Published: 5th April, 2024
Contents
New article – A progressive approach to managing atrial fibrillation
Atrial fibrillation (AF) is the most common form of sustained cardiac arrhythmia in adults, but people with AF are often asymptomatic. Detection in primary care therefore mostly relies on opportunistic assessment in patients aged ≥ 65 years, or sooner in those with other risk factors, e.g. Māori or Pacific peoples, previous TIA, hypertension.
Early action is essential as AF significantly increases the risk of stroke. However, the approach taken should not expose patients to an unnecessary risk of harm. Unless the onset of AF occurred within the past 12 hours, referral for electrical cardioversion is usually not appropriate in haemodynamically stable patients without prior anticoagulation due to the risk of thromboembolic complications. In most cases, treatment using direct oral anticoagulants (DOACs) and rate control medicines, alongside relevant lifestyle changes, is sufficient in primary care. AF will often spontaneously resolve without the need for intensifying management.
Nevertheless, the management of AF is an evolving discipline. There is ongoing debate in the literature regarding the merits of rhythm control, which is usually initiated in secondary care, and may be warranted early in younger or more symptomatic patients. In particular, catheter ablation is being increasingly recommended in guidelines, particularly for patients with AF and heart failure with a reduced ejection fraction, due to evidence that it improves symptoms and quality of life.
The full article can be accessed here. A B-QuiCK summary is also available.
Calls to ban engineered stone in New Zealand
The Royal Australasian College of Physicians (RACP) has called for the government to ban the use of engineered (artificial) stone in New Zealand or to implement strict controls on engineered stone importers and fabricators due to the unacceptable risk of accelerated silicosis, a deadly occupational disease. The RACP is also calling for a Registry to be established which would allow long-term follow-up and support for people already exposed to silica dust. From 1st July, 2024, Australia will become the first country to ban the manufacture, supply, processing and installation of engineered stone (as reported in Bulletin 90).
Accelerated silicosis is a progressive respiratory condition caused by exposure to high concentrations of respirable crystalline silica (RCS). This mainly affects people involved in fabricating artificial stone into benchtops, where the RCS concentration in dust can be more than 80%. WorkSafe New Zealand is currently encouraging workers to contact their primary care clinic for assessment. bpacnz has published an article covering the pathology and diagnosis of accelerated silicosis, and referral into the Accelerated Silicosis Assessment Pathway, as well as workplace safety recommendations to reduce risk.
Influenza vaccination programme has begun
The Influenza Immunisation Programme has begun for this year. Influvac® Tetra is the sole funded influenza vaccine for 2024 for people who meet eligibility criteria. It is also available to purchase for those not eligible for funded vaccination.
Four other non-funded influenza vaccines are also available for purchase this year: Flucelvax® Quad and FluQuadri™ for use in children aged six months and over and adults, Fluad® Quad for use in adults aged 65 years and over and Alfuria® Quad for use in children aged three years and over and adults.
Two common questions that patients may have:
- Can I have an influenza vaccination at the same time as a COVID-19 vaccination?
Yes – this is considered safe and will not compromise the effectiveness of either vaccination
- Can I have an influenza vaccination if I have had COVID-19?
Yes, as soon as you have recovered
The 2024 Flu kit booklet for health professionals is available here
IMAC recently hosted a webinar on the 2024 Influenza Immunisation Programme. If you missed it, a recording of the webinar can be found here.
Be alert for potential mumps cases
Health New Zealand, Te Whatu Ora, has asked travellers to be vigilant for mumps, following a reported case involving an infected person who flew from Chennai (India) to Singapore on 13th March, and then onwards to Auckland on 14th March. Healthcare professionals should be alert for potential symptoms and signs of mumps in patients, e.g. swollen salivary glands, headache, fever, tiredness and jaw pain, particularly those with relevant travel history. The incubation period can be up to 25 days following contact with a positive case (i.e. symptoms may develop up until 8th April after contact with the index case, or later if subsequent cases have occurred).
All suspected cases of mumps must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before notifying.
Check MMR vaccination status
This is a reminder to opportunistically check whether patients have received both doses of the MMR vaccine and offer vaccination where appropriate. Also ensure that patients with upcoming international travel are fully vaccinated with MMR (unless their age means that they are considered immune, i.e. born prior to 1969).
MMR vaccination is funded for all children in New Zealand and anyone born from 1969 onwards who has not received two doses. Some people born overseas, including remote island nations, prior to 1969 are considered susceptible to MMR and may be eligible for funded vaccination (see the Immunisation Handbook for further information). N.B. MMR vaccination is contraindicated during pregnancy.
For further information on MMR vaccination, see: https://bpac.org.nz/2021/mmr.aspx
Reminder: Fournier’s gangrene with SGLT-2 inhibitors
Medsafe is reminding clinicians to be alert for Fournier’s gangrene, a rare, but serious adverse effect associated with SGLT-2 inhibitors, e.g. empagliflozin. Fournier's gangrene is a necrotising fasciitis of the perineum. It has been reported in both males and females taking empagliflozin, and the most serious cases can result in death.
Patients taking a SGLT-2 inhibitor should be informed of this rare adverse effect, be given advice about good hygiene of the genital and perianal area, and be advised to seek immediate medical attention if they have pain, tenderness, erythema or swelling of the genital or perineal area, fever or malaise. The SGLT-2 inhibitor should be stopped if Fournier’s gangrene is suspected. A consumer information leaflet can be given to patients.
For further information on empagliflozin and associated adverse effects, see: https://bpac.org.nz/2021/diabetes.aspx
Proposal to fund continuous glucose monitors, insulin pumps and consumables
Pharmac has released a proposal to fund a range of devices for people with type 1 diabetes. If the proposal is accepted this would mean that all people with type 1 diabetes would have access to funded continuous glucose monitors, as well as access to new brands of insulin pumps (and automated insulin delivery system algorithms) and associated consumables. Funded access to these products for people with type 2 diabetes is not included in the consultation. Submissions are due by 4 pm, Friday 26th April, 2024.
Read more about the proposal
It is proposed that:
From 1st July, 2024:
- Abbott (Freestyle Libre 2) and Dexcom (Dexcom G6, G7 and One Plus) branded continuous glucose monitors would be funded with Special Authority approval
- Tandem t:slim X2 insulin pump (and consumables) with Basal-IQ or Control-IQ (an automated insulin delivery system algorithm) would be funded with Special Authority approval
- The Special Authority criteria for insulin pumps and consumables would be simplified
- The maximum number of funded packs of insulin pump consumables would be increased from 13 to 19 packs per year. This increase is intended to help people who require more frequent changes to their infusion set or whose insulin needs are higher.
From 1st October, 2024:
- YpsoPump brand of insulin pump (and consumables) with CamAPS FX (an automated insulin delivery system algorithm), would be funded with Special Authority approval
- An Abbot branded insulin pump compatible continuous glucose monitor would be funded with Special Authority approval (further details are expected to be released closer to October)
- MiniMed 770G insulin pump would be delisted from the Pharmaceutical Schedule
The proposal would result in a brand change for people currently accessing MiniMed 770G insulin pump. MiniMed 770G pump would not be funded for new patients from 1st October, 2024, and from 1st July, 2025, associated consumables would no longer be funded.
Pharmac advises that funding multiple products provides people with type 1 diabetes the ability to choose which product (continuous glucose monitor, insulin pump, automated delivery system) is most appropriate for them. No single product or system is suitable for all people with type 1 diabetes; some people may be more suited to certain products or systems than to others.
Under this proposal, any relevant practitioner would be able to apply for initial Special Authority approval (and renewals) for continuous glucose monitors. While initial applications for funded insulin pumps and consumables would also be able to be made by any relevant practitioner, the patient would first require assessment by a diabetes multidisciplinary team (before an application can be made).
Read more about the proposal here. A summary of the proposal is also available, here.
For further information on the role of insulin in the management of patients with type 1 diabetes, see: https://bpac.org.nz/2019/diabetes-insulin.aspx
Medicine supply news: fluticasone, omeprazole
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.
Flixonase supply issue
Omeprazole stock update
There is an ongoing supply issue affecting stock of omeprazole 20 mg and 40 mg capsules. Supply of 10 mg omeprazole capsules is currently unaffected. As reported in Bulletin 93, stat dispensing has been temporarily removed for all three omeprazole capsule presentations and switched to monthly to maintain continuity of supply until new stock arrives.
Resupply of the 20 and 40 mg capsules has been delayed and stock is now expected to arrive mid to late April. Prescribers can advise patients to take two 10 mg capsules to achieve a 20 mg dose, or an alternative funded proton pump inhibitor may need to be prescribed, e.g. pantoprazole.
Annual diabetes foot examination: overcoming barriers to attendance
Diabetes-related foot complications are reported to affect more than one-third of people with diabetes in New Zealand. However, attendance rates at annual diabetes reviews to prevent and detect these complications are low in some areas. A recently published small New Zealand based study looked at patient-reported barriers to attending an annual diabetes review in primary care, including a foot examination, and offers some practical solutions for overcoming certain modifiable barriers.
Read more
For further information on the annual diabetes review, see: https://bpac.org.nz/2021/diabetes-review.aspx
NZF updates for April
Significant changes to the NZF in the April, 2024, release include:
- Withdrawal advice updated in the gabapentin and pregabalin monographs
- Breast feeding and patient advice updated in the HIV infection monographs
- Age bands updated in the dosing table for the emergency treatment of anaphylaxis in the therapeutic notes for intramuscular adrenaline (epinephrine)
- S7 (Narcotics) use in sport category added for tramadol
- Information updated for the following categories in the Drugs and sport therapeutic notes: S3 Beta-2 agonists, S5 Diuretics and masking agents, S6 Stimulants, S8 Cannabinoids, S9 Glucocorticoids and P1 Beta blockers
You can read about all the changes in the April release here. Also read about any significant changes to the NZF for Children (NZFC), here, including a new dosing regimen added to the amitriptyline monograph for neuropathic pain in children aged 2 - 12 years.
Paper of the Week: Using medicines to combat obesity
Obesity is an increasing global health concern. In New Zealand, approximately one in three adults and one in seven children are obese (BMI ≥ 30 kg/m2), with significantly higher rates among Māori and Pacific peoples. It is well established that excess body weight increases the risk of numerous conditions (e.g. type 2 diabetes, hypertension and other cardiovascular disease) and reduces overall life expectancy. First-line strategies for maintaining a healthy weight include appropriate nutrition and regular exercise. However, primary healthcare professionals will be well aware that such lifestyle changes can be challenging for many patients to make, and even more difficult for them to maintain.
Given the expanding knowledge base around physiologic processes underpinning weight regulation, many international societies are considering the place of medicines in the long-term management of obesity. A recent review in the BMJ examines evidence regarding the effectiveness and safety of “anti-obesity” medicines, and provides guidance around their prescribing.
Some of these pharmacological options are already approved for weight loss in New Zealand (e.g. naltrexone + bupropion, liraglutide, phentermine, orlistat) but none are funded for this indication. Unprecedented global demand for GLP-1 receptor agonists for weight loss has contributed to stock shortages and concern about reserving these medicines for people who require them for type 2 diabetes management. Liraglutide has been temporarily funded in New Zealand to offset stock shortages of dulaglutide, but its popularity as a weight loss adjunct may potentially place further pressure on the already constrained supply. Semaglutide (Ozempic) is arguably the most talked about GLP-1 receptor agonist that is being used internationally (off-label) for weight loss: it is not yet available in New Zealand although it is now approved here for use in type 2 diabetes. It is important that the right people are getting the right medicines for their individual circumstances; weight loss medicines may not be the “simple solution”.
How often do patients ask you about the use of weight loss medicines? At what point would you consider recommending them for obesity management? Do you feel confident in prescribing them?
Read more
- There is mounting evidence that medicines can be effective for supporting weight loss. However, these options should be considered as an adjunct to lifestyle changes; they do not replace the need for maintaining healthy diet and engaging in regular exercise.
- In New Zealand, Ministry of Health guidelines recommend that prescribing should usually only be considered if lifestyle changes have not produced clinically significant benefits after six months in patients with a BMI ≥ 30 kg/m2
- There is some evidence that these medicines can also be considered in patients with a BMI ≥ 27 kg/m2 and a weight-related co-morbidity (e.g. impaired glucose tolerance, hypertension, dyslipidaemia, obstructive sleep apnoea), however, this would be considered off-label use
- Medicines used for weight loss vary in their efficacy and associated adverse effects, depending on the dose and duration of use. They may also have other positive health-related effects, e.g. liraglutide can contribute to glycaemic control. These factors should be used to inform discussions around the best options for patients, if required. However, there is limited head-to-head data available on comparative efficacy; most trials are placebo-controlled.
- Pharmacological options currently approved and indicated for weight loss in New Zealand include:
- Phentermine (oral). Appetite suppressant. Limited trials assessing efficacy of phentermine as a monotherapy. Only approved for short-term use, e.g. less than three months (however, off-label prescribing for longer durations is common in other countries such as the United States). Phentermine is a sympathomimetic amine that may have addictive potential; clinicians should assess for signs of dependence.
- Orlistat (oral; no prescription required). Blocks dietary fat absorption. Average placebo-subtracted weight loss at 12 – 24 months = 3.2%. Adverse effects can be significant and inconvenient in daily life, e.g. faecal urgency, flatulence, cramps, bloating and impaired absorption of fat-soluble vitamins. A low-fat diet is recommended while taking this medicine.
- Naltrexone + bupropion (oral). Reduces appetite and increases energy expenditure; controls food cravings and modifies eating behaviours. Average placebo-subtracted weight loss at 12 – 24 months = 4.1%. Generally well-tolerated; nausea, headache and dizziness are the most common adverse effects. Transient increase in blood pressure may occur in some patients (initial monitoring recommended).
- Liraglutide (subcutaneous injection, once daily). Reduces appetite and increases satiety. Average placebo-subtracted weight loss at 12 – 24 months = 4.7%. Adherence to liraglutide in real world studies is generally higher than for other weight loss medicines. Generally well-tolerated; common adverse effects include gastrointestinal disturbances, e.g. nausea, constipation or diarrhoea. N.B. Victoza-branded liraglutide is funded (with Special Authority approval) and approved for the treatment of type 2 diabetes, and due to supply issues is only recommended for current patients (i.e. not to be started for new patients). The Saxenda-branded liraglutide is approved for weight loss, and is not funded. It is likely affected by the same supply shortages. Dulaglutide is not approved for weight loss in New Zealand.
- There is ongoing investigation into how the selection of weight loss medicines can be personalised. The review indicates that naltrexone-bupropion might be preferred for patients with depression, binge eating or food cravings, whereas phentermine may be more effective in patients who eat excessively due to hunger (as opposed to emotional stress or boredom). GLP-1 receptor agonists are most useful in patients with type 2 diabetes as they also provide glycaemic control.
- Most adverse effects reported in trials using weight loss medicines are mild-to-moderate. However, long-term safety data outside of clinical trials is lacking (particularly for newer options), and further studies are required. Gastrointestinal effects are common with most weight loss medicines, which may influence the decision to use them in certain patients, e.g. those with a significant history of gastrointestinal disease. Contraindications are medicine specific (see specific NZF monographs for further information); for example, phentermine is contraindicated in patients with cardiac abnormalities and hypertension, orlistat is contraindicated in patients with chronic malabsorption syndrome (e.g. coeliac disease, inflammatory bowel disease) or cholestasis and liraglutide is contraindicated in people with inflammatory bowel disease and in those aged over 75 years.
- None of the medicines approved for weight loss in New Zealand are funded. Estimated costs vary, ranging between $100 (phentermine) and $500 (liraglutide) per month, which will likely impose a barrier to equitable access. However, the review notes that prices are expected to decrease over time as additional classes and generics enter the market. For example, liraglutide is expected to come off patent within five years.
- There are other medicines for weight loss not available in New Zealand that have shown more substantial efficacy in clinical trials, including the GLP-1 receptor agonist semaglutide, and the novel combination GLP-1 receptor agonist/glucose-dependent insulinotropic polypeptide receptor agonist tirzepatide. N.B. Semaglutide (Ozempic) is approved in New Zealand (but not available) for the treatment of adults with insufficiently controlled type 2 diabetes as an adjunct to diet and exercise (but not funded); use for weight loss would be considered “off-label”. Wegovy-branded semaglutide is indicated (FDA approved) for weight loss, but is currently neither approved nor available in New Zealand.
- The average placebo-subtracted weight loss at 12 – 24 months for both semaglutide and tirzepatide is > 11%. Approximately four out of five patients achieve > 5% weight loss over this timeframe.
- One of the few available direct comparison studies in overweight or obese patients without diabetes (N = 338) found that once weekly subcutaneous semaglutide resulted in significantly greater weight loss (15.8%) versus once daily subcutaneous liraglutide (6.4%). There were also significantly fewer discontinuations due to adverse effects in the semaglutide group.
- Both semaglutide and tirzepatide require a single weekly injection (as opposed to the daily injections required with liraglutide)
- Medicines used in the management of other conditions may also cause weight loss in some patients. For example, metformin and SGLT-2 inhibitors (e.g. empagliflozin) have been associated with an average placebo-subtracted weight loss of > 2% at 12 – 24 months when used in the management of patients with type 2 diabetes.
- If a decision is made to prescribe a medicine for weight loss, initiate at a low starting dose and titrate upwards based on the weight response and impact of adverse effects. Patients should have monthly checks for at least three months.
- Weight is often regained after weight loss medicines are discontinued, meaning that long-term continuous use or multiple courses over time are usually required. However, treatment should be discontinued and an alternative considered if patients do not achieve at least 5% weight loss after three to six months.
Henderson Lewis K, Sloan CE, Bessesen DH, et al. Effectiveness and safety of drugs for obesity. BMJ 2024;384:e072686. doi:10.1136/bmj-2022-072686
For further information on weight loss, see:
This Bulletin is supported by the South Link Education Trust
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