cause (sufficient to result in fracture in a younger patient) as well as fractures to the skull, face, fingers, toes and cervical spine were excluded
- The method of measuring bone mineral density varied between studies, however, data was standardised to allow interpretation. Only 17 studies included bone mineral density data after 24 months of treatment.
- Medicines for osteoporosis reduced the risk of vertebral fracture by approximately half, both in patients aged under 70 years and in those aged 70 years and over (odds ratio [OR]: 0.47 and 0.5, respectively)
- Comparable reductions were also seen between patients aged under 70 years and in those aged 70 years and over for the risk of hip fracture (OR: 0.65 and 0.72, respectively) and all fractures (OR: 0.72 and 0.70, respectively)
- While similar results were observed when the analysis was restricted to the 11 studies involving bisphosphonate treatment, participants aged under 70 years had an even greater reduction in hip fracture risk compared to people aged 70 years and over (OR: 0.44 and 0.79, respectively)
- Participants aged 70 years and over experienced a greater increase in hip and spine bone mineral density after 24 months of osteoporosis treatment compared to those who were younger. However, when looking at the bisphosphonate studies alone, this increase was only observed in hip bone mineral density of participants aged 70 years and over.
- The study authors note that almost all (99%) participants were of female sex which may be a limitation of the study. Further research is required to confirm if the results of this study are applicable to males. Other limitations included the small number of clinical studies for some medicines, e.g. only one placebo-controlled trial was analysed for both denosumab and teriparatide, and the effect of other risk factors on fracture risk in older adults was not investigated, e.g. body mass index.
Schini M, Vilaca T, Vittinghoff E, et al. Influence of age on the efficacy of pharmacologic treatments on fracture risk reduction and increases in BMD: RCT results from the FNIH-ASBMR-SABRE project. Journal of Bone and Mineral Research 2024;:zjae040. doi:10.1093/jbmr/zjae040
For further information on the use of bisphosphonates in the management of patients with osteoporosis, see: https://bpac.org.nz/2019/bisphosphonates.aspx
This Bulletin is supported by the South Link Education Trust
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