Watch or listen to the November 2023 clinical update from Dr Jo Scott-Jones joined by Dr Dave Maplesden, Pinnacle GP liaison in this 38 minute podcast/video. (Written version below.)
Clinical snippets are now available as a podcast! Search on your favourite podcast platform for The New Zealand General Practice Podcast to listen, or click here to listen on Anchor.
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:
For further information, please contact firstname.lastname@example.org.
(i) A RNZCGP statement on medicinal cannabis prescribing has been recently released. Pertinent points include The College:
(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:
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.
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.
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.