Clinical Zoom meeting snippets - October 2023

Two recent Goodfellow Gems looked at acne treatment. A recent meta-analysis of treatments concluded the most effective treatment was oral isotretinoin, followed by triple therapy containing a topical antibiotic, a topical retinoid and benzyl peroxide.

For monotherapies, oral or topical antibiotics, or topical retinoids have comparable efficacy for inflammatory lesions, while oral or topical antibiotics have less effect on noninflammatory lesions.

In NZ the only topical antibiotic available for acne is clindamycin and benzoyl peroxide (trade name Duac – cheapest I could find on-line was $64 for a 30g tube). Topical mupirocin and fusidic acid should not be used as topical antibiotics for acne as they are generally reserved for clearing bacterial nasal carriage.

An earlier Gem reported an expert opinion study regarding monitoring of patients on oral isotretinoin suggesting current recommendations may be excessive.  A systematic review on actual lab test results found that even with 40 mg or more per day, there were few laboratory abnormalities and most NZ primary care clinicians rarely go above 10 mg per day.

Consensus statements included:

• check alanine aminotransferase (ALT) and triglycerides within a month prior to initiation and at peak dose but not monthly or after treatment completion (unless abnormalities)
• do not check complete blood cell count or basic metabolic panel parameters at any point during isotretinoin treatment.
• do not check other liver tests or lipid tests, or C-reactive protein.

A 2017 BPAC article states: A pragmatic approach would be to ensure there is a recent assessment of the patient’s hepatic function and lipid profile and to monitor patients with risks factors, e.g. a history of either hepatic dysfunction or hyperlipidaemia. Isotretinoin dosing should be reduced or treatment withdrawn in patients with persistently raised serum lipids, or transaminase e.g. ALT greater than three times the upper limit of normal. Discussion with a dermatologist is recommended for patients with significantly elevated serum triglycerides; levels > 9 mmol/L have been associated with acute pancreatitis.

NZF: Monitor liver function 1 month after starting then every 3 months (reduce dose or discontinue if transaminases persistently raised). Measure serum lipids 1 month after starting then every 3 months (reduce dose or discontinue if serum lipids persistently raised; discontinue if uncontrolled hypertriglyceridaemia or pancreatitis).  HealthPathways:  Variable advice: Liver function, lipids, CBC pre-treatment, at one month, then every three months (Canterbury).  Midlands – no need for further testing unless clinically indicated if results at one month are normal

NB Pregnancy prevention requirements presented in NZF: In people of child-bearing potential, exclude pregnancy up to 3 days before treatment (start treatment on day 2 or 3 of menstrual cycle), every month during treatment (unless there are compelling reasons to indicate that there is no risk of pregnancy), and 5 weeks after stopping treatment—perform pregnancy test in the first 3 days of the menstrual cycle.

People of child-bearing potential must use effective contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment. They should be advised to use at least 1 method of contraception, but ideally they should use 2 methods of contraception. Oral progestogen-only contraceptives are not considered sufficiently effective. Barrier methods should not be used alone, but can be used in conjunction with other contraceptive methods.

Issue 222 of GP Research Review looked at a UK study published in the British Journal of General Practice examining the association between strong opioid and antibiotic prescribing and practice-weighted GP burnout and wellness between December 2019 and April 2020.  Associations were found between greater strong opioid prescribing/greater antibiotic prescribing and increased emotional exhaustion, depersonalisation, job dissatisfaction, diagnostic uncertainty, and turnover intention in GPs. GPs who worked longer hours exhibited increased strong opioid and antibiotic prescribing. 

EAP:  All RNZCGP members can access free EAP services confidentially by calling 800 327 669 (international number +64 9 353 0906). They have clinical psychologists, budget and financial advisors, legal advisors, and other professionals ready to support you. Please mention The Royal New Zealand College of General Practitioners when you call. View more information on the EAP website.  A similar service is available for clients of MAS and MPS - details on their websites. 

Goodfellow Unit:  There is a webinar available on the Goodfellow Unit website titled Practical tips to encourage wellbeing and avoid burnout 

If you want to see how your opioid prescribing has altered over time compared with national and practice data check your He Ako Hiringa EPIC dashboard. 

(i)  Medsafe has announced that approval for PHOLCODINE to be sold in New Zealand will be withdrawn on 12 January 2024.  The decision was made on safety grounds as there is a small risk that taking pholcodine in the previous 12 months may make patients more susceptible to anaphylaxis during surgery involving neuromuscular blocking anaesthetic agents.

Pharmacists may continue to sell pholcodine-containing medicines until 11 January 2024. Pholcodine will not be recalled to help manage the winter cold season.

Recommendations for health professionals include: Inform consumers about the small but potential risk of perioperative anaphylaxis to NMBAs from prior pholcodine exposure.

(ii)  TRIAZOLAM  - The latest Pharmac update states Hypam 125 mcg tablets have run out. Supplies of the 250 mcg tablets are expected to run out in Oct/Nov 2023. Both tablets will be delisted on 1 February 2024.  This may be a time to review appropriateness of long-term benzodiazepine prescribing and He Ako Hiringa have developed some resources to aid in this decision-making including advice on withdrawal strategies.   

• The Gout Guide builds on findings from several gout projects including the Whanganui GOUT STOP programme and ProCare Gout Collaborative. It provides practical tools and insights for a fresh take on gout treatment. 

• Contains a whole range of practical resources including team education, treatment pathways, point of care testing, involvement of community pharmacy and standing order examples. There is a focus on improving inequities in gout diagnosis, treatment and outcomes with heaps of advice and examples on how to approach this issue as a practice care team.  

• The Benecheck meter referred to in the guide (Blood Glucose / Total Cholesterol / Uric Acid) is currently available from Pharmacy Direct for $82.70 with uric acid test strips less than $2.00 per strip.

A recent Research Review Expert Forum on prostate issues included an update on efficacy of PSA as a screening tool.  Comments include:

Initial research published in 2012 after 11 years of follow-up showed the number needed to screen to prevent one death from prostate cancer was 1055 and the number needed to diagnose was 37. Follow-up of this study cohort 5 years later (16 years of follow-up), revealed that in order to prevent one death from prostate cancer, the number needed to screen had decreased to 570 and the number needed to diagnose to 18, which is similar to other screening programmes such as mammography.

A 2013 study showed that even just a single PSA measurement for a patient in their 40s is very useful for predicting future risk of prostate cancer.  The study involved a random sample of 268 people with prostates aged 40-49 years followed for a median of 16.3 years. The risk of Gleason 6 prostate cancer diagnosis by 55 years was 0.6% for those with a baseline PSA <1.0 ng/mL and 15.7% for those with a baseline PSA ≥ 1.0 ng/mL. 

The increasing use of multiparametric-MRI of the prostate in people referred with elevated PSA has been shown to reduce the need for biopsy and subsequent overdiagnosis (although the false negative rate is around 10%).  MRI targeted trans-perineal biopsy is being used increasingly with much lower rates of post-procedure sepsis compared with trans-rectal biopsy.    

Use of PSMA PET-CT enables accurate detection of prostate cancer spread and assists with individualising treatment options. 

Some case studies are presented including: 

• A 47-year-old with a family history of prostate cancer presents requesting a PSA measurement. This person's PSA can be tested, as it is a very good measurement for stratification of future risk of prostate cancer in this age group. It is good to establish a baseline PSA. People with prostates from families with the BRACA mutation and history of early breast cancer and prostate cancer have a much higher risk of developing prostate cancer, and these individuals should be monitored carefully.
• A 72-year-old with a PSA of 6.5. In this person, the PSA measurement should be repeated. Their physiological age rather than just their chronological age should be considered and if they are very fit and well for their age, then this should be included on the referral letter, as according to the current 2015 Ministry of health guidelines, their PSA would not be considered abnormal, but given their potential lifespan, further assessment or treatment may be appropriate.

Updated recommendations for PSA testing can be found in a position statement from the Urological Society of Australia and NZ released last year. 

September Prescriber Update included information on:

• The importance of slow tapering of antidepressants to reduce the risk of withdrawal symptoms and discontinuation syndrome. Patients should be provided with information on antidepressant withdrawal and monitored for withdrawal symptoms.  Medsafe provide a patient information leaflet regarding stopping antidepressants.  Specific advice on tapering regimes varies and factors such as dose, duration of treatment, drug pharmacokinetics and emergence of symptoms (withdrawal or relapse) need to be considered.  Recent NICE guidelines recommend a hyperbolic dose reduction strategy ( eg each dose reduction being 50% of the previous dose and consider dropping to 25% reduction at lower doses) which may take months but is less likely to cause withdrawal symptoms than more rapid reduction.   

• Adverse reactions associated with fluroquinolones continue to be reported. Tendonitis and tendon rupture may occur at sites other than the ankle.  Time to onset has varied from within 48 hours after treatment initiation up to several months after discontinuation. The risk is increased in older patients, patients with renal impairment or solid organ transplants, and during concurrent treatment with corticosteroids. Peripheral neuropathy has also been reported in patients receiving fluoroquinolones.  Very rare cases of prolonged, disabling and potentially irreversible muscle pain or weakness, joint pain or swelling, fatigue, depression, problems with memory, sleeping, vision, hearing, and altered taste and smell have also been reported. 

• New warning information on datasheet for gabapentin: people of childbearing potential must use contraception during treatment (NZF states: People of child-bearing potential should use two forms of effective contraception during treatment to avoid unplanned pregnancy).

Useful one-page algorithms on symptom control at end of life adapted from the Ministry of Health Te Ara Whakapiri resources have been produced by Te Whatu Ora Te Wai Pounamu.  Topics include Pain Management Flowchart, Pain (with renal impairment), Dyspnoea/breathlessness Agitation/delirium/restlessness, Nausea/vomiting and Excessive respiratory tract secretions.  For a more comprehensive review of end of life care, including important cultural aspects to consider,  there is a recently published BPAC article  Navigating the last days of life: a general practice perspective which provides a wealth of practical information and advice.