Clinical Zoom meeting snippets - October 2024

I have recently looked at a complaint where the consumer had declined follow-up of an elevated PSA level over several years although did get occasional tests done which confirmed progressive elevation of the PSA. He was eventually diagnosed with metastatic prostate cancer and a complaint was made that he had not been adequately informed of the risks of not proceeding earlier with further investigations. 

MPS have published some general advice on this situation in the latest issue of Casebook noting the consumer has a right to refuse treatment even if the clinician feels this is unwise. Advice includes the following.

• There should be clear written documentation that the consumer has been offered treatment but has declined it. This should include that the possible consequences of declining the treatment have been explained to the patient, including the worst possible outcome. Giving the consumer written information about the recommended treatment is always helpful and you should document in the notes what written material has been provided. 

• Available alternative treatments should be discussed including pros and cons of these and the discussion documented. Try and arrange a follow-up appointment to allow the consumer time to reconsider their choice.  If possible, it is helpful for a relative or support person to be with the consumer at follow-up, both to support the consumer and also so whānau are aware of the choices being offered to the consumer. 

• There is no legal requirement for the patient to sign a document saying they have declined treatment and good contemporaneous notes detailing the discussion undertaken is appropriate. It should be made clear to the patient that if they were to change their mind in the future and wish to undertake treatment, whether that may be possible and what pathway the patient would follow to achieve this. 

• If there is any concern that the patient may not have the decision-making capacity to consent or decline treatment, a formal competence assessment is advisable.

(i)  Goodfellow Gem #224 recommends neonatal umbilical granulomas are treated with cooking salt. Due to a propensity to infection potentially leading to omphalitis and necrotizing fasciitis, an umbilical granuloma should be treated. Silver nitrate is often advocated as the first-line treatment for umbilical granulomas. However, along with its antiseptic effect, it is caustic and could damage healthy tissue adjacent to the umbilicus. A systematic review demonstrated that salt treatment was effective in most of 10 studies with no adverse effects. The NHS provide a treatment pamphlet outlining the regime and Children’s Health Queensland also provide a printable resource that could be adapted for local practice use.  

(ii)  Duct tape has been used to treat warts in children for many years with several studies attesting to its efficacy and tolerability and in these constrained economic times the fact it is an inexpensive treatment option is important. Instructions are to cut a piece of duct tape close to the size of the wart, place it on the wart and leave in place for six days. Then remove the tape, soak the wart in warm water, pare off any soft skin, and leave overnight. Replace the tape the next morning and follow the process for up to two months or until the wart is gone, whichever comes first. A printable instruction sheet for patients is available on the Healthinfo website. 

(iii) Pharmac has confirmed that from 1 November 2024, Estrogel (oestradiol gel) will be funded without restriction alongside other funded presentations of oestradiol. The Australasian Menopause Society produces a guide to MHT progestogen and oestrogen doses comparing strength of the various products. 

Issue 242 of GP Research Review looked at a cohort study on habitual coffee drinking and the chance of prediabetes remission. A total of 334 patients with pre-diabetes (mean age 49.4 years; 51.5% male) were followed over a period of 9 years. Overall, 39.8% of all patients returned to normal glycaemia, while 39.8% progressed to type 2 diabetes. The likelihood of achieving normal glycaemia was substantially higher among patients who reported habitual coffee consumption (OR 2.26; 95% CI 1.03-4.97), although there was no association with total daily caffeine intake. Previous studies have suggested a protective association between habitual coffee intake and risk of developing type 2 diabetes in women with a history of gestational diabetes and in prevalence of metabolic syndrome in men and women. 

• BreastNet NZ is a knowledge base for clinicians, including GPs, practice and breast nurses, SMOs and allied health providers. It promotes adherence to best-practice care through equipping primary care professionals with accurate, up-to-date information about breast cancer. By providing trusted information to medical professionals, BreastNet hopes to support the development of a skilled breast cancer workforce. 

• The site has a searchable database on all things breast and breast cancer related including descriptions of investigations and breast cancer treatments and support for cancer patients. There are currently two clinical tools available – a breast cancer risk calculator and Screen 70+ tool to help a patient to decide whether or not to continue screening beyond age 70 years. 

• For example – comment on breast density: Cancer cells and dense breast tissue appear white on mammograms. Dense breasts can make it harder to interpret mammogram results, and can ‘mask’ cancer cells. However, the risk of the masking effect has reduced since BreastScreen Aotearoa, the national breast screening programme, became fully digital. Breast density is not currently measured through BreastScreen Aotearoa (BSA). Women must have mammograms through the private system if they wish to know their density grade. Those with high breast density could consider having yearly mammograms at their own cost. These patients may also be offered ultrasound, digital breast tomosynthesis or MRI (for high-risk patients) for more accurate imaging.

(i) Novo Nordisk is discontinuing its supply of Penmix30, Penmix50 and Mixtard30 to the NZ market from September 30th 2024. If you have patients that still require changing from these products there is a 1-page advisory document available to download on the NZSSD Noticeboard. This advises on alternative products and their dose equivalents with respect to the discontinued products. The importance of monitoring and titrating accordingly after any dose or product change is emphasised. 

(ii)  From 1 October 2024 some patients will become eligible for subsidised continuous glucose monitors and insulin pumps.  Pharmac has provided a list of resources for clinicians and patients to assist with new prescribing of or transition on to the subsidies products and you can subscribe to the resource to be kept updated on any developments.  Goodfellow Unit have published a half-hour podcast on the devices with links to additional training resources.  Starship Hospital has also produced a resource which compares features of the subsidised CGM and pump devices. 

(iii)  A meta-analysis on efficacy and safety of the ultra-long-acting basal insulin analogue icodec administered one weekly in type 2 diabetics concluded Once-weekly insulin icodec showed a better HbA1c reduction with a higher proportion of patients achieving HbA1c targets in comparison with once-daily basal insulin analogues. They were no major safety concerns with respect to hypoglycaemia or adverse events.

BPAC’s best practice bulletin Issue 105 reviewed a UK study on provision of safety netting advice in after-hours primary care. The article published in the British Journal of General Practice found safety-netting advice was provided in more than three-quarters of consultations, however, patients were given generic advice in approximately half of those consultations and only one-fifth were advised of a specific timeframe after which to seek medical attention (if their symptoms did not improve or deteriorated). Clinicians were also more likely to provide safety-netting advice in-person, when prescribing or if an infection was suspected. Surprisingly, situations where safety-netting advice was less commonly given included mental health and telephone consultations. As primary care continues to evolve in the face of current challenges, safety-netting advice remains a critical tool in preventing serious patient harms, but clinicians must keep their tools sharp. BPAC provided a list of ‘Clinical Sharpeners: Safety-netting advice’.

• Provide specific rather than generic advice where possible (enabling patients to take more responsibility for their health).
• Give timeframes for when to seek further medical attention.
• Use written advice (if available), especially with more complex information, e.g. multiple symptoms.
• Document any advice given in the patient’s notes, e.g. symptoms, timeframes.

The NZ Formulary September 2024 update includes a practice highlight on nitrofurantoin with safety reminders for prescribing, dispensing, and monitoring. Comments and recommendations include the following.

• Nitrofurantoin is commonly used for the treatment of urinary-tract infection (UTI) and may also be used in some cases for prophylaxis of recurrent UTI. Duration of treatment for prophylactic doses may be up to 6 months, and in some instances longer if treatment is reviewed and the benefits outweigh the risk. 

• Always check you are prescribing and dispensing the correct product and dose—immediate-release and modified-release preparations are available and funded: Standard dosing of modified-release capsules is twice daily for a urinary-tract infection, while the immediate-release tablets are typically prescribed four times daily. 

• Prescribers should ensure the correct brand is noted on the prescription so that it is clear whether they intend to prescribe the modified-release or immediate-release preparation, and pharmacists should query any non-standard dosing to ensure it is intentional. 

• Serious pulmonary reactions such as pulmonary fibrosis (may be irreversible) and interstitial pneumonitis can occur with short-term or long-term use: Keep an eye out for signs and symptoms of pulmonary toxicity in your patients on nitrofurantoin.  Ensure your patient is aware of what to watch for, including new or worsening symptoms of cough or shortness of breath, and that they must report these.  Monitor lung function in patients on long-term nitrofurantoin. Stop treatment at the first sign of pulmonary toxicity. 

• Creatinine clearance of less than 60 mL/minute is listed as a contraindication to prescribing of nitrofurantoin with specialist advice recommended if prescribing is required. NZF also includes the comment that concomitant urinary alkalinisers (e.g. Ural^®) are no longer routinely recommended in the acute treatment of urinary tract infections as they raise urinary pH which may decrease the effectiveness of nitrofurantoin.

Pharmac is regularly updating their information regarding methylphenidate supplies. The latest update (23 September) includes detailed clinical advice regarding management options for affected patients including dose equivalence charts and pharmacokinetics summaries of the products concerned.  General advice includes the following.

Do not start any new patients on a methylphenidate extended-release formulation unless absolutely necessary. Instead consider alternative shorter duration methylphenidate formulations, i.e. immediate release tablets, or one of the 8-hour formulations Ritalin LA or Rubifen SR (note the release profiles of these two formulations are different).

For patients currently treated with a methylphenidate extended-release formulation, make an individual case by case decision. You may wish to consider the following.

• Can the patient/parent/carer liaise with their usual pharmacy to establish whether they are expecting deliveries of their required strength of methylphenidate?
• Is the patient’s prescribed strength anticipated to have an upcoming shortage?
• Is a treatment break an option?
• Is an alternative formulation of methylphenidate an appropriate interim measure?
• Is an alternative formulation appropriate to switch to over a longer period?
• Does the patient have an appropriate Special Authority approval?

Note that while the SA approval criteria apply to methylphenidate rather than a specific formulation of the drug, a different SA form/number is required for Concerta and Ritalin LA (SA 2305) with the SA 1964 form required for other preparations. Pharmac notes that GPs and nurse practitioners can legally apply for an alternative Special Authority for a methylphenidate presentation if needed, provided that all other relevant eligibility criteria are met. This relates to the legal situation only. From a clinical perspective, GPs and nurse practitioners may still need specialist advice to change presentations of methylphenidate.

The Community Health Pathway on Mpox has been updated since the recent outbreak with advice as follows.

Clinicians are asked to:

• be alert for cases linked to the Queenstown Winter Pride festival
• prioritise assessment and testing of people with symptoms compatible with mpox who attended Winter Pride or related events, or had sexual contact with event attendees
• notify Public Health urgently of suspected and confirmed cases. Public Health will contact these people to provide advice and support.

Note

• Isolation is not routinely required; covering lesions is the mainstay of preventing transmission. Public Health will advise cases of any additional restrictions required to prevent transmission.
• Mpox vaccination is recommended for mpox contacts as post-exposure prophylaxis, ideally within 4 days of exposure to a case, although it can be given up to 14 days after exposure. A list of established Mpox clinics is available on the Pathway.
• Mpox consultations and vaccinations at sexual health clinics are free.

The Pathway includes more detailed information on assessment and diagnosis including criteria for testing and appropriate use of PPE when assessing and testing suspected cases.