Clinical Zoom meeting snippets - November 2023

A recent issue of GP Voice described how patients can apply for non-subsidised pharmaceuticals to be included in Disability Allowance. 

The cost of an ongoing non-subsidised pharmaceutical can be included as an expense for Disability Allowance if you, as the client’s medical practitioner, verify that the pharmaceutical item is essential and there are no suitable subsidised or partly subsidised alternatives. 

Examples of non-subsidised pharmaceuticals include melatonin, empagliflozin, dulaglutide, liraglutide, medicinal cannabis products and others, but to be considered it must be confirmed that any subsidised or partly subsidised alternatives are not suitable for your patient. 

The application requires a Disability Allowance medical certificate and a letter from you confirming: 

• the reasons for prescribing the non-subsidised pharmaceutical 
• that there is not a suitable subsidised or partly subsidised alternative 
• that the medication is essential and directly related to the client’s disability 
• if PHARMAC funding has been applied for and declined, the reasons for this decision 
• if there is no suitable subsidised or partly subsidised alternative, and if PHARMAC funding has not been applied for, the reasons why funding has not been sought. 

For further information, please contact cathy.stephenson006@msd.govt.nz. 

(i)  A RNZCGP statement on medicinal cannabis prescribing has been recently released. Pertinent points include The College:

• neither recommends nor encourages the use of medicinal cannabis products; however, it recognises that as specialists, GPs may offer to prescribe medicinal cannabis products. The sole medicolegal responsibility for prescribing rests with the prescriber
• has assessed the evidence about the safety and effectiveness of medicinal cannabis products that have not been approved as medicines by Medsafe and has found it to be limited and inconclusive
• asserts that medicinal cannabis products should only be considered when all first-line, conventional, evidence-based treatment options have been exhausted
• supports specialist GPs who, based on their clinical assessment, decline to prescribe or to issue a repeat prescription in response to patient requests for medicinal cannabis products that have not been approved as medicines by Medsafe
• reminds specialist GPs that if they have concerns about the prescribing or record keeping of a prescriber, they should talk to them directly in the first instance. If their concerns remain, they should consider notifying the Medical Council of New Zealand or the Health and Disability Commissioner. 

(ii)  BPAC provided a comprehensive article on prescribing of medicinal cannabis last year.  The Ministry of Health constantly updates its medicinal cannabis product website with medicinal cannabis products that have met the minimum quality standard under the Misuse of Drugs (Medicinal Cannabis) Regulations 2019.  However, it is important to note the products that are listed as having been verified as meeting the minimum quality standard are unapproved medicines – there has been no assessment of their safety or efficacy. Being listed does not guarantee that the products is currently available in New Zealand.  Medsafe has published advice on use of unapproved medicines or approved medicines for unapproved conditions and this advice is contained in the NZMC statement on good prescribing practice which also notes: Medicines or treatment must not be prescribed for your own convenience or simply because patients demand them.   

(iii) On a related note, Medsafe has reclassified the medicinal cannabis product, cannabidiol (CBD), from a prescription-only medicine to a restricted (pharmacist-only) medicine, aligning the NZ approach with Australia, which made a similar change in December 2020. While no CBD products are currently approved in New Zealand, this change means that from mid-October 2023, any low-dose CBD product which becomes approved in the future can be supplied by registered pharmacists to patients over 18 years. The supply is restricted to medicines with dosing instructions for 150 mg or less CBD per day and containing not more than 4.5 grams, when sold in the manufacturer’s original pack.   

Having recently reviewed a case of adverse reaction to MMR vaccination related to IFNAR1 deficiency, I came across a statement from Te Whatu Ora released in 2020 but last updated in June this year, which includes the following information: 

• IFNAR1 deficiency is an extremely rare immune disorder that results in the individual’s immune system not responding to certain viruses. The disorder requires genetic testing to be diagnosed and cannot be prevented. IFNAR1 deficiency was only discovered in 2019.  

• This genetic condition increases the risk of serious illness and death to the individual when they are exposed to certain viruses, including measles and COVID-19.  

• IFNAR1 deficiency also increases risk of severe reaction from some vaccines containing weakened live virus such as MMR, yellow fever, and possibly varicella vaccines. Other childhood vaccines and COVID-19 vaccines can be safely given to someone who has IFNAR1 deficiency.   

• The study identifying the mutation suggests that some Pacific groups (people with Samoan, Tongan and Niuean heritage) could be at more risk of having the deficiency than the general population. Initial estimates are that the number of children with two Samoan parents who may be affected is 1 in every 6,450 births. Although equivalent data in Tongan and Niuean populations is lacking, cases have occurred where parents are Tongan or Niuean. This may roughly equate to one child per year born in Aotearoa New Zealand, but much more work is needed. For comparison, cystic fibrosis affects about 1 in every 3,500 births.  

• Health care providers may wish to inform aiga or whanau of children with Samoan, Tongan and Niuean heritage of the newly discovered risk as part of obtaining informed consent for the first dose of MMR at 12 months. It is important to also provide information about the risks associated with deciding not to vaccinate against measles, mumps and rubella. We know the risks of not vaccinating, are far greater than the risks of vaccinating. If an older sibling or relative had a severe illness following MMR this should be discussed with immunisation experts. 

Issue 224 of GP Research Review reviewed an interesting Lancet article on combining piroxicam 40mg with standard levonorgestrel EC  (LNG-EC) dose of 1.5mg concluded the combination of levonorgestrel plus piroxicam prevented 94.7% of expected pregnancies versus 63.4% with levonorgestrel plus placebo. There were no differences in advancement or delay of the next period, nor in the adverse event profile. A response to the article by the UK FSRH notes that LNG-EC acts to delay ovulation until sperm from unprotected sex that has already taken place are no longer viable, thus preventing fertilisation. There are not significant post-ovulatory contraceptive effects, therefore LNG-EC can be effective only if taken early enough in the menstrual cycle to delay ovulation. The rationale for the trial of piroxicam was that as prostaglandins support ovulation, fertilisation, tubal function and implantation, COX inhibitors (which inhibit prostaglandin production) could act synergistically with LNG-EC to affect ovulation, and could also have post-ovulatory contraceptive effects. The study did not compare effectiveness of use prior to ovulation with use after ovulation as it had intended, because too few individuals agreed to have blood tests. And no comparison was made between individuals with higher and lower BMI and weights. FSRH concluded that while in certain settings, LNG-EC/piroxicam could offer an alternative to use of LNG-EC alone, their current guidance regarding emergency contraception remains unchanged. 

Current Health Pathways guidance includes the following.

• Offer Cu‑IUD unless contraindicated. Cu‑IUD is the first choice EC unless contraindicated because it is the most effective method of EC. 
• LNG-EC is effective when taken as soon as possible after coitus, preferably within 12 hours, but within 72 hours. Pregnancy rate after taking oral LNG‑EC within 72 hours of unprotected sexual intercourse (UPSI) is approximately 2.2%. 
• Efficacy has been demonstrated for up to 96 hours (unapproved indication). 
• Efficacy diminishes with time. 
• There is no evidence that oral emergency contraception is effective if taken after ovulation or more than 96 hours after UPSI. 

The FSRH guideline on emergency contraception includes a useful one-page algorithm to aid in choosing EC taking into account factors such as time since UPSI, previous UPSI in the same cycle, and proximity of UPSI to ovulation.  Note there is an additional oral EC preparation available in the UK (Ulipristal) which is a little more efficacious than levonorgestrel although again only if used prior to ovulation.   

• I have reviewed a complaint recently relating to development of acute urinary retention in a man with pre-existing LUTS suggestive of bladder outflow issues (poor stream and frequency) who was prescribed oxybutynin for urinary frequency. He was not provided with any information regarding the risk of urinary retention and had Googled the drug and noted contraindications included significant bladder outflow obstruction.     
• Had he been provided with a NZF patient information leaflet, this refers to potential side effect of trouble peeing – inform your doctor and also to remind your doctor before taking the drug if you have known prostate problems.    
• The list of drugs that may cause retention is quite lengthy and includes some anticholinergic agents, SSRIs, calcium channel blockers, opioids, first generation antihistamines, TCAs, some NSAIDs, and many antipsychotics including quetiapine. It is certainly worth considering your older male and people assigned male at birth patient’s LUTS if you are considering prescribing any of these.   

NZ Research Review Issue 225 includes review of a study that examined the associations of retirement with cardiovascular risk factors and disease. Overall, 106,927 individuals aged 50–70 years were included in the analysis. During a mean follow-up of 6.7 years, there was a 2.2 percentage-point decrease in the risk of heart disease and a 3.0 percentage point decrease in physical inactivity among retirees compared with workers. In people with high educational levels, retirement was associated with decreased risks of stroke, obesity and physical inactivity. In people who retired from non-physical labour, retirement was associated with reduced risks of heart disease, obesity and physical inactivity. However, those who retired from physical labour were at increased risk for obesity.  

• HQSC has released updated frailty care guides. The guides are focused on the aged residential care environment; however, they may be helpful in other health care settings serving older people living with frailty. They are designed for use by health care professionals, and they support and do not replace clinical judgement.    

• One guide quite applicable to frail patients inside and outside the  aged care facility environment is that relating to de-prescribing and includes a tool and associated algorithm which aid in identifying medications which are most often suitable for de-prescribing and when stopping or continuing a drug might be indicated.               

• On the horizon is the Polyscan tool developed in NZ, a primary care information technology tool, to triage older adults with polypharmacy who are prescribed potentially inappropriate medicines. The initial study of the tool involving review of medical records of 300 older patients identified nine individuals (3%) with polypharmacy and indicators of potentially inappropriate medicine. Five unique indicators were detected. PolyScan achieved 100% sensitivity, specificity, and positive and negative predictive values.