BEST PRACTICE 38 SEPTEMBER 2011 Dabigatran Amoxicillin clavulanate bpac nz IV treatment in the community better medicin e Editor-in-chief We would like to acknowledge the following people for Professor Murray Tilyard their guidance and expertise in developing this edition: Professor Carl Burgess, Wellington Editor Dr Gerry Devlin, Hamilton Rebecca Harris Dr John Fink, Christchurch Dr Lisa Houghton, Dunedin Programme Development Dr Rosemary Ikram, Christchurch Mark Caswell Dr Sisira Jayathissa, Wellington Rachael Clarke Kate Laidlow, Rotorua Peter Ellison Dr Hywel Lloyd, GP Reviewer, Dunedin Julie Knight Associate Professor Stewart Mann, Wellington Noni Richards Dr Richard Medlicott, Wellington Dr AnneMarie Tangney Dr Alan Panting, Nelson Dr Sharyn Willis Dr Helen Patterson, Dunedin Dave Woods David Rankin, Wellington Report Development Dr Ralph Stewart, Auckland Justine Broadley Dr Neil Whittaker, GP Reviewer, Nelson Tim Powell Dr Howard Wilson, Akaroa Design Michael Crawford Best Practice Journal (BPJ) ISSN 1177-5645 Web BPJ, Issue 38, September 2011 Gordon Smith BPJ is published and owned by bpacnz Ltd Management and Administration Level 8, 10 George Street, Dunedin, New Zealand. Jaala Baldwin Bpacnz Ltd is an independent organisation that promotes health Kaye Baldwin care interventions which meet patients’ needs and are evidence Tony Fraser based, cost effective and suitable for the New Zealand context. Kyla Letman We develop and distribute evidence based resources which describe, facilitate and help overcome the barriers to best Clinical Advisory Group practice. Clive Cannons nz Michele Cray Bpac Ltd is currently funded through contracts with PHARMAC and DHBNZ. Margaret Gibbs nz Dr Rosemary Ikram Bpac Ltd has five shareholders: Procare Health, South Link Health, General Practice NZ, the University of Otago and Pegasus Dr Cam Kyle Health. Dr Chris Leathart Dr Lynn McBain Janet MacKay SOUTH LINK Janet Maloney-Moni HEALTH Dr Peter Moodie Stewart Pye Associate Professor Jim Reid Contact us: Associate Professor David Reith Mail: P.O. Box 6032, Dunedin Professor Murray Tilyard Email: [email protected] This magazine is printed on an environmentally responsible Free-fax: 0800 27 22 69 paper managed under the environmental management system ISO 14001, produced using Certified ECF pulp sourced from Certified Sustainable & Legally Harvested Forests. www.bpac.org.nz CONTENTS The use of dabigatran in general practice: a cautious 10 approach is recommended Dabigatran is a new medicine, available without restriction, indicated for the prevention of stroke in people with non-valvular atrial fibrillation and prevention of thromboembolism after major orthopaedic surgery. Dabigatran is renally excreted so should not be used in patients with severe renal impairment. There is limited clinical experience with dabigatran so its potential adverse effects and medicine interactions are somewhat unknown. Routine anticoagulation monitoring is not required although creatinine clearance should be reassessed during long-term use. Bleeding is the main adverse effect associated with dabigatran and there is no reversal agent available. It is important to carefully weigh up the benefits and risks for individual patients before commencing treatment with dabigatran. 28 Appropriate use of amoxicillin clavulanate Amoxicillin clavulanate is an important and effective medicine but its use must be reserved for specific indications in order to reduce the rate of antimicrobial resistant infections. First-line indications for amoxicillin clavulanate are; mammalian bites (including human), diabetic foot infections and periorbital/ facial cellulitis. There are also a limited number of indications where amoxicillin clavulanate is a suitable second-line treatment for persistent infection, such as in acute pyelonephritis when treatment with ciprofloxacin is not effective. Community-based IV administration: primary care 34 reducing hospital admissions Intravenous (IV) administration of medicines in general practice clinics or in patient’s homes, is becoming increasingly common in New Zealand. Conditions that may be suitable for IV treatment in primary care include; cellulitis, dehydration and respiratory and kidney infections. Medicines such as zoledronic acid (a bisphosphonate designed for IV infusion) are now also available for prescription and administration in primary care. BPJ | Issue 38 | 1 CONTENTS Diabetes detection: what are the PHO Performance 42 Programme indicators and how are they best achieved? The purpose of the PHO Performance Programme is to improve health and reduce disparities among people using primary healthcare services in New Zealand, through the implementation of key indicators. The PHO performance indicator and target for diabetes detection is for 90% of enrolled patients with diabetes to have been indentified and coded within their patient notes. Targeted screening should be considered for people with symptoms of diabetes or who are at increased risk (e.g. family history, Maori, Pacific or Asian ethnicity). Testing for diabetes should also be part of a cardiovascular risk assessment. Supporting the PHO Performance Programme The information in this publication is specifically designed to address conditions and requirements in New Zealand and no other country. BPAC NZ Limited assumes no responsibility for action or inaction by any other party based on the information found in this publication and readers are urged to seek appropriate professional advice before taking any steps in reliance on this information. 2 | BPJ | Issue 38 CONTENTS Essentials 4 Upfront Detecting child abuse in general practice – Contributed by David Rankin, Senior Advisor, Child, Youth and Family 46 Short article Medicine safety – Contributed by the Health Quality & Safety Commission 49 News in brief New maternity referral guidelines released • Simvastatin: risk associated with high doses 51 Correspondence Use of vitamin D during pregnancy • Vitamin D in people with impaired renal function All web links in this journal can be accessed via the online version. www.bpac.org.nz BPJ | Issue 38 | 3 UPFRONT Detecting child abuse in general practice Contributed by David Rankin, Senior Advisor, Child, Youth and Family Children who come to the attention of Child, Youth of the Gateway Assessment programme and will and Family are some of New Zealand’s most support the development of several mental health vulnerable people. They have been exposed to initiatives. significant trauma and are often disconnected from regular health and education services. They This second article in our series on children and are likely to have high physical, behavioural and young people in New Zealand who have been emotional needs that create a barrier to them abused or neglected, aims to provide primary care achieving their potential. professionals with an awareness of some of the indicators of child abuse and ways to intervene. It In the Budget 2011, the Government announced also outlines the initiatives that Child, Youth and funding of $30 million over four years to provide Family have underway to identify and address the services to this group of young people. This needs of these children. money will enable the national implementation 4 | BPJ | Issue 38 Recognising neglect and abuse of children Signs of emotional abuse, in addition to those from neglect, include: Neglect is the most common form of abuse ▪ Sleep problems – including bed-wetting or soiling ▪ Frequent physical complaints – real or imagined Although the effects of neglect may not be as obvious ▪ Anxiety – including poor self esteem, inability to as physical abuse, the consequences can be just as cope in social settings and sometimes obsessive serious. behaviour. May include self-harming and suicidal ideation. Neglect can consist of: ▪ Physical neglect – not providing the necessities of life Physical abuse is any behaviour which results in ▪ Neglectful supervision – leaving children without physical harm to a child someone safe looking after them Signs of physical abuse include: ▪ Emotional neglect – not giving children the comfort, ▪ Unexplained bruises, welts, cuts and abrasions – attention and love they need particularly in unusual places like the face, trunk, ▪ Medical neglect – the failure to ensure their health buttocks or the backs of the legs. Concern should needs are met be raised when the explanations change or do not ▪ Educational neglect – allowing chronic truancy, make sense. failure to enrol children in school, or inattention to ▪ Unexplained fractures or dislocations – especially their special education needs worrying are fractures to the head or face, and hip or shoulder dislocations, particularly in young infants. Signs of neglect may include: ▪ Burns – anywhere on the body are concerning, ▪ A rough and uncared for appearance and if not easily explained need to be notified. Be ▪ Persistent skin disorders or infections mindful of burns in the shape of on object like a ▪ Lack of supervision (and as a consequence risk of stove ring or iron, cigarette marks or rope burn. injury, conduct problems and offending) ▪ Falling behind in educational achievement and Sexual abuse is any act where an adult or a more attendance powerful person uses a child or young person for a ▪ Indiscriminate attachment to adults sexual purpose Sexual abuse may be consensual or not, and can happen Emotional abuse is a component of all abuse and within or outside the family. Most sexual abuse is neglect perpetrated by someone the child knows and trusts.