Published: 7 July, 2023
Contents
Celebrate Matariki
Ngā mihi o Matariki, te tau hou Māori
Next Friday, 14th July marks the celebration of Te Iwa o Matariki – Māori New Year. South Link Health has produced a short video to commemorate this special time. We welcome you to share this video with your kaimahi (team) and whānau (family and loved ones).
Tukuna te wairua o Matariki ki rere ki te ao, kia whakakaha i ngā ngākau katoa Let the spirit of Matariki fly into the world, strengthening all hearts.
What’s trending at bpacnz this week?
We publish many resources each year and keep a close eye on which ones are most well used. This is also a good way for us to determine which of our older resources may be due for an update. What are your “go-to” bpacnz resources? Let us know if you would like us to revise a certain topic next: [email protected]
Here are the ten most viewed resources by website users in
New Zealand over the past seven days:
Updates to clinical audits
We have made some small changes to the format of bpacnz clinical audits. The Royal New Zealand College of General Practitioners (RNZCGP) has updated their Te Whanake CPD programme. Clinical audits are no longer compulsory nor require approval before use, however, it is suggested that the proposed audit topic is discussed within your practice or peer group before commencing, to ensure that the audit is relevant. Clinical audits can be an influential tool in improving clinical practice and patient outcomes and we will continue to produce evidence-based audit plans that are relevant to New Zealand primary care.
Here are four revised audits to get you started:
Colorectal cancer surveillance recommendations updated
Te Whatu Ora, Health New Zealand, has published an Update on Surveillance Recommendations for Individuals with a Family/Whānau History of Colorectal Cancer. This is an update to the 2012 New Zealand Guidelines Group recommendations for the surveillance of people with a family/whānau history of colorectal cancer and incorporates international recommendations and recent changes to the National Bowel Screening Programme (NBSP), e.g. Māori and Pacific people aged 50 years are now eligible for bowel screening under the NBSP (see: Bulletin 75).
Read more
Changes from the 2012 recommendations include:
- All patients at increased risk of colorectal cancer should be encouraged to make healthy lifestyle choices
- Category 1 – people with slightly above-average risk (i.e. one first-degree relative diagnosed with colorectal cancer at age ≥ 55 years) are “strongly advised” to take part in the National Bowel Screening Programme (NBSP) when they become eligible. Previously, there were no specific surveillance recommendations for this group.
- Category 2 – people with moderately increased risk (i.e. one first-degree relative diagnosed with colorectal cancer at age < 55 years or two first-degree relatives within same family diagnosed at any age) aged ≥ 50 years should receive a colonoscopy every five years (or 10 years earlier than the age of the first colorectal cancer diagnosis in the family). Māori and Pacific people aged ≥ 50 years at moderately increased risk of colorectal cancer should receive colonoscopy surveillance instead of joining the NBSP (even though they are now eligible to join). At age 60 years, people with a moderately increased risk of colorectal cancer should join the NBSP, unless further colonoscopy surveillance is indicated by their previous results, e.g. polyps were detected.
Surveillance recommendations for people with high risk of colorectal cancer (Category 3) remain the same.
Clinicians are advised to apply the principles of this guideline to situations that are not directly covered in the update. This update does not apply to people with a personal history of colorectal cancer or inflammatory bowel disease.
Read the full guideline update here
For further information on colonoscopy for active surveillance, see: https://bpac.org.nz/2020/bowel-cancer.aspx
Education modules for general practitioners on eating disorders
Whāraurau, the national centre for Infant, Child and Adolescent Mental Health (ICAMH) workforce development, has developed a free e-learning course aimed at general practitioners for supporting patients with eating disorders and disordered eating (abnormal eating patterns that do not meet criteria for an eating disorder), including referral pathways.
The course – "Eating Disorders: core skills for GPs" contains five modules which cover:
- Tools to help facilitate early identification of disordered eating and eating disorders
- Strategies on how to screen and assess a patient who may be presenting with disordered eating or an eating disorder
- The role of general practitioners in the integrated system of care for eating disorders
- Treatment of disordered eating and eating disorders
- Strategies for ongoing recovery support for the patient
The course, which includes case studies, videos from medical professionals, Māori health providers and people with a lived experience of an eating disorder, takes approximately four hours to complete and is self-directed. Each module can be completed separately and does not need to be completed all at once, i.e. you can pause your progress and complete each module over time. The course has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and is approved for up to 4 CME credits for Continuing Professional Development purposes.
Click here to register. Once you have registered, you will be sent an email with a link to access the course.
New version of the Immunisation Handbook now out
The latest version of the Immunisation Handbook 2020 (version 23) has now been released. Key updates include changes to MMR vaccination (can be given from age four months for pre-exposure prophylaxis and from age six months for post-exposure, vaccination can be considered for some people born overseas prior to 1969), changes to meningococcal vaccine eligibility and spacing, HPV9 (Gardasil 9) now registered for use in males aged up to 45 years, although funding remains the same (previously Gardasil 9 was only registered for use in males aged up to 26 years inclusive).
Consultation on safe and quality prescribing
A draft statement on Principles for quality and safe prescribing practice is now out for consultation. This work was led by the Medical Council and Pharmacy Council of New Zealand and developed in collaboration with the five other regulators of health professionals who are authorised to prescribe.
The draft statement details 12 principles that are based on current regulatory frameworks that aim to improve the safety and quality of prescribing by standardising prescribing expectations and maintaining consistent regulation of prescribers. The principles are split into two groups: the “person-centred prescribing process” and “professional practice to support quality and safe prescribing”. Click here for further information, including what is covered in each principle.
The consultation closes on 31 August, 2023. You can submit your response here.
Medicine supply news in brief
The following issues relating to medicine supply, of particular interest to primary care, have recently been announced. Supply information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Chlorpromazine 10 mg tablets to be discontinued
Chlorpromazine hydrochloride 10 mg tablets are being discontinued; Largactil – indicated for schizophrenia, mania and other psychoses, intractable hiccup and nausea and vomiting in palliative care. Current stock is expected to be exhausted in September, 2023, and 10 mg tablets will be delisted from the Pharmaceutical Schedule in 2024. The 25 mg and 100 mg tablets will remain available as well as the injection and oral liquid formulations.
No new patients to start 10 mg long-acting nifedipine
Nifedipine 10 mg long-acting tablets (Tensipine MR10) are being delisted from the Pharmaceutical Schedule due to ongoing issues around supply. As of 1 July, 2023, an endorsement has been added to this presentation which restricts use to existing patients only; therefore, no new patients can be started on these tablets. The 20 mg, 30 mg and 60 mg long-acting nifedipine tablets are unaffected.
Patients currently taking Tensipine MR10 need to be switched to an alternative medicine before January, 2024. 20 mg long-acting nifedipine tablets cannot be halved to achieve the dose as this is equivalent to giving the patient 10 mg of immediate-acting nifedipine, causing acute hypotension.
Ivermectin Special Authority criteria amended
The Special Authority criteria for ivermectin were recently amended (June, 2023). Any relevant practitioner can now complete the Special Authority form for ivermectin in patients with scabies and close contacts who meet Special Authority criteria. Discussion with a dermatologist, infectious diseases specialist or clinical microbiologist is no longer required.
For information on the management of scabies, including the role of ivermectin, see: https://bpac.org.nz/2022/scabies.aspx
Permethrin supply update
A potential supply issue affecting stock of permethrin due to high demand was reported in Bulletin 72 . A total of 40,000 units have now arrived and are being distributed throughout New Zealand; demand for this product is still being monitored. Pharmac is advising pharmacies to order stock at normal levels and to avoid stockpiling.
For the latest updates, click here
Prescription co-payment removed
Since 1 July, 2023, the standard $5 prescription charge has been removed. A co-payment will still be required for medicines prescribed by specialists and other prescribers, e.g. dentists, for non-publicly funded services and patients will still need to cover some costs, e.g. blister packaging, and for partly funded medicines.
Removal of the co-payment may mean that prescribers and pharmacists no longer have to have the difficult conversations with patients over which medicines they can afford to get. Remind patients that it is now usually free for them to pick up their medicines.
Unmet health care need in people who have experienced racial discrimination
Manatū Hauora, Ministry of Health, has published a report on racial discrimination using data from the New Zealand Health Survey in 2011/12, 2016/17 and 2020/21.
People’s experiences of racial discrimination over their lifetime and within 12 months of the 2020/21 survey were reported. In general, the number of adults experiencing racial discrimination has been increasing over time. Verbal abuse was the most common type. When stratified by ethnicity, Māori had the highest rate of self-reported racial discrimination within the previous 12 months (13.8%), followed by Asian (12.3%) and Pacific peoples (9.5%).
The report also highlighted that racial discrimination impacts health outcomes, with affected people reporting lower rates of good/very good/excellent self-rated health and a more significant unmet need for primary health care.
Read more
Higher rates of unmet need for primary health care were reported in people who experienced racial discrimination in the past 12 months (41.9%), compared to those who did not (26.7%). This includes being unable to get an appointment at their usual medical centre within 24 hours and unmet need for general practice services or after-hours services due to cost or transport. When adjusted by age and sex, people who experienced racial discrimination in the past 12 months were 1.5 times as likely to have an unmet need for primary health care as those who did not experience racial discrimination. Māori who have experienced racial discrimination generally have the highest unmet need for primary health care, compared with other ethnic groups.
Although these data show an association only, i.e. it does not show that racial discrimination is the cause of unmet need for primary health care, health care providers should consider if there are any ways they could improve barriers to access and inclusivity for patients most at risk of poorer health outcomes. Resources are available to help avoid racism in health care, e.g. learning and education modules on understanding bias in health care, anti-racism video and podcast series, Ao Mai te Rā: the Anti-Racism Kaupapa Literature Review Summary Paper – Lessons for the Aotearoa New Zealand Health System.
Read the full report here
NZF updates for July
Significant changes to the NZF in the July, 2023, release:
- Pregnancy category modified to “Human Data Suggest Low Risk” in the amoxicillin and amoxicillin + clavulanic acid monographs to more accurately reflect the low risk of developmental toxicity (previously “Human Data Suggest Risk in 1st and 3rd Trimesters”). The pregnancy summary has also changed.
- Pregnancy and breastfeeding advice has been updated in the nefopam hydrochloride (Acupan) monograph
- New monograph added for risankizumab (indicated for moderate to severe plaque psoriasis; active psoriatic arthritis and moderate to severe Crohn’s disease where patients have not responded, are intolerant to or when response has been lost to first-line treatments)
- New caution added to the nitrofurantoin monograph: avoid concomitant urinary alkalinisers (e.g. Ural)
- New caution added to the ustekinumab monograph: avoid close contact with people recently immunised with live vaccines. Pregnancy advice and adverse effects have also been updated.
- Adverse effects have been updated in the individual SGLT-2 inhibitor monographs to include the potential risk of polycythaemia – see Bulletin 76 for further information on this adverse effect
- Information on valproate use in females and males of reproductive potential has been updated in the following monographs: sodium valproate, valproate (for epilepsy), valproate (for bipolar disorders), prophylaxis of migraine – see Bulletin 76 for further information on sodium valproate use in males
- The controlled drugs and drug dependence monograph has been updated to align with the Misuse of Drugs Amendment Regulations 2022
You can read about all the changes in the July release here. Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Managing home-based alcohol and other drug withdrawal in low-risk patients in primary care
Drinking is heavily ingrained in New Zealand culture; each year approximately 80% of adults report having consumed alcohol in the last 12 months. In some cases, people may have thought they were doing the right thing, as previous studies have indicated that mild-to-moderate alcohol consumption may have cardioprotective benefits. However, the New Zealand Heart Foundation has released new guidance stating that no amount of alcohol is safe and people who do not already drink alcohol should avoid starting. People who already drink should reduce their alcohol intake to lower their risk of alcohol-related harm.
Hazardous drinking is also prevalent in New Zealand. Among adults who reported having consumed alcohol within the past 12 months in the 2020/21 Health survey, 24% met the criteria for hazardous drinking, putting them at higher risk of alcohol-related harm. Making behavioural changes related to alcohol use is never easy. For dependent/heavy users of alcohol and other drugs, reducing or stopping can be complicated and hazardous. These patients will usually require inpatient management of withdrawal. Home-based withdrawal under the guidance of a general practitioner may be appropriate for patients at lower risk of serious adverse events. An article published in the Australian Journal of General Practice provides an overview and framework for managing home-based alcohol or other drug withdrawal in low-risk patients.
Information on assessing and managing alcohol misuse is also available here: https://bpac.org.nz/2018/alcohol.aspx
Read more
A four-step framework (Who, Prepare, Withdrawal and Follow-up) can aid the planning and management of successful alcohol withdrawal in the community. Considerations when supporting home-based alcohol or other drug withdrawal include:
Who
- Only low-risk patients are appropriate for home-based withdrawal – they need to be motivated to make a change, not using multiple substances, have stable housing and support already in place and sufficient physical and mental health, i.e. no significant co-morbidities, normal renal function, minimal derangement of liver function, not suicidal
- The severity of withdrawal symptoms should be predicted to ensure the patient is appropriate for home-based withdrawal. This can be estimated based on the patient's current substance use and previous withdrawal attempts. Questionnaires and screening tools may be useful to determine this, e.g. the AUDIT-C tool or the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
- More severe withdrawal is associated with higher volume and long-term substance use, using multiple substances, severe illness or co-morbid conditions
- Patients who have experienced seizures during previous withdrawal attempts are at risk of more severe symptoms, i.e. kindling effect, and home-based withdrawal is not appropriate
- Consider referral for specialist inpatient withdrawal services for patients:
- Aged under 18 years
- Who are pregnant or breastfeeding
- With emotional trauma
- Who are older (due to increased risk of co-morbidities)
- With specific cultural requirements
Prepare
- Explain common withdrawal symptoms, their expected timeline/duration and when to seek medical assistance. Ensure that the patients support person is also given this information. Providing this information in written form can be helpful.
- Daily reviews (either in person or via telehealth) are recommended for the first three days, and then depending on the patient’s symptoms, this may be extended to every second day
- Assess withdrawal symptoms at every review. Specific substances may have withdrawal scales, e.g. the Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar).
- In some situations, practice nurses may be able to carry out daily reviews
- Provide contact details for appropriate services that will aid the patient in their withdrawal attempt, e.g. Alcohol and Drug Helpline (0800 787 797), Need to Talk? (1737)
- Inform other general practitioners and nursing staff at your practice that the patient is attempting a planned withdrawal. Establish systems and operating procedures in case the patient presents to the clinic and their regular general practitioner is not available.
Withdrawal
- The beginning of withdrawal should coincide with the start of the general practitioner’s work week to allow for daily patient review
- Consider prescribing medicines to control withdrawal symptoms when they develop, e.g. an antiemetic, anti-diarrhoeal, benzodiazepine
- Refer patients to the emergency department for monitoring if they experience severe refractory symptoms that do not respond to medicines or life-threatening symptoms, e.g. delirium or seizures
- Home-based withdrawal should be discontinued in patients who are assessed to no longer be low-risk for severe withdrawal symptoms, e.g. worsening mental health or changes in housing situation. These patients should be referred to an inpatient setting.
- Encourage patients to drink plenty of fluid and have regular smaller meals
- Prescribing thiamine or a multivitamin may be beneficial for patients with a poor diet
Follow-up
- Patients with substance use disorder are at risk of relapse so regular follow-up should continue for at least 12 months
- Discuss the risk of overdose if relapse occurs; tolerance will decrease following a period of abstinence
- Adjunct medicines to prevent relapse may be appropriate for some patients, e.g. disulfiram
- Funded naltrexone may be an option for patients enrolled in a community addiction programme who meet Special Authority criteria, however, initial applications must come from a clinician affiliated with alcohol and addiction services
- Some patients may benefit from support groups (e.g. 12-step programmes), motivational interviewing or cognitive behavioural therapy
If home-based withdrawal is not appropriate, patients can be referred to a community addiction service. Different levels of support can be provided according to the patient’s needs, including 24-hour medical support for patients with complex psychiatric conditions or history of serious withdrawal symptoms. Local referral guidelines and criteria vary; some community services can be accessed by self-referral.
A directory of local services available in New Zealand is available from: www.alcoholdrughelp.org.nz/directory/
Macaulay S, Grinzi P, Slota-Kan S. General-practitioner-led alcohol and other drugs withdrawal: supporting patient choice, safety and success. Aust J Gen Pract 2023;52:359–65. doi:10.31128/AJGP-09-22-6575
To download the Substance withdrawal management: Guidelines for medical and nursing practitioners, click here
This Bulletin is supported by the South Link Education Trust
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