Published: 12 May, 2023
Contents
Promoting bowel screening in primary care
The organisers of the National Bowel Screening Programme are encouraging primary care health professionals to promote bowel screening this month, with a particular focus on increasing participation of eligible Māori and Pacific peoples. Screening rates remain under 60% in many regions, and rates are much lower for Māori and Pacific peoples. The eligibility age is in the process of being lowered across all regions for Māori and Pacific peoples to age 50 years. Colorectal cancer is highly amenable to screening, which picks up both cancer and pre-cancerous polyps. Removal of polyps and earlier diagnosis, as a result of the bowel screening programme, is already making a difference in preventing death and reducing the need for chemotherapy.
General practices are encouraged to opportunistically check if eligible patients have received a bowel screening kit and to identify and address any barriers to completing the test.
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Bowel cancer is the second highest cause of cancer mortality in New Zealand, with approximately 1,200 deaths per year (second only to lung cancer) – comparable to prostate and breast cancer combined. Many people with bowel cancer are asymptomatic, and more than one-quarter of people have metastatic disease at the time of diagnosis. The introduction of bowel screening has led to an increase in the number of people being diagnosed with stage I bowel cancer. Diagnosis at an early stage offers a significant survival benefit; the five-year survival rate reduces from approximately 91% for stage I bowel cancer to approximately 14% for stage IV.
People aged 60 – 74 years are currently eligible for funded bowel cancer screening. The age of eligibility is being lowered for Māori and Pacific peoples to age 50 years to address the increasing incidence of bowel cancer in this population. This change has already been implemented in Waikato and Tairāwhiti and is expected to be rolled out to other regions in the second half of 2023.
Eligible people are sent a test kit in the mail which includes a faecal immunohistochemical test (FIT), instructions, a consent form and a return envelope. Bowel screening with FIT is recommended every two years as the test may not be positive if the cancer or polyp was not bleeding on the test day.
For further information on the National Bowel Screening Programme, see:
https://www.health.govt.nz/our-work/preventative-health-wellness/screening/national-bowel-screening-programme and https://www.timetoscreen.nz/bowel-screening/
ADHD medicines to be funded for up to three months’ supply
Pharmac has announced that from 1 June, 2023, methylphenidate and dexamfetamine will be funded for up to three-months’ supply when an electronic prescription is used. The quantity prescribed using a paper prescription will remain as up to one month. These are stimulant medicines used for the treatment of ADHD in children (methylphenidate and dexamfetamine) and adults (methylphenidate), as well as some other indications including narcolepsy. This announcement aligns with the recent changes in legislation to the electronic prescribing and dispensing of Class B controlled drugs.
Key points
- Patients will require less frequent prescription renewals (three monthly, instead of monthly) if they are prescribed electronically, therefore potentially reducing consultation or prescription costs for them and reducing the number of visits, if appropriate
- If applicable, only one prescription co-payment will be required for three months’ supply (instead of three co-payments)
- One month’s supply remains the maximum that can be dispensed at once. Methylphenidate and dexamfetamine are regarded as “safety medicines” and so prescribers can specify more frequent dispensing if appropriate/required.
N.B. There are no changes to the Special Authority regulations for these medicines (renewal by a specialist prescriber every two years), but Pharmac acknowledges the feedback received on improving access and "intend[s] to work with our sector partners on these suggestions".
Click here for further information.
Eligibility widened for additional COVID-19 boosters for pregnant women
From 1 May, 2023, eligibility for additional COVID-19 boosters has widened to include people aged 16 years and older who are pregnant (previously pregnant women were only eligible if they were aged 30 years or older). An additional COVID-19 booster dose is recommended for all pregnant women, particularly those who are at risk of severe illness from COVID-19.
Check in with your patients who meet eligibility criteria to ensure that they are aware an additional booster dose is available. The influenza vaccine can also be given concomitantly.
Read more about additional COVID-19 boosters
As reported in Bulletin 69 and 72, people aged 30 years and older and those at higher risk of severe illness from COVID-19 are eligible for an additional booster dose (irrespective of the number of prior boosters received). Full eligibility criteria can be found here.
People can receive an additional booster if they have completed their primary course and it has been at least six months since their previous dose or positive COVID-19 test. Clinicians or vaccinators can, however, use their discretion with regard to the spacing of booster doses following informed consent from the recipient, but there should be a minimum of five months between the primary course and first booster, four months between booster doses and a minimum of three months after infection with COVID-19.
Updated resources will be available from the Immunisation Advisory Centre soon.
News in brief: cilazapril delisting date moved to end of 2023
Pharmac has announced that the proposed delisting date for cilazapril has been moved from mid-2023 to the end of the year. 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: "Prescribing ACE inhibitors: time to reconsider old habits."
Monitoring Communication: risk of pancreatitis with interleukin inhibitors
Medsafe has issued a Monitoring Communication to seek more information from clinicians on the risk of pancreatitis associated with the use of interleukin inhibitors.
Interleukin inhibitors are monoclonal antibodies that act on interleukin-mediated cell signalling pathways to reduce inflammation. These medicines are indicated for various inflammatory conditions, e.g. eosinophilic asthma, rheumatoid arthritis, Crohn’s disease, ulcerative colitis. Examples include tocilizumab, ustekinumab and secukinumab (see the Medsafe communication for a full list).
During the March, 2023 meeting of the Medicines Adverse Reaction Committee (MARC) it was agreed that there is evidence to support an association between tocilizumab* (interleukin 6 inhibitor) and pancreatitis. However, there is not enough evidence to extend this association to all available interleukin inhibitor medicines. This safety communication has been made to identify any relevant information to support an association.
*Indicated for the treatment of rheumatoid arthritis and giant cell arteritis
Healthcare professionals should report any suspected cases of pancreatitis associated with the use of interleukin inhibitors to CARM.
Registrations still open for Rotorua GP CME conference 2023
The Rotorua GP CME conference 2023 is being held at the Rotorua Energy Convention Centre, 8 – 11 June, 2023. While registrations are still open, accommodation options are filling up fast, so don’t delay.
A wide range of sessions and workshops will be available at the conference to cater to the diverse interests of primary care health professionals; for the full agenda click here.
Some of the newly announced workshops include:
- "What to do when the first antidepressant you prescribe doesn't work"" with Dr Rob Shieff. This workshop is designed to give primary care professionals step-by-step information to increase the likelihood their next approach for treating depression will be effective.
- "Point of Care and Rapid Diagnostics" with Louise Wilson and Allister Girvan
- "Optimising Management of Heart Failure in the Community" with Dr Raewyn Fisher, Johanna Lim and Natalie Presnall
- "Digital Tools and Cybersecurity" with Sanjeewa Samaraweera
The South Link Education Trust is a Diamond Sponsor for the GPCME Conferences and is excited to showcase the range of activities from its associated organisations, including South Link Health Services, BPAC Clinical Solutions, bpacnz Publications and the New Zealand Medicines Formulary (NZF and NZFc). We warmly welcome you to come chat to our team at the conference about our suite of innovative Smart Care products and other services.
NZF updates for May
Significant changes to the May, 2023 release include:
You can read about all the changes in the May release here.
Also read about any significant changes to the NZF for Children (NZFC), here
In case you missed it: latest resources from bpacnz
Gynaecological cancers:
all topics are now available in this series, including cervical, ovarian, endometrial, vaginal and vulval cancers. A follow-up article and CME resources will be published soon to complete this series.
Diverticulitis :
a recent global re-think on the management of this condition has resulted in latest guidelines recommending that antibiotics are not routinely used in every case. Advice on restricting the diet while managing acute symptoms has also changed.
Osteoarthritis:
exercise is at least as effective as NSAIDs for improving pain and function in people with osteoarthritis. Many people worry that doing exercise will cause further damage to their joints, but they can be reassured that this is not the case. Listen to this interesting and informative narrated slideshow presentation with physiotherapist Ben Darlow and orthopaedic surgeon John Scanelli.
Paper of the Week: "Can you show me how you use your inhaler?"
Inhalers are fundamental for the treatment of asthma, COPD and other chronic respiratory conditions, but patients require sufficient physical capabilities, co-ordination and dexterity to operate them. Incorrect inhaler technique limits medicine delivery, increases the risk of respiratory symptom exacerbation and reduces the patient’s quality of life. New Zealand Asthma Guidelines and the 2023 Global strategy for prevention, diagnosis and management of COPD report both emphasise the importance of regular assessment and correction of inhaler technique for patients with chronic respiratory conditions to improve outcomes. However, evidence suggests the number of primary care clinicians who frequently assess their patient’s inhaler technique is low; 39% do this “often” and only 17% do it “almost always”.
While patient inhaler technique shows short-term improvement following a single education or “training” session, regression is likely over the next two to three months. A review article to be published in The Journal of Allergy and Clinical Immunology: In Practice examines the evidence for this regression and explores ways to resolve any issues and support patients to use correct inhaler technique. This information is likely to be applicable to a range of healthcare professionals, including general practitioners, nurse practitioners, practice nurses and pharmacists.
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- After deciding which medicine (or combination) is required, consider the patient’s clinical condition (e.g. inhalation capacity and co-ordination), and co-morbidities, (e.g. visual impairment, arthritis), when prescribing a specific inhaler if multiple devices are available
- Common “critical” inhaler errors can be divided into three groups:
- Actuation errors – mistiming the inhalation with the actuation in MDIs,* not removing the cap or cover
- Inhalation errors – inadequate respiratory capacity, no prior exhale or exhaling too early after delivering dose, incorrect head position
- Priming errors – mistiming the second dose, improper loading of dose into the device in dry powder inhalers (DPIs)
- One-off education (often at the time of prescribing or altering medicines regimens) is unlikely to lead to sustained use of the correct inhaler technique
- Correct inhaler technique can be maintained by regular assessment and education, however, regression will still occur if regular intervention is interrupted
- Reminder labels, e.g. attached to the device, should not replace regular assessment and education
- Regression of a patient’s inhaler technique following education occurs regardless of who provided the training or where it occurred
- Ideally, inhaler technique should be assessed and further education provided every two-to-three months. Healthcare professionals are presented with opportunities to check inhaler technique every time a new prescription is written or dispensed.
- A checklist to assess the patient's current inhaler technique may be useful (checklists are available for multiple devices)
- One-on-one education delivered in-person with a healthcare professional including general practitioners, respiratory specialists, nurses and pharmacists, is superior to relying on written instructions
- Assessment and education of inhaler technique is possible during video consultations and may be appropriate if accessibility is limited, e.g. patients who live in remote areas or have limited mobility
- Regular education should involve a combination of verbal instruction, demonstration and written material
- Education should be tailored to the health literacy level of the individual patient
- Patient motivation is a significant determinant of medicines adherence; regular patient education should reinforce the links between correct inhaler technique, reduced symptom exacerbations and improved quality of life
*Using a spacer with a MDI is beneficial for most patients, but particularly those who struggle to time their inhalation with the actuation of the dose
Bosnic-Anticevich S, Bender B, Shuler M, et al. Recognizing and tackling inhaler technique decay in asthma and COPD clinical practice. The Journal of Allergy and Clinical Immunology: In Practice 2023;:S2213219823004725. doi:10.1016/j.jaip.2023.04.031
For further information on selecting medicines and inhalers for asthma, see; https://bpac.org.nz/2020/asthma.aspx
For patient-directed information on inhaler devices currently available in New Zealand, see: https://www.healthnavigator.org.nz/medicines/i/inhaler-devices/#Overview
This Bulletin is supported by the South Link Education Trust
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