GP_Practice_Review_Issue_3

Practice Review

In this issue:

Identifying inappropriate polypharmacy in older adults in NZ GOLD 2023 COPD guidelines

Canada’s guidance on alcohol and health

Treatments of adults in the acute phase of major depressive disorder

Complementary and alternative medicines in the management of HF

USPSTF draft recommendation for prevention of HIV infection

Molnupiravir and Evusheld no longer recommended in NZ

New CDC definition for multisystem inflammatory syndrome in children associated with SARS-CoV-2

Characteristics of mpox in vaccinated vs unvaccinated individuals

Updated COVID-19 booster vaccine in NZ

Pharmac listings

Medsafe Prescriber Update

Imported measles case confirmed in NZ

Physical interventions to reduce the spread of respiratory viruses

High prevalence of geriatric conditions among older adults with CVD

COVID-19 resources

Workshops, conferences and CPD

Abbreviations used in this issue

AHA = American Heart Association

CARM = Centre for Adverse Reactions Monitoring

CDC = Centers for Disease Control and Prevention

COPD = chronic obstructive pulmonary disease

CVD = cardiovascular disease

GOLD = Global Initiative for Chronic Obstructive Lung Disease

HF = heart failure

ICS = inhaled corticosteroid

LABA = long-acting beta-agonist

LAMA = long-acting muscarinic antagonist

SNRI = serotonin–norepinephrine reuptake inhibitors

SSRI = selective serotonin reuptake inhibitors

USPSTF = US Preventive Services Task Force

Welcome to the third issue of GP Practice Review.

This new Review covers news and issues relevant to general practice. It will bring you the latest updates, both locally and from around the globe, in relation to topics such as new and updated treatment guidelines, changes to medicines reimbursement and licensing, educational, professional body news and more. We highlight that from 1 April, Pharmac will increase funding criteria for the influenza vaccine to also include children who are 6 months to 12 years of age and Māori and Pacific peoples who are 55 to 64 years of age. Funded access will remain for people aged >65 years or with chronic health conditions. Also, measles has been confirmed in New Zealand for the first time since the 2019 outbreak. Finally, on the back cover you will find our COVID-19 resources, including Pharmac’s COVID-19 antivirals access criteria assessment tool

We hope you enjoy this new Research Review publication and look forward to hearing your comments and feedback. Kind regards, Dr Bryan Betty admin@researchreview.co.nz

Clinical Practice

Development of explicit criteria identifying potentially inappropriate polypharmacy in older adults in New Zealand primary care

As the prevalence of disease increases with age, so does polypharmacy, and while several medicines may be needed to manage comorbidities, there is also an increased risk of medicines interactions and medicines-related harms. Criteria for identifying harmful prescribing have been developed internationally, e.g., Beers Criteria, however, significant variation in healthcare systems and medicines use makes it difficult to apply these criteria to New Zealand primary care.

These authors developed a New Zealand-specific system to identify medicines prescribing that puts patients aged over 65 years at higher risk of medicines-related harms. A panel of nine clinicians were chosen based on their experience relating to polypharmacy in the elderly. The group comprised two general practitioners, one geriatrician, two nurse practitioners and four clinical pharmacists. Members of the panel suggested specific indicators for inappropriate medicines prescribing in polypharmacy, then voted for indicators they believed were most important. These were combined with specific indicators from the Beers Criteria that are relevant to New Zealand. A two-round modified Delphi analysis was then performed on a total of 82 specific indicators (23 proposed by the expert panel and 59 from the Beers criteria). A consensus was defined as agreement between six of the nine panellists (≥66%).

A total of 61 indicators for inappropriate medicines prescribing in polypharmacy that are relevant to people aged over 65 years in New Zealand were identified, and form the “New Zealand Criteria”. Indicators that were considered ‘very important’ or ‘important’ in New Zealand were similar to published international criteria. Medicines that were identified as being of particular concern included NSAIDs, benzodiazepines, anticholinergics, antipsychotics and first-generation antihistamines. There were two indicators that reached 100% consensus: a combination of three or more CNS active medicines (e.g., antidepressants, antipsychotics, antiepileptics, benzodiazepines, zopiclone, opioids); and the use of long-acting sulfonylureas (e.g., glibenclamide). Eight out of nine experts agreed that it was very important to correct the prescribing of alpha blockers in older patients with postural hypotension and NSAIDs in older patients with stage 4 chronic kidney disease or higher. A complete list of potentially inappropriate medicines indicators is available in the full article.

J Prim Health Care. 2023 [Epub ahead of print]

You may be interested to know about our new CPD Accredited E- Learning Module on the use of paracetamol and ibuprofen in young infants

This module presents guidance on the management of pain and distress in febrile infants, as well as a comprehensive head-tohead review on the use of paracetamol versus ibuprofen in infants. The module is based on Professor Stuart Dalziel’s talk at the 2022 Goodfellow Symposium entitled “Paracetamol versus ibuprofen: What to do with the hot infant on Monday?” CLICK HERE to read the article.

FUNDED FULLY

GOLD 2023 COPD guidelines

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published updated guidelines on chronic obstructive pulmonary disease (COPD). The guidelines include several important changes, particularly concerning the use of long-acting bronchodilators in treatment.

Key changes in the GOLD 2023 guidelines include:

• A revised definition of COPD has been suggested: “COPD is a heterogeneous lung condition characterised by chronic respiratory symptoms (dyspnoea, cough, sputum production, exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive airflow obstruction”. This new definition describes symptoms more comprehensively and emphasises the heterogeneity of COPD as previous definitions had mostly focused on exposure to particles or other pollutants (e.g., smoking). While these are the most common causes, there are other contributing factors, such as exposure to coal or wood soot, genetics, abnormal lung development and infections.

Jaydess® provides >99% contraceptive efficacy for 3 years, at one-third of the levonorgestrel dose of Mirena®1,2*

*As measured at the end of Year 1.

• No impact on ovulation1

• Narrow (3.8 mm), flexible insertion tube for easier, less painful insertion3

• Shorter, lighter and less frequent bleeding during use1,3

References: 1. Jaydess® Data Sheet. 2. Mirena® Data Sheet. 3. Nelson A et al. Obstet Gynecol. 2013; 122(6):1205–1213. 4. PHARMAC Schedule; accessed December 2022.

MIRENA® (levonorgestrel) / JAYDESS® (levonorgestrel). MIRENA® Prescription Medicine. 52 mg intrauterine delivery system containing levonorgestrel. JAYDESS® Prescription Medicine. 13.5 mg intrauterine delivery system containing levonorgestrel. INDICATIONS: Mirena: Contraception; treatment of idiopathic menorrhagia provided there is no underlying pathology; prevention of endometrial hyperplasia during estrogen replacement therapy. Jaydess: Contraception for up to 3 years. DOSAGE AND ADMINISTRATION: Insert into the uterine cavity. Refer to Data Sheet (DS) for instructions on insertion and removal. Mirena: Up to 5 year in-situ life. Jaydess: Up to 3 year in-situ life. CONTRAINDICATIONS: Known/suspected pregnancy (Category B3); current or recurrent pelvic inflammatory disease or conditions associated with increased risk of pelvic infections; lower genital tract infection; postpartum endometritis or infected abortion during the past three months; cervicitis, cervical dysplasia/ intraepithelial neoplasia; uterine or cervical malignancy; confirmed or suspected hormone dependent tumours including breast cancer; undiagnosed abnormal uterine bleeding; congenital or acquired uterine anomaly including fibroids if they distort the uterine cavity; acute liver disease or liver tumour; hypersensitivity to the active substance or to any of the excipients. PRECAUTIONS: Use with caution after specialist consultation or consider removal if following exist or arise for the first time: migraine, focal migraine with asymmetrical visual loss or other symptoms indicating transient cerebral ischemia, exceptionally severe headache, jaundice, marked increase in blood pressure, severe arterial disease, acute venous thromboembolism. Tumours; Endometrial polyps, hyperplasia or cancer; Congenital or valvular heart disease and are at risk of infective endocarditis; Diabetes; Oligomenorrhoea and/or amenorrhea; Pelvic infections; Expulsion; Perforation; Ectopic pregnancy; Sexually transmitted infections; Lost threads; Ovarian cysts/enlarged ovarian follicles. Others see full DS. Mirena only: Nulligravid women; postmenopausal women with advanced uterine atrophy. INTERACTIONS: Interactions can occur with medicines that induce or inhibit microsomal enzymes, however, influence is not known. See full DS. Jaydess only: Magnetic resonance imaging. ADVERSE EFFECTS: Headache, abdominal/pelvic pain, acne/seborrhea, bleeding changes, ovarian cyst, vulvovaginitis, genital discharge, depressed mood/depression, migraine, nausea, upper genital tract infection, dysmenorrhea, breast tenderness/pain, device expulsion, hirsutism, alopecia. Uterine perforation, ectopic pregnancy, hypersensitivity, sepsis. Insertion/removal may precipitate a seizure in an epileptic patient.

Mirena only: Nervousness, decreased libido, back pain, weight gain, breast cancer, cervicitis. Others see full DS. Based on Mirena DS dated 10 September 2020, Jaydess DS dated 10 September 2020.

MIRENA® and JAYDESS® are fully funded – no special authority. Before prescribing, please review full Data Sheet for further information on the risks and benefits. Full Mirena Data Sheet is available from https://www.medsafe.govt.nz/profs/Datasheet/m/Mirenaius.pdf; Full Jaydess Data Sheet is available from https://www.medsafe.govt.nz/profs/Datasheet/j/jaydessIVD.pdf or Bayer New Zealand Limited, PO Box 2825, Shortland Street, Auckland 1140, telephone 0800 233 988.

®Registered Trademark of the Bayer Group, Germany. Bayer New Zealand Ltd, B:HIVE, Smales Farm, 72-74 Taharoto Road, Takapuna, Auckland 0622. PP-JAY-NZ-0020-2. TAPS NP18830. January 2023. BY11323.

• An updated and more specific definition for COPD exacerbations is proposed; this emphasises a timeframe for distinguishing whether increased symptoms are an exacerbation or overall worsening of disease severity, and offers a better framework for assessment and identification.

• Changes to the recommended assessment tool for predicting patient outcomes and making treatment decisions have been made. Previously, an “ABCD” criteria was used. Now, a revised “ABE” assessment tool is proposed to recognise the clinical relevance of exacerbations, regardless of the patient symptom severity (i.e., categories “C” and “D” are combined into a single “E” category).

• Revised guidance on pharmacological treatment of COPD:

- LABA/LAMA combination treatment is now recommended as first-line treatment in patients requiring a long-acting bronchodilator, including those who are more symptomatic or at high exacerbation risk. This supersedes previous guidance to use LAMA or LABA monotherapy first.

- Use of an ICS + LABA alone is now discouraged throughout COPD management unless prescribed for a concurrent diagnosis such as asthma, and a more targeted approach for ICS use is suggested. Download the guidelines here

Jaydess® is fully funded with no special authority.4

13.5 MG INTRAUTERINE LEVONORGESTREL DELIVERY SYSTEM

Canada’s guidance on alcohol and health

The risk of health harms from alcohol is low for people who consume two standard drinks or fewer per week, but it’s higher with greater consumption, according to new guidance from the Canadian Centre on Substance Use and Addiction. “Drinking less is better,” says the guidance, which replaces Canada’s 2011 Low-Risk Drinking Guidelines (LRDGs).

The guidance presents the following findings:

• Consuming no drinks per week has benefits, such as better health and better sleep, and it’s the only safe option during pregnancy.

• Consuming one or two standard drinks weekly will likely not have alcohol-related consequences.

• Three to six drinks raise the risk of developing breast, colon, and other cancers.

• Seven or more increase the risk of heart disease or stroke.

• Each additional drink “radically increases” the risk of these health consequences.

The rationale for the new guidance came from the fact that the 2011 LRDGs were no longer current, and there was emerging evidence that people drinking within those levels were coming to harm. That evidence indicates that alcohol causes at least seven types of cancer, mostly of the breast or colon; is a risk factor for most types of heart disease; and is a main cause of liver disease. Evidence also indicates that avoiding drinking to the point of intoxication will reduce people’s risk of perpetrating alcohol-related violence.

Responding to the need to accurately quantify the risk, the guidance defines a “standard” drink as 12 oz of beer, cooler, or cider (5% alcohol); 5 oz of wine (12% alcohol); and 1.5 oz of spirits such as whiskey, vodka, or gin (40% alcohol).

Using different mortality risk thresholds, the authors developed the following continuum of risk:

• Low for individuals who consume two standard drinks or fewer per week.

• Moderate for those who consume from three to six standard drinks per week.

• Increasingly high for those who consume seven standard drinks or more per week.

The guidance makes the following observations:

• Consuming more than two standard drinks per drinking occasion is associated with an increased risk of harms to self and others, including injuries and violence.

• When pregnant or trying to get pregnant, no amount of alcohol is safe.

• When breastfeeding, not drinking is safest.

• Above the upper limit of the moderate risk zone, health risks increase more steeply for females than males.

• Far more injuries, violence, and deaths result from men’s alcohol use, especially for per occasion drinking, than from women’s alcohol use.

• Young people should delay alcohol use for as long as possible.

• Individuals should not start to use alcohol or increase their alcohol use for health benefits.

• Any reduction in alcohol use is beneficial.

Download the report here

Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: A living clinical guideline from the American College of Physicians

This guideline from the American College of Physicians (ACP) presents updated clinical recommendations on nonpharmacological and pharmacological interventions as initial and second-line treatments for adults with acute major depressive disorder (MDD).

For patients in the acute phase of mild MDD, monotherapy with CBT is conditionally recommended as initial treatment, based on low-certainty evidence.

For patients in the acute phase of moderate-to-severe MDD, monotherapy with either cognitive behavioural therapy (CBT) or a second-generation antidepressant (e.g., SSRIs and SNRIs) is strongly recommended as initial treatment, based on moderate certainty evidence. Combination therapy with CBT and a second-generation antidepressant is conditionally recommended as initial treatment, based on low-certainty evidence.

For patients in the acute phase of moderate-to-severe MDD not responding to initial treatment with an adequate dose of a second-generation antidepressant, ACP recommends switching to or augmenting with CBT (conditional recommendation) or switching to a different second-generation antidepressant or augmenting with a second pharmacological treatment (conditional recommendation).

Treatment choices should be personalised and based on discussion of potential benefits and harms, cost, feasibility, patients’ symptoms and comorbidities, concomitant medications, and patient preferences.

Ann Intern Med. 2023;176(2):239-52

Complementary and alternative medicines in the management of heart failure: A scientific statement from the American Heart Association

This scientific statement summarises the efficacy and safety data of complementary and alternative medicine (CAM) - estimated to be used by one in three patients with heart failure (HF) who often do not report CAM use to their physician - as well as adjunctive interventional wellness approaches in HF. The authors emphasise the importance of healthcare professionals inquiring about CAM use with their patients at every clinical visit and discussing the interactions, benefits, and adverse effects of CAM and guideline-directed medical therapy that could influence the safety of patients with HF.

A useful table is provided with potential beneficial and harmful CAMs. Limited published reports suggest that select alternative therapies might have some clinical benefit. Omega-3 PUFAs (fish oil) have the strongest evidence among CAM agents for clinical benefit in patients with HF and can safely be used in moderation. Other potentially beneficial agents include Coenzyme-Q10, D-ribose, and L-carnitine. Clinical data do not support routine thiamine supplementation in the absence of deficiency in patients with HF. Yoga and tai chi can be used as adjunctive wellness approaches to guideline-directed medical therapy to improve exercise tolerance and quality of life.

Potentially harmful CAMs, due to interactions, include bitter orange, blue cohosh, devil’s claw, ginkgo, gossypol, grapefruit juice, khella, liquorice, lily of the valley, oleander, strophanthus and vitamin E. Agents with uncertain safety include alcohol, aloe vera, caffeine, guar gum, hawthorn, L-arginine and policosanol. Circulation. 2023;147(2):e4-e30

Practice Reviews cover news and issues relevant to New Zealand clinical practice. Research Review Ltd is an independent publisher. Research Review receives funding from a variety of sources including Government depts., pharmaceutical companies, insurers and other organisations with an interest in health. Journal content is created independently of advertisers with assistance from leading local specialists.

Publications are free to receive for health care professionals, to subscribe go to www.researchreview.co.nz

Research Review publications are intended for New Zealand health professionals.

LOOK CLOSER

Cxbladder is a non-invasive genomic urine test that enables the safe rule out of bladder cancer.

Learn how a co-developed haematuria pathway is transforming primary practice.

USPSTF draft recommendation statement on prevention of HIV infection: Pre-exposure prophylaxis

The US Preventive Services Task Force (USPSTF) has published revised draft recommendations for HIV preexposure prophylaxis (PrEP) based on a review of evidence of new formulations, including long-acting drugs.

Consistent with 2019 recommendations, the ‘grade A rating’ attributed to PrEP remained unchanged, and the Task Force draft reinforced that clinicians continue to prescribe PrEP to currently uninfected adults and adolescents at increased risk for acquiring HIV.

Among the various clinical considerations, the draft guidance highlighted that although men who have sex with men (MSM) remained the highest at-risk population (they accounted for 68% of new diagnoses in 2020), other populations, including all sexually active adults and adolescents, sex workers, injection drug users, and the transgender population also be considered. This is especially true for persons who’ve engaged in anal or vaginal sex in the past months, with possible exposure to HIV or a bacterial sexually transmitted infection (syphilis, gonorrhoea, or chlamydia for MSM, gonorrhoea and syphilis for heterosexual men or women), or who report inconsistent or no condom use (especially with a partner or partners whose HIV status is unknown). However, the Task Force also acknowledged that HIV acquisition existed on a continuum, and that well-validated tools to identify at-risk patients were lacking.

Additional considerations

Clinicians who treat at-risk patients are encouraged to take sexual and injection drug use histories in a nonjudgmental manner, and also familiarise themselves with local laws and regulations applicable to PrEP provision in adolescents. Patients being considered for PrEP should have a recently documented negative HIV antigen-antibody test result. The CDC also recommends both an HIV antigen-antibody assay and an HIV-1 RNA assay be conducted in patients who’ve taken oral PrEP or post-exposure prophylaxis in the past 3 months, or injectable cabotegravir in the past 12 months. USPSTF draft recommendation statement

Molnupiravir and Evusheld no longer recommended in NZ

The Therapeutic Technical Advisory Group no longer recommends molnupiravir or tixagevimab/cilgavimab (Evusheld) treatment in non-hospitalised patients with COVID-19. Evusheld should also no longer be used as pre-exposure prophylaxis for SARS-CoV-2 infection. Accumulating evidence suggests that at the present time molnupiravir and Evusheld are unlikely to be of benefit against current circulating variants. Nirmatrelivr (Paxlovid) (or remdesivir) are preferable treatments to molnupiravir or Evusheld.

Read more here and here

US CDC surveillance case definition for multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection

A new surveillance case definition for multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 infection has been developed by the US Centers for Disease Control and Prevention (CDC).

The methods used to develop the definition included convening MIS-C clinical experts regarding identification of MIS-C and its distinction from other paediatric conditions, a review of the literature comparing the MIS-C phenotype to that of other syndromes, and retrospective application of different criteria to data from previously reported MIS-C cases.

The authors note that four important changes are included in the surveillance case definition versus the 2020 MIS-C case definition:

1. no required duration of subjective or measured fever;

2. requirement for C-reactive protein ≥3.0 mg/dL;

3. adjustments to criteria of organ system involvement to include shock as a distinct category and eliminate respiratory, neurologic, and renal criteria; and

4. new requirements of timing of positive SARS-CoV-2 laboratory testing relative to MIS-C.

Read more here

Demographic and clinical characteristics of mpox in persons who had previously received one dose of JYNNEOS vaccine and in unvaccinated persons

As of November 14, 2022, monkeypox (mpox) cases had been reported from more than 110 countries. This report from the US Centers for Disease Control and Prevention (CDC) compared the rates of mpox cases between 276 individuals who had received one dose of the JYNNEOS mpox vaccine at least 2 weeks prior to illness onset and 6329 individuals who were unvaccinated.

They found that unvaccinated individuals were significantly more likely to self-identify as Black or African American. Vaccinated individuals experienced significantly lower rates of hospitalisation (2.1% vs 7.5%), fever, headache, malaise, myalgia and chills, compared with unvaccinated individuals. The odds of rectal signs and symptoms (e.g., proctitis, rectal bleeding, tenesmus, and rectal pain) were similar among vaccinated and unvaccinated mpox patients.

Among both vaccinated and unvaccinated patients, the genital area was the rash location most commonly reported (55.0% of vaccinated patients and 46.7% of unvaccinated patients), suggesting that sexual transmission in this population was a common mechanism of transmission. The odds of reporting rash in all other locations except the perianal area were significantly lower among vaccinated than among unvaccinated patients, suggesting that possible prevention of spread of rash from site of inoculation among even partially vaccinated persons. No deaths occurred in either group.

The authors concluded that although one dose of JYNNEOS vaccine offers some protection from disease, mpox infection can occur after receipt of one dose, and the duration of protection conferred by one dose is unknown. Providers and public health officials should therefore encourage persons at risk for acquiring mpox to complete the two-dose vaccination series and provide guidance and education regarding nonvaccinerelated prevention strategies.

Read the report here

Regulatory and Funding News

COVID-19 vaccine: Boosters

The Pfizer BA.4/5 COVID-19 bivalent booster vaccine has replaced the original Pfizer booster vaccine; people who are eligible for a first or second COVID-19 booster dose will now receive the bivalent vaccine.

An additional booster dose will be available from 1 April, 2023, for people aged 30 years and older, and for those at higher risk of severe illness from COVID-19 if it has been at least six months since their previous dose or positive COVID-19 test.

Read more here

Pharmac listings

• Pharmac is widening access to the influenza vaccine from 1 April 2023 for the following two groups, for the duration of the 2023:

- Children who are 6 months to 12 years of age.

- Māori and Pacific peoples who are 55 to 64 years of age. - (Funded access will remain for people aged >65 years or with chronic health conditions).

• Two treatments for locally advanced and metastatic non-small cell lung cancer will be funded from 1 April 2023:

- Pembrolizumab (Keytruda), will be funded for the treatment of people with advanced NSCLC as first-line treatment.

- Atezolizumab (Tecentriq) will be funded for people with advanced NSCLC as second or later line treatment.

• Elexacaftor with tezacaftor and ivacaftor (Trikafta) will be funded for people aged 6 years and above with cystic fibrosis, subject to eligibility criteria, from 1 April 2023.

New Zealand Research Review subscribers can claim CPD/CME points for time spent reading our reviews from a wide range of local medical and nursing colleges. Find out more on our CPD page

Medsafe Prescriber Update

Monitoring communication: Reports of pericarditis following mpox vaccination

Medsafe has issued a Monitoring Communication to seek more information on cases of pericarditis following mpox vaccination. This safety communication has been made following two reports to CARM of pericarditis suspected to be related to vaccination with mpox. Healthcare professionals should discuss this potential adverse effect with patients receiving mpox vaccination and advise them to seek medical attention if they experience any symptoms or signs of pericarditis. Any cases of pericarditis after mpox vaccination should be reported to CARM.

Read more here

Risk of neurotoxicity with cephalosporins

Medsafe has received reports of neurotoxicity with cephalosporins, including encephalopathy, seizures and/or myoclonus. Risk factors include older age, renal impairment, central nervous system disorders and intravenous administration. Cephalosporins should be considered as a potential cause of neurotoxicity in patients with these risk factors and an unexplained, new onset neurological condition.

Read more here

Starting empagliflozin or dapagliflozin in patients on lithium?

Monitor lithium levels

In patients on lithium, sodium-glucose co-transporter 2 (SGLT2) inhibitors, such as empagliflozin and dapagliflozin, may increase the renal excretion of lithium and lead to decreased serum lithium levels. Patients’ serum lithium levels should be monitored more frequently when a SGLT2 inhibitor is initiated or following dose changes. Adjust the lithium dose if necessary. Up to 9 January 2023, CARM had not received any reports of an interaction between lithium and SGLT2 inhibitors.

Read more here

Metoclopramide: risk of dystonic side effects in children and young adults

Metoclopramide is used for the treatment of nausea and vomiting. CARM has received several reports of dystonic reactions in children prescribed metoclopramide; 86 as of 1 December 2022. Due to the risk of dystonic side effects, metoclopramide use in children and young adults (aged 1 to 19 years) is limited to certain conditions and for second-line therapy. Dystonia can occur after a single dose of metoclopramide and occurs more often in children and young adults, and in females. Metoclopramide should not be used in people under 20 years of age unless absolutely necessary, and the dose recommendations must be followed strictly.

Read more here

Digoxin toxicity – don’t break my heart

Digoxin is a cardiac glycoside used in the management of systolic heart failure and supraventricular arrhythmias. CARM recently received a report of digoxin toxicity, where the patient experienced renal failure, hyperkalaemia, bradycardia and cardiac failure. Digoxin has a narrow therapeutic index, and digoxin toxicity can occur when serum levels are within the therapeutic range. Toxicity can occur following an acute overdose and in patients on long-term therapy. Patients with digoxin toxicity may present with cardiac and non-cardiac symptoms. Healthcare professionals should remain vigilant about the possibility of digoxin toxicity and consider dose adjustments in patients predisposed to toxicity. Remind patients taking digoxin to seek medical attention if they feel unwell.

Read more here

Use caution if switching between long-acting methylphenidate products due to formulation differences

Methylphenidate is a CNS stimulant used for the treatment of ADHD. Immediate-release and longacting methylphenidate products are available. The long-acting methylphenidate products available in NZ are Concerta, methylphenidate extended release (Teva), Ritalin LA and Rubifen S. Different longacting methylphenidate products have different formulations, with distinct release profiles and dosing requirements, which may affect symptom management. The choice of long-acting methylphenidate product should match the patient’s needs. Healthcare professionals should use caution if switching between longacting methylphenidate products and communicate any changes to the patient.

Read more here

Administration of methotrexate in patients taking sodium valproate may reduce seizure or mood control

The sodium valproate (Epilim) data sheet has been updated to include an interaction with methotrexate. Some international case reports describe a significant reduction in the serum level of sodium valproate soon after administration of methotrexate, resulting in seizures. As of 1 December 2022, no cases of this drugdrug interaction had been reported to CARM. When starting methotrexate therapy in patients on valproate, monitor the patient’s clinical response (seizure control or mood control) and serum valproate levels.

Read more here

Imported measles case confirmed in New Zealand

Measles has been confirmed in New Zealand for the first time since the 2019 outbreak. The case was infected overseas but became infectious once back in New Zealand. Te Whatu Ora, Health New Zealand, is advising healthcare professionals to be alert for symptoms and signs of measles in patients, particularly those who are not vaccinated or are immunocompromised, and have a history of recent overseas travel.

Read more here

Physical interventions to interrupt or reduce the spread of respiratory viruses

This update of a 2020 Cochrane Review evaluated the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. A literature search identified 11 new randomised controlled trials and clusterrandomised controlled trials (n=610,872) that were suitable for inclusion, bringing the total number of randomised controlled trials reviewed to 78. Results showed that wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness/COVID-19-like illness compared to not wearing masks. In healthcare settings, using an N95 mask was no more effective than an ordinary surgical mask in preventing infection. Hand hygiene was found to modestly reduce the burden of respiratory illness. The review acknowledges many of the studies had a high risk of bias.

Cochrane Database Syst Rev. 2023;1(1):CD006207

High prevalence of geriatric conditions among older adults with cardiovascular disease

In the field of geriatric cardiology, the combination of older age, multiple comorbidities, polypharmacy, frailty, and adverse non-cardiovascular outcomes is challenging routine clinical practice. The authors of this narrative review, which provides additional evidence of so-called “accelerated aging” in older patients with cardiovascular disease (CVD), conclude that the presence of a high comorbidity burden in older people with CVD suggests that a comprehensive specific approach to caring for this especially vulnerable patient population is essential. The authors also assert that the high prevalence of geriatric conditions associated with CVD emphasises the need for an integrated, multisystem approach.

J Am Heart Assoc. 2023;12(2):e026850

SHIELD THE

IMMUNOCOMPROMISED.1

HELP PREVENT COVID-19.

PRE-EXPOSURE PROPHYLAXIS AGAINST COVID-191

BEFORE PRESCRIBING PLEASE REVIEW FULL DATA SHEET AVAILABLE ON REQUEST FROM ASTRAZENECA ON (09) 306 5650 OR http://www.medsafe.govt.nz/

EVUSHELDTM, 2 vials: 150 mg of tixagevimab in 1.5 mL (100 mg/mL) and 150 mg of cilgavimab in 1.5 mL (100 mg/mL). Solution for injection. Prescription Medicine. Therapeutic indication: EVUSHELD is indicated for the pre-exposure prophylaxis of COVID-19 in adults and adolescents aged 12 years and older weighing at least 40 kg, - Who have moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments that make it likely that they will not mount an adequate immune response to COVID-19 vaccination, or - For whom vaccination with any approved COVID-19 vaccine is not recommended due to a history of severe adverse reaction (e.g., severe allergic reaction) to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s). Dose and method of administration: EVUSHELD administration should be under conditions where management of severe hypersensitivity reactions, such as anaphylaxis, is possible. The recommended dose is 150 mg of tixagevimab and 150 mg of cilgavimab, administered as two separate sequential intramuscular injections at different injection sites in two different muscles, preferably in the gluteal muscles. Contraindications: Hypersensitivity to the active substances or any of its excipients. Precautions: Serious hypersensitivity reactions, including anaphylaxis; Patients with thrombocytopenia or any coagulation disorder; Individuals at high risk for cardiovascular or thrombo-embolic events; Children under 12; EVUSHELD should only be used during pregnancy if the potential benefit outweighs the potential risk for the mother and the foetus; It is not known whether the active ingredients are excreted in human milk, exposure to the breast-fed child cannot be excluded. Adverse effects: Common (≥1% frequency): Hypersensitivity, including rash and urticaria; Injection site reaction, including injection site pain, injection site erythema, injection site pruritus, injection site reaction and injection site induration; Less common (≤1% frequency): Injection related reaction. See full Data Sheet for details. EVUSHELD is temporarily funded by Pharmac for the pre-exposure prophylaxis of COVID-19, subject to access criteria. For further details please refer to https://pharmac.govt.nz or https://www.evusheldpinz.com. Before prescribing EVUSHELD, please read the manufacturer’s Data Sheet available at www.medsafe.govt.nz Date of first approval: 29 July 2022. Date of revision: 29 July 2022

References:

1. EVUSHELDTM (tixagevimab and cilgavimab) Data Sheet.

EVUSHELDTM is a registered trademark of the AstraZeneca group of companies. AstraZeneca Limited, PO Box 87453, Meadowbank, Auckland 1742. For Medical Information enquiries or to report an adverse event or product quality complaint: Telephone (09) 306 5650 or via https://contactazmedical.astrazeneca.com Or email Medical Information enquiries to medinfo.nz@astrazeneca.com. NZ-1829. TAPS MR8564. September 2022.

For more information, please go to www.medsafe.govt.nz

COVID-19 Resources

Ministry of Health – Manatū Hauora

IMAC

RNZCGP

COVID-19 antivirals access criteria assessment tool BPAC

Goodfellow Unit 2023

Goodfellow Symposium March 25-26, 2023

Antibiotics in primary care – March 28, 2023

The impact of diabetes on sexual function April 04, 2023

Colorectal cancer - reducing the risks and screening April 11, 2023

RNZCGP and College of Nurses

Endorsed CPD Modules

Paediatric Analgesia - E-Learning Module for GPs

Heavy Menstrual Bleeding - E-Learning Module for GPs

Countering Vaccine Misinformation - E-Learning Module for GPs

Paediatric Analgesia - E-Learning Module for Nurses, Nurse Practitioners and Nurse Prescribers

Countering Vaccine Misinformation - E-Learning Module for Nurses, Nurse Practitioners and Nurse Prescribers

Heavy Menstrual Bleeding - E-Learning Module for Nurses, Nurse Practitioners and Nurse Prescribers

Conferences and Workshops

Rotorua GP CME 2023 8-11 June

South GP CME 2023 10-13 August, Christchurch

IMAC courses and events

College of Nurses Aotearoa NZ events

Recent Research Review publications

GP Research Review with Associate Professor

Jim Reid and Dr Chris Tofield

Speaker Series - COPD management in New Zealand: A survey of real-world GP prescribing

Educational Series - Diabetes management during Ramadan

Speaker Series - Shingles vaccination in adults 50 years and older

Educational Series - 2023 update on long-acting reversible contraceptives

This Research Review has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and has been approved for up to 1 CME credit for the General Practice Educational Programme (GPEP) and Continuing Professional Development (CPD) purposes. You can record your CME credits in your RNZCGP Dashboard

Time spent reading this publication has been approved for CNE by The College of Nurses Aotearoa (NZ) for RNs and NPs. For more information on how to claim CNE hours please CLICK HERE