Clinical Zoom meeting snippets - March 2023

• The He Ako Hiringa agency’s mission is to contribute to creating equitable access to funded medicines, by providing education and updates to primary care clinicians. You can register with the agency and access a variety of educational resources related to equitable and best practice prescribing.    

• This includes your own EPiC dashboard which facilitates learning and reflective activities comparing your personal, practice and national prescribing data on an increasing number of themes such as equitable prescribing of cardiovascular medications for patients with CVD, antibiotic stewardship, asthma and diabetes prescribing.  Highly recommended!   

• Kiwifruit is a commonly suggested treatment for constipation in New Zealand and previous studies (Two Gold Kiwifruit Daily for Effective Treatment of Constipation in Adults-A Randomized Clinical Trial and 
  here and Exploratory Comparative Effectiveness Trial of Green Kiwifruit, Psyllium, or Prunes in US Patients With Chronic Constipation) examining the effects of kiwifruit on patients with constipation have demonstrated potential benefit. However, clinical guidelines favour the use of soluble fibre bulking agents as first line management options for patients with constipation.   
• With New Zealand currently experiencing ongoing supply issues with funded psyllium husk powder and other laxative products, patients need more options for symptom relief.  A 2023 paper published in the American Journal of Gastroenterology examined the effects of daily kiwifruit consumption on gastrointestinal function and comfort. This randomised controlled trial provides evidence that consumption of kiwifruit is beneficial for people with constipation and may have greater benefit than psyllium husk. 
• Further information on the management of constipation. 
• Further information on the management of irritable bowel syndrome in adults.

• Just a Thought is a New Zealand organisation that offers free online cognitive behavioural therapy (CBT) courses and hosts other resources for a range of mental health conditions. A new online CBT course has now been released for people with obsessive compulsive disorder (OCD). The course has been adapted for New Zealand from an Australian online CBT course for OCD. The Australian course by This Way Up has been evaluated in a randomised controlled trial showing good efficacy. 
• In many areas across New Zealand, there are significant wait times to access publicly funded psychological or psychiatric services, or even sometimes private services. Online therapy courses for OCD may have a role in supporting patients while they await access to secondary care services. The course can either be completed by the patient in a self-guided manner or through prescription by a clinician. Adherence rates are higher when a clinician prescribes the course and incorporates it into their follow-up consultations. 
• Further information on the recognition and management of a patient with OCD.  

• A recent issue of NZ GP Research Review commented on a Dutch retrospective study looking at the added value of CRP to clinical features when assessing appendicitis in children with acute abdominal pain in primary care. The study showed the sensitivity and specificity of a CRP cut-off ≥10 mg/L were 0.87 and 0.77 respectively. When symptoms lasted > 48 h, this sensitivity increased to 1.00. Positive predictive values for CRP alone were low (0.18–0.38) for all cut-off values.   
• The reviewer noted: Point-of-care CRP testing is very common in the Netherlands. It is used in identifying viral versus bacterial infection especially for acute respiratory symptoms in children and this study demonstrates that it is valuable in diagnosing acute appendicitis versus mesenteric lymphadenitis, which can have very similar symptoms and signs. If CRP is <10 mg/L along with non-progressive symptoms over a 48-hour time span, appendicitis is unlikely. 

• A recent PEARL in NZ Doctor looked at the question: Are glucocorticoids effective and safe for treating croup in children aged 18 years and under? Citing a Cochrane systematic review, the bottom line is that compared with placebo, budesonide (2mg per nebuliser) and dexamethasone reduced the symptoms of croup within 2 hours of treatment, with the effect lasting at least 24 hours. One trial showed that prednisolone reduced the symptoms of croup within 6 hours, with the effect lasting at least 12 hours. One trial showed that fluticasone did not reduce the symptoms of croup after 2, 6 or 24 hours compared with placebo. 
• There was little to no difference between dexamethasone and prednisolone for reduction in croup symptoms 2 hours following treatment, and likely no difference after 6 hours. However, dexamethasone probably reduced the rate of return visits and/or (re)admissions for croup by almost half. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg but more studies are needed to confirm this.  
• Starship Hospital croup guidelines include the following recommendation: Oral dexamethasone 0.15mg/kg/dose and oral prednisolone 1mg/kg/dose are both as effective as oral dexamethasone 0.6mg/kg/dose. In the community, where oral dexamethasone may not be available, community providers can prescribe oral prednisolone at 1mg/kg/dose once daily for 2 days. 
• It is important to differentiate the steroid advice for croup and asthma from that for bronchiolitis where Starship Hospital and BPAC guidance advises:    
  • do not administer beta-agonists 
  • do not administer corticosteroids (systemic or nebulised) 
  • do not administer adrenaline (except in peri-arrest/arrest) 
  • do not administer hypertonic saline 
  • antibiotics and antivirals are not indicated in bronchiolitis. 

The March 2023 Medsafe Prescriber Update included the following updates and reminders. 

(i)  Risk of neurotoxicity with cephalosporins 

• There have been reports of neurotoxicity with cephalosporins, including encephalopathy, seizures and/or myoclonus. Risk factors include older age groups, renal impairment, underlying central nervous system disorders and intravenous administration.    
• Consider cephalosporins as a potential cause of neurotoxicity in patients with these risk factors and an unexplained, new onset neurological condition. Symptoms of neurotoxicity have been reported to develop within several days after starting treatment and to resolve following discontinuation. Note maximum doses dependent on eGFR are listed in NZF and drug data sheets. 

(ii)  Lithium and new diabetes agents 

• 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. 

• Monitor the patient’s serum lithium levels more frequently when a SGLT2 inhibitor is initiated or following dose changes. Adjust the lithium dose if necessary. 

(iii)  Metoclopramide in children and young adults 

• Due to the risk of dystonic side effects, metoclopramide use in children and young adults (aged 1 to 19 years, inclusive) is limited   to certain conditions and for second-line therapy.  NZF states:  Patients under 20 years:  Use restricted to severe intractable vomiting of known cause, vomiting of radiotherapy and cytotoxics, aid to gastro-intestinal intubation, premedication; dose should be determined on the basis of body-weight. 
• Dystonia can occur after a single dose of metoclopramide and occurs more frequently in children and young adults, and in females. 
• Do not use in people under 20 years of age unless absolutely necessary, and then strictly follow the dose recommendations in the metoclopramide data sheets to reduce the risk of dystonic side effects.