GP_Practice_Review_Issue_4

Practice Review

In this issue:

American Academy of Pediatrics guideline for children with obesity

Diagnosing iron deficiency in chronic disease

Time to reconsider PSA screening in prostate cancer

Major global coronary artery calcium guidelines

ADA/EASD: Management of hyperglycaemia in diabetes

Stepwise approach to prescribing novel lipid-lowering medications

Worsening spread of Candida auris in the US

Outcomes for pregnant COVID-19 patients treated with nirmatrelvir/ ritonavir

Review of guidelines for conjunctivitis

ACG guideline for gastrooesophageal reflux disease

IBD patients want to discuss insomnia treatments

ECCO guidelines on IBD and family planning

US CDC recommends universal hepatitis B vaccination

Factors affecting outcomes in cutaneous SCC

Pharmac news

Medsafe updates

Third infant whooping cough death in NZ

Syphilis increase in NZ

Abbreviations used in this issue

ACE = angiotensin converting enzyme

ACG = American College of Gastroenterology

ADA = American Diabetes Association

ARB = angiotensin receptor blocker

CDC = Centers for Disease Control and Prevention

CKD = chronic kidney disease

EASD = European Association for the Study of Diabetes

ECCO = European Crohn’s and Colitis Organisation

GLP1RA = glucagon-like peptide-1 receptor agonist

IBD = inflammatory bowel disease

NAFLD = non-alcoholic fatty liver disease

NZSSD = New Zealand Society for the Study of Diabetes

PSA = prostate-specific antigen

QoL = quality of life

SCC = squamous cell carcinoma

SGLT2i = sodium glucose co-transporter 2 inhibitor

Welcometo the 4th issue of GP Practice Review.

This 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. And finally, on the back cover you will find our COVID-19 resources, including Pharmac’s COVID-19 antivirals access criteria assessment tool, and a summary of upcoming Goodfellow educational opportunities.

We hope you enjoy this Research Review publication and look forward to hearing your comments and feedback.

Kind regards, The team at Research Review admin@researchreview.co.nz

Clinical Practice

American Academy of Pediatrics clinical practice guideline for the evaluation and treatment of children and adolescents with obesity

The American Academy of Pediatrics has published a guideline for the evaluation and treatment of children who are overweight or obese.  Overweight was defined as BMI ≥85th percentile to <95th percentile, obesity as BMI ≥95th percentile, and severe obesity as BMI ≥120% of the 95th percentile for age and sex. Key recommendations are listed below.

• Children should be screened annually for overweight or obesity.

• Children should be evaluated for obesity-related comorbidities by taking a patient history, mental and behavioural health screening, social determinants of health evaluation, physical examination, and diagnostic studies. Overweight/obesity and comorbidities should be treated concurrently.

• In children older than 10 years, those who are obese should be evaluated for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function.

• Those who are overweight as oppose to obese should be evaluated for lipid abnormalities only. However, if overweight children have risk factors for T2D or NAFLD, also measure glucose metabolism and liver function.

• In children less than 10 years of age with obesity, evaluate for lipid abnormalities.

• Blood pressure should be measured at every visit starting at 3 years of age in children and adolescents with overweight and obesity.

• Overweight and obesity should be managed using a family-centred and non-stigmatising approach, and by using motivational interviewing to engage patients and caregivers.

• Intensive health behaviour and lifestyle treatment is more effective with greater contact hours; the most effective treatment involves at least 26 hours of face-to-face, family-based, treatment over a 3- to 12-month period.

• Adolescents 12 years and older with obesity should be offered weight loss pharmacotherapy, in combination with health behaviour and lifestyle treatment.

• Adolescents 13 years and older with severe obesity should be referred for evaluation for metabolic and bariatric surgery.  Pediatrics. 2023;151(2):e2022060641

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

An Apology to bpacnz

When providing commentary on local and global updates relevant to clinical practice, Research Review is careful to comply with copyright obligations and provide references and links to original material. We therefore sincerely regret that some items in previous issues of GP Practice Review were copies of material originally published by bpacnz in its Best Practice Bulletin. We accept that this was a copyright infringement. Research Review acknowledges and respects the contribution that bpacnz makes to the primary health care sector in New Zealand and has apologised to bpacnz for this breach of our normally strict protocols. We can assure you that any future commentary relating to the Best Practice Bulletin will be independent of the original material and we will provide appropriate links to enable you to access that material directly.

MY PERIODS DON’T RULE MY LIFE ANYMORE

Are heavy periods impacting your patients’ life?

FOR THE TREATMENT OF HEAVY MENSTRUAL BLEEDING

(HMB)*

• Up to 95% reduction in menstrual blood loss1,2

• Recommended as first-line treatment for HMB in international guidelines3,4

• Alleviates dysmenorrhea1

*Mirena® is indicated for the treatment of idiopathic menorrhagia provided there is no underlying pathology.

References: 1. Mirena® Data Sheet. 2. Reid PC et al. BJOG. 2005; 112(8):1121-1125. 3. Australian Commission on Safety and Quality in Health Care. Heavy Menstrual Bleeding Clinical Care Standard 2017. 4. National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. Available at https://www. nice.org.uk/guidance/ng88/chapter/Recommendations#management-of-hmb. Accessed December 2022. MIRENA® (levonorgestrel). MIRENA® is used for contraception, idiopathic menorrhagia and endometrial protection. Prescription Medicine. 52 mg intrauterine delivery system containing levonorgestrel. Initial release rate 20 μg/24 hrs. INDICATIONS: Contraception, idiopathic menorrhagia and prevention of endometrial hyperplasia during oestrogen replacement therapy. DOSAGE AND ADMINISTRATION: Insert into the uterine cavity. Up to 5 year in-situ life. Refer to Data Sheet for instructions on insertion and removal. CONTRAINDICATIONS: Known/ suspected pregnancy; current or recurrent pelvic inflammatory disease; lower genital tract infection; postpartum endometritis; infected abortion during the past three months; cervicitis, cervical dysplasia; 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; conditions associated with increased infection susceptibility; acute liver disease/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. Young nulligravid women; post-menopausal women with advanced uterine atrophy; breast cancer; congenital or valvular heart disease and are at risk of infective endocarditis; diabetes; oligomenorrhoea and/or amenorrhoea; lost threads; pelvic infections; expulsion; perforation; ectopic pregnancy; sexually transmitted infections; ovarian cysts.

INTERACTIONS: Phenytoin; barbiturates; primidone; carbamazepine; rifampicin; oxcarbazepine; topiramate; felbamate; griseofulvin; products containing St. John’s wort; HIV/HCV protease inhibitors and non-nucleoside reverse transcriptase inhibitors; strong and moderate CYP3A4 inhibitors such as azole antifungals (e.g. fluconazole, itraconazole, ketoconazole, voriconazole), verapamil, macrolides (e.g. clarithromycin, erythromycin), diltiazem, grapefruit juice. ADVERSE EFFECTS: headache, abdominal/pelvic pain, changes in menstrual bleeding, vulvovaginitis, genital discharge, depressed mood, nervousness, decreased libido, migraine, nausea, acne, hirsutism, back pain, upper genital tract infection, ovarian cyst, dysmenorrhoea, breast tenderness, breast pain, intrauterine contraceptive device expulsion, weight gain, cervicitis. Uterine perforation, ectopic pregnancy, breast cancer, hypersensitivity, and sepsis have also been reported. For other events refer to full Data Sheet. Based on DS dated 10 September 2020.

MIRENA is fully funded – no special authority. Before prescribing, please review full Data Sheet for further information on the risks and benefits. Full Data Sheet is available from https://www.medsafe.govt.nz/profs/Datasheet/m/Mirenaius.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-MIR-NZ-0074-1. TAPS NP18764. December 2022. BY11325.

How to diagnose iron deficiency in chronic disease: A review of current methods and potential marker for the outcome

Iron deficiency (ID) is associated with an increased risk of hospitalisation and mortality and reduced QoL. ID is frequently diagnosed in patients with a range of longterm conditions such as CKD, heart failure, inflammatory bowel disease (IBD) and cancer. This review offers an overview of the role of ID in chronic diseases. Different interpretations or definitions of ID in guidelines and studies have resulted in a number of different diagnostic approaches and variable prevalence data, which could be the reason that ID is not completely recognised as a stand-alone medical condition and is often overlooked. Recommendations for the management of ID may vary. However, across all chronic conditions, serum ferritin and transferrin saturation (TSAT) are the two parameters emphasised in guidelines to define ID and guide treatment. The most commonly used threshold values for the diagnosis of ID are TSAT of <20% and serum ferritin of <100-300 μg/L, which are independent of a diagnosis of anaemia.

Eur J Med Res. 2023;28(1):15

Prostate-specific antigen testing for prostate cancer: Time to reconsider the approach to screening

Prostate cancer is the most common cancer in men in Australia, often remaining asymptomatic until advanced. This paper stresses that Australian guidelines for primary care prostate-specific antigen (PSA) testing should be updated to reflect long-term data showing survival advantages from PSA testing. Indeed, recent studies show improved metastasis-free survival rates with early intervention compared with observation/delayed treatment. The use of MRI and PSMA PET has lowered risk, increased accuracy and improved staging. Biopsy techniques have improved to reduce the risk of infection. Studies show that the increased use of active surveillance in patients with low to intermediate risk of prostate cancer can lessen the risk of treatment-related harms in men with low risk of progression. There have also been improvements in medical therapies for advanced disease.

Aust J Gen Pract. 2023;52(3):91-95

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

Major global coronary artery calcium guidelines

This state-of-the-art review summarises the rationale behind the global guidelines of coronary artery calcium (CAC) screening during atherosclerotic cardiovascular disease risk assessment. There is significant variation in global CAC guidelines, although clinical practice guidelines agree that CAC scoring is vital to up- or down-grade risk in intermediate-risk individuals. The key agreements among global CAC guidelines are to indicate CAC screening for asymptomatic intermediate-risk individuals older than 40 years. Among those having a CAC >100, statin initiation should be considered, whereas those with a CAC = 0 should have the risk downgraded and statins withheld, with screening repeated within 5 to 10 years.

JACC Cardiovasc Imaging. 2023;16(1):98-117

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the ADA and the EASD

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) gathered an expert panel to update consensus statements on the management of hyperglycaemia in type 2 diabetes in adults. New recommendations include a focus on social determinants of health, the health care system, and physical behaviours, including sleep. There is more emphasis on weight control for diabetes management. The results of cardiovascular and kidney outcomes trials of sodium–glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists, inform wider recommendations for cardiorenal protection in patients with diabetes at high risk of cardiorenal disease. Practical tips for application of the recommendations are provided.

Diabetologia. 2022;65(12):1925-66

A stepwise approach to prescribing novel lipidlowering medications

The American College of Cardiology has published review article on a stepwise approach to prescribing lipid-lowering therapies. The paper aims to familiarise clinicians with newer lipidlowering therapies and offers a practical guide for how to prescribe these drugs in clinical practice. Of note, some of these newer medicines are not available in New Zealand, including proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.

Key points

1. Pharmacologic therapies with proven benefit are recommended, i.e., statins, ezetimibe, PCSK9 monoclonal antibodies (evolocumab and alirocumab), and icosapent ethyl.

2. Statins are the therapy of choice for initial reduction of LDL-C.

3. Patients who cannot tolerate statins should receive the maximally tolerated statin dose even if very low, rather than discontinue statins.

4. In patients at very high risk of atherosclerotic cardiovascular disease (ASCVD):

• Ezetimibe should be added if LDL-C is ≥1.8 mmol/L on maximally tolerated statins.

• A PCSK9 monoclonal antibody should be added if LDL-C remains ≥1.8 mmol/L or non–HDL-C ≥2.6 mmol/L despite ezetimibe and maximally tolerated statin.

- Consider bempedoic acid* if concerned about the high cost of a PCSK9 inhibitor.

- Consider inclisiran* for patients who prefer less frequent injections.

• Consider lomitapide* or evinacumab* in patients with homozygous familial hypercholesterolaemia.

5. In patients not at very high risk of ASCVD who are ≤75 years of age:

• Ezetimibe should be prescribed if LDL-C ≥1.8 mmol/L on maximally tolerated statin.

• Bempedoic acid* should be considered if LDL-C remains ≥1.8 mmol/L despite ezetimibe and maximally tolerated statin.

6. In patients not at very high risk of ASCVD who are >75 years of age, offer moderate-intensity or high-intensity statin, with subsequent intensification if required.

7. Icosapent ethyl should be considered in patients with triglycerides ≥1.5 mmol/L who meet REDUCE-IT criteria.

Read more here

* Not available in NZ

Worsening spread of Candida auris in the United States

The US Centers for Disease Control and Prevention has reported that fungal infections with Candida auris are spreading rapidly in the US. There were 756 cases in 2020, increasing by 95% to 1471 cases in 2021. The infection is potentially fatal. Of concern, the number of cases resistant to echinocandins tripled in 2021.

Ann Intern Med. 2023;176(4):489-95

One case of C. auris detected in NZ

Manatū Hauora, Ministry of Health is aware that the number of cases of  C. auris is increasing overseas, particularly in the US, and is monitoring the outbreak. One case has been detected in New Zealand, which was acquired overseas. Infections from the fungus mainly occur in long-term residents of aged care homes or hospitals who have medical devices such as intravenous lines or urinary catheters, or have previously received antibiotics or antifungals.

Read more here

UNWIND YOUR PATIENT’S PAIN

References: 1. PHARMAC Online Pharmaceutical Schedule - July 2021. 2 NORFLEX Data Sheet. 3. Waldman, H. Centrally Acting Skeletal Muscle Relaxants and Associated Drugs. Journal of Pain and Symptom Management. Volume 9. No. 7. 1994. NORFLEX® is a prescription medicine (orphenadrine citrate 100 mg). Please review the full Data Sheet before prescribing, available on the Medsafe website www.medsafe.govt.nz NORFLEX Tablets are fully funded on the Pharmaceutical Schedule. NORFLEX: Orphenadrine citrate 100 mg tablets. Indications: NORFLEX is indicated for the relief of stiffness and pain resulting from skeletal muscle spasm in sprains and strains, local muscle injury, prolapsed intervertebral disc, lumbago, fibrositis, non-articular rheumatism, acute torticollis, surgery, fractures, anxiety, and tension. Orphenadrine citrate has also been shown to be effective for treatment of tension headache and persistent hiccoughs. Contraindications: Hypersensititvity to orphenadrine, glaucoma, paralytic ileus, pyloric or duodenal obstruction, stenosing peptic ulcers, prostatic hypertrophy or obstruction of the prostate or bladder neck, oesophageal spasm (megaesophagus) and myasthenia gravis. Warnings and Precautions: Hepatic, renal impairment, tachycardia, cardiac decompensation, coronary insufficiency or cardiac arrhythmias, glaucoma risk. Safety of continuous long-term therapy with orphenadrine has not been established. Therefore, periodic monitoring of blood, urine and liver function values is recommended if orphenadrine is prescribed for prolonged use. Pregnancy and lactation: Category B2. Safe use of orphenadrine has not been established with respect to adverse effects on foetal development. NORFLEX should therefore be used in women of childbearing potential and particularly during early pregnancy only when the potential benefits outweigh the risks. Orphenadrine is excreted in breast milk and is not recommended for use while breastfeeding. Effects on ability to drive and operate machinery: NORFLEX may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle. Elderly patients: The elderly may be more susceptible to anticholinergic side effects and should be given a reduced dosage. Adverse Effects: common: dryness of mouth, tachycardia, palpitation, urinary hesitancy or retention, blurred vision, dilation of pupils, increased ocular tension, weakness, nausea, vomiting, headache, dizziness, constipation, drowsiness, hypersensitivity reactions, pruritus, hallucinations, agitation, tremor, gastric irritation, and rarely urticaria and other dermatoses. Less common: transient episodes of light-headedness, dizziness or syncope. Infrequently, mental confusion in the elderly. These adverse reactions can usually be eliminated by reduction in dosage. Serious or life-threatening reactions: Very rare cases of aplastic anaemia associated with the use of orphenadrine tablets have been reported. No causal relationship has been established. Interactions: Confusion, anxiety and tremors have been reported in some patients receiving dextropropoxyphene or dextropropoxyphene combinations and orphenadrine concomitantly. Interactions have also been reported with phenothiazines and other drugs with anti-muscarinic properties. Avoid concomitant use of alcohol or other CNS depressants. Dosage and Administration: Adults -NORFLEX tablets: Two tablets per day; one in the morning and one in the evening. Children: not recommended for children under 12 years. © 2021 Radiant Health, an iNova Pharmaceuticals company. Norflex is a registered trademark of iNova Pharmaceuticals. Distributed in New Zealand by Radiant

Clinical outcomes of pregnant patients treated with nirmatrelvir and ritonavir for acute SARS-CoV-2 infection

Pregnant patients treated with nirmatrelvir and ritonavir (Paxlovid) for COVID-19 tolerate the treatment well, according to a recently published study of 47 women. Nirmatrelvir/ritonavir was initiated at a median of one day after symptom onset, and only two patients (4.3%) did not complete the regimen because of adverse effects. Nearly two-thirds of treated patients (63.8%) had a comorbidity in addition to pregnancy that could be a risk factor for developing severe COVID-19. Half of the patients (53.2%) delivered after treatment with nirmatrelvir/ritonavir, of whom 12 (48%) underwent caesarean delivery, nine of which were scheduled. Two of 47 patients (4.3%) were hospitalised for pre-existing comorbidities.

JAMA Netw Open. 2022;5(11):e2244141

A systematic review of clinical practice guidelines for infectious and non-infectious conjunctivitis

In this systematic review, the authors critically appraised 15 clinical guidelines for the management of patients with infectious and non-infectious conjunctivitis. For non-infectious conjunctivitis, all guidelines recommended conservative measures such as artificial tears, cool compresses and avoidance/removal of allergens. There was general agreement for the use of topical antihistamines, mast-cell stabilisers and dual-therapy agents for allergic conjunctivitis. Recommended treatment for bacterial conjunctivitis (excluding chlamydial and gonorrhoeal), as well as non-herpetic viral conjunctivitis, was observation without treatment, due to the often self-limiting nature of these conditions. There was some disagreement among the guidelines based on the primary target audience (primary care, optometry, and ophthalmology).

Ophthalmic Epidemiol. 2022;29(5):473-82

ACG clinical guideline for the diagnosis and management of gastro-oesophageal reflux disease

This American College of Gastroenterology (ACG) clinical guideline provides practical, evidence-based recommendations for gastro-oesophageal reflux disease (GORD), including lifestyle, pharmacologic, and interventional management options. Patients with typical GORD symptoms (heartburn and regurgitation) without alarm symptoms (dysphagia, weight loss, and bleeding) may be administered an 8-week trial of antisecretory therapy, whereas further diagnostic evaluation (including endoscopy) is appropriate for patients whose symptoms do not respond appropriately. Among patients without a confirmed diagnosis of GORD, ambulatory reflux monitoring should be performed off antisecretory therapy, whereas pH-impedance monitoring on antisecretory therapy is appropriate for patients with persistent symptoms in the setting of an established diagnosis of GORD (i.e., advanced reflux oesophagitis, long-segment Barrett’s oesophagus, peptic strictures, and prior abnormal reflux monitoring).

Am J Gastroenterol. 2022;117(1):27-56

Patients with IBD want to talk about sleep and treatments for insomnia

Poor sleep may be associated with worse outcomes in inflammatory bowel disease (IBD), with chronic insomnia thought to be the most frequent cause of poor sleep in such patients. These authors conducted an online survey of 312 people with IBD and asked questions about sleep patterns, thoughts and behaviours related to sleep, treatment preferences, and barriers to treatment. Mean age of patients was 48.6 years, and most patients had Crohn’s disease (60.9%). Fifty percent of respondents met the clinical threshold for insomnia. Compared to patients without insomnia, those with insomnia were significantly more worried about sleep deprivation, felt more helpless about their sleep, and were more likely to prolong insomnia by, for example, spending time in bed in pain. 70.3% of participants would like to discuss sleep as part of IBD management, 63.5% would consider receiving sleep recommendations, and 84.6% of those with insomnia would like to receive sleep treatments.

Therefore, due to the high rates of poor sleep and insomnia in IBD and the patient interest in this area, clinicians should include sleep assessment as part of care. Questions to consider asking patients include:

• Are you having any issues with sleep or tiredness?

• Are your weekday and weekend sleep schedules different? [The same schedule is recommended 7 days per week]

• When you are tired or in pain, where do you go? [A couch is recommended, not bed]

Clinicians can also consider screening using validated tools, such as the Insomnia Severity Index, Pittsburgh Sleep Quality Index, or PROMIS sleep disturbance measure. Such questioning and screening may prompt referral to a sleep specialist for further evaluations (e.g., in lab polysomnography, home sleep study) or treatment within the hospital or community.

Dig Dis Sci. 2023 Feb 25

European Crohn’s and Colitis guidelines on sexuality, fertility, pregnancy, and lactation

The European Crohn’s and Colitis Organisation (ECCO) has updated their guidelines on reproduction in patients with inflammatory bowel disease (IBD). IBD has a high incidence and prevalence in young individuals, affecting people in their reproductive years. Uncertainty about the impact of pregnancy on disease control and medications on the health of potential offspring may influence patients’ choices in family planning. Therefore, the management of IBD patients who wish to conceive or who are pregnant requires specialised counselling and appropriate management. Conception and pregnancy are important life events for patients, and a concomitant diagnosis of IBD brings further concern and anxiety. Achieving and maintaining disease remission is key for a successful and uneventful pregnancy. The guidelines aim to optimise preconceptional, pregnancy, and post-pregnancy management of IBD and counselling. J Crohns Colitis. 2023;17(1):1-27

Universal hepatitis B vaccination in adults aged 19-59 years: Updated recommendations of the Advisory Committee on Immunization Practices — United States, 2022

All adults aged 19 to 59 years should receive hepatitis B (HepB) vaccination, as should those aged 60 years or older with risk factors for HepB, according to the US Centers for Disease Control and Prevention. The updated recommendations are based on a review and discussion of the relevant scientific evidence. The review was informed by 263 studies.

The report notes that around half of HepB cases reported in 2019 were in people aged 30 to 49 years and that the number of cases of HepB increased among adults aged 40 to 59 years from 2011 to 2019. Furthermore, HepB vaccination rates are low among adults. Thus, the Advisory Committee on Immunization Practices recommends that all adults aged 19 to 59 years should receive HepB vaccination. Individuals aged over 60 years with risk factors should receive HepB vaccination, although vaccination should still be offered to those aged over 60 without risk factors. People who are fully immunised against HepB or with a history of HepB infection should not receive further vaccines, with the exception of cases where revaccination may be indicated.

According to the authors, immunising all adults up to age 59 years removes the requirement for screening and may improve vaccination rates and reduce rates of HepB.

Download the report here

Association of patient risk factors, tumour characteristics, and treatment modality with poor outcomes in primary cutaneous squamous cell carcinoma

This systematic review and meta-analysis determined the association of patient risk factors, tumour characteristics, and treatment modality with poor outcomes in patients with primary cutaneous squamous cell carcinoma (SCC). A search of PubMed, Embase, and SCOPUS databases identified 129 studies (n=137,449) that were suitable for inclusion. Meta-analysis of the data revealed that tumour invasion beyond subcutaneous fat was associated with the highest risk of local recurrence and disease-specific death; perineural invasion was associated with the highest risk of metastasis. Patients who received Mohs micrographic surgery had the lowest incidence of nearly all poor outcomes.

JAMA Dermatol 2023;159(2):160-71

Australian New Zealand Mental Health Association Virtual Pass+ allows delegates to register for every single one of the ANZMHA mental health conferences for the next 12 months REGISTER NOW

Regulatory and Funding News

Pharmac news

Risdiplam (Evrysdi®) funded for spinal muscular atrophy

Risdiplam (Evrysdi®) will be funded for people with spinal muscular atrophy (SMA), who meet eligibility criteria from 1 May 2023. Risdiplam is an oral treatment that can be given or taken daily at home. Nusinersen (Spinraza®), the first funded treatment in New Zealand for SMA was funded from 1 January 2023. Nusinersen is given in hospital as an intrathecal injection into the spinal canal. Therefore there are now two funded treatments with the same access criteria for symptomatic and pre-symptomatic SMA.

Read more here

Seeking feedback on the COVID-19 antiviral molnupiravir

Pharmac is seeking feedback to clarify the role of molnupiravir for the treatment of COVID-19. There is recent evidence suggesting that molnupiravir is not effective for the treatment of COVID-19; subsequently, the Therapeutic Technical Advisory Group recommended that molnupiravir should no longer be funded for the treatment of COVID-19 in New Zealand. The feedback Pharmac has received to date suggests two options for the role of molnupiravir:

• Stop funding molnupiravir and delist it from the Pharmaceutical Schedule, meaning that it would no longer be publicly funded for any person for the treatment of COVID-19 in New Zealand.

• Make changes to the eligibility criteria for molnupiravir to limit funded access to a smaller group of people who may still be expected to benefit from treatment.

Pharmac is seeking wider feedback on these proposals.

Read more here

Medsafe updates

New legislation about medicines that can impair driving

Medsafe is alerting individuals that new legislation has been introduced to further deter drug driving, which includes both illicit drugs and prescription medicines. The most important change is the addition of Schedule 5 and new blood tests to measure the concentration of drugs in the blood. Schedule 5 lists four illicit drugs and 21 prescription medicines identified as having the highest risk to road safety. Clinicians should have knowledge of the medicines listed in Schedule 5 and check prescription Data Sheets for effects of medicines on driving. Discuss with patients the possibility that their medicines could impair driving and ask them whether they have any side effects that could affect driving.

Read more here

Abnormal uterine bleeding and oral anticoagulants

Medsafe is reviewing the risk of abnormal uterine bleeding in individuals using oral anticoagulant medicines. During the monitoring period (25 August 2022 to 28 February 2023), the Centre for Adverse Reactions Monitoring (CARM) received four reports of abnormal uterine bleeding in patients taking rivaroxaban, but not for other anticoagulants such as apixaban, dabigatran or warfarin. While the current data sheets and consumer medicine information sheets for oral anticoagulants list bleeding/urogenital haemorrhage as a side effect, Medsafe will discuss oral anticoagulants and abnormal uterine bleeding in a future edition of Prescriber Update to increase awareness of this effect.

Read more here

News in Brief

Third infant whooping cough death in NZ

Te Whatu Ora Health New Zealand is advising people to be alert to the symptoms of whooping cough and to get immunised following a third infant death in this country. Eleven cases have been reported in New Zealand so far this year. Vaccination is recommended for pregnant women, infants from 6 weeks of age, and their caregivers. Read more here

Syphilis increase in NZ

Manatū Hauora, Ministry of Health and Institute of Environmental Science and Research (ESR) are advising people to taking steps to protect themselves from syphilis, due to an increase in cases reported in New Zealand. This is of particular concern for pregnant women and their partners because unborn babies are especially at risk. There has been a 41% increase in syphilis cases in New Zealand in the second half of 2022, after a steady reduction in cases since 2019.

Read more here

COVID-19 Resources

Ministry of Health – Manatū Hauora

IMAC

RNZCGP

COVID-19 antivirals access criteria assessment tool

BPAC

Goodfellow Unit 2023

Spinal muscular atrophy: how to recognise, plus update on newly funded therapies May 02, 2023

RNZGP Auckland Facility Education Day: What’s new, HealthPathways 2023 May 13, 2023

Facial dermatitis, acne, rosacea and more Category, Tuesday 9 May 2023

Travel medicine (with a focus on high altitude travel) July 04, 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

Perceptions of Asthma Control – 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

Educational Series: Herpes zoster in immunocompromised adults

Speaker Series: Oral corticosteroid stewardship and corticosteroid treatment minimisation

Educational Series: Combined lung cancer screening and coronary artery calcium scoring

Study Review: Renal decline in patients with non-valvular atrial fibrillation

Educational Series: Pancreatic enzyme replacement therapy (PERT) for the treatment of pancreatic exocrine insufficiency

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