ACUTE KIDNEY INJURY | RESPIRATORY INFECTIONS | VERTIGO | CVD RISK www.bpac.org.nz Issue 46 September 2012 A delicate balance: managing nz vertigo in general practice bpac better medicine EDITOR-IN-CHIEF Professor Murray Tilyard EDITOR Rebecca Harris Issue 46 September 2012 PROGRAMME DEVELOPMENT Gareth Barton, Mark Caswell, Rachael Clarke, Peter Ellison, Julie Knight, Dr Hywel Lloyd, Dr Lik Loh, Best Practice Journal (BPJ) Dr Sharyn Willis ISSN 1177-5645 nz REPORTS AND ANALYSIS BPJ is published and owned by bpac Ltd Todd Gillies, Tim Powell, Andy Tomlin Level 8, 10 George Street, Dunedin, New Zealand. DESIGN Bpacnz Ltd is an independent organisation that promotes Michael Crawford health care interventions which meet patients’ needs and WEB are evidence based, cost effective and suitable for the New Gordon Smith Zealand context. We develop and distribute evidence based resources which MANAGEMENT AND ADMINISTRATION describe, facilitate and help overcome the barriers to best Kaye Baldwin, Tony Fraser, Kyla Letman practice. CLINICAL ADVISORY GROUP Bpacnz Ltd is currently funded through contracts with Professor John Campbell, Leanne Hutt, Dr Rosemary PHARMAC and DHB Shared Services. Ikram, Dr Cam Kyle, Dr Liza Lack, Dr Chris Leathart, nz Janet Mackay, Natasha Maraku, Dr Peter Moodie, Bpac Ltd has five shareholders: Procare Health, Barbara Moore, Associate Professor Jim Reid, South Link Health, General Practice NZ, the University of Otago and Pegasus Health. Associate Professor David Reith, Leanne Te Karu, Professor Murray Tilyard ACKNOWLEDGEMENT SOUTH LINK We would like to acknowledge the following people HEALTH for their guidance and expertise in developing this edition: Dr Emma Best, Auckland Dr Andrew Chan Mow, Auckland The information in this publication is specifically designed to address conditions and requirements in New Zealand and no other country. BPAC NZ Dr Maryann Heather, Auckland Limited assumes no responsibility for action or inaction by any other party Professor Jeremy Hornibrook, Christchurch based on the information found in this publication and readers are urged to Dr David McNamara, Auckland seek appropriate professional advice before taking any steps in reliance on Professor Ian Reid, Auckland this information. Dr John Schollum, Dunedin Printed in New Zealand on paper sourced from well-managed sustainable Dr Mike Shepherd, Auckland forests using mineral oil free, soy-based vegetable inks Dr Andrea Sievwright, Auckland Dr Jake Twiss, Auckland Dr Tony Walls, Christchurch CONTACT US: Mail: P.O. Box 6032, Dunedin Email: [email protected] Phone: 03 477 5418 Free-fax: 0800 27 22 69 www.bpac.org.nz CONTENTS Issue 46 September 2012 10 Acute-on-chronic kidney disease: prevention, 10 diagnosis, management and referral in primary care Acute kidney injury (in a community setting) occurs most commonly in people with existing chronic kidney disease. The first focus of primary care is to prevent acute-on-chronic kidney disease from occurring. However, preventative strategies cannot remove the risk completely. Acute kidney injury should be considered a medical emergency. If there is a clearly identifiable cause then this should be managed. If the cause of deterioration is not clear then this warrants early discussion with nephrology services. 16 16 Bronchiolitis in infants Bronchiolitis is the most common lower respiratory tract infection in infants, and between 2006 and 2010 accounted for almost 15% of all childhood illness-related hospital admissions in New Zealand. Bronchiolitis is diagnosed clinically, and children can usually be managed at home, unless symptoms are severe, or risk factors for complications are present, e.g. very young age, co-morbidities, socioeconomic factors. Bronchiectasis: rates still increasing among Pacific 21 peoples Bronchiectasis is a lung disease characterised by irreversible bronchial dilation and chronic inflammation, resulting in 25 chronic wet cough. It occurs in both children and adults, and although a relatively uncommon condition, bronchiectasis disproportionately affects Māori and Pacific peoples and people from lower socioeconomic communities. 25 Otitis media: a common childhood illness It has been suggested that otitis media is an unavoidable illness of childhood. In most cases, symptomatic treatment is all that is required, however, in severe cases, complications can occur, such as perforation of the tympanic membrane, otitis externa, mastoiditis and disturbances to balance, motor control and hearing. Children living in lower decile communities, where overcrowding is common, are at increased risk of developing otitis media and complications. BPJ Issue 46 1 CONTENTS Issue 46 September 2012 A delicate balance: managing vertigo in general 30 30 practice Vertigo is a symptom, not a diagnosis. Although usually benign, vertigo can be a symptom of a significant underlying problem. Differentiating between the simple and the serious causes is a challenging process of elimination, based on the patient’s description of their symptoms and the interpretation of signs found on examination. 38 Assessing cardiovascular risk in people with high clinical risk factors Cardiovascular risk assessment tools automatically adjust risk 38 to greater than 20% for people with high risk factors, e.g. a prior cardiovascular event or overt diabetic nephropathy. This is leading to a blurring of the concept of primary and secondary prevention and in some cases, patients are not receiving the intensive interventions required as the perception is that their risk is always high and cannot be reduced. People with high clinical risk factors have the most to gain from cardiovascular risk lowering interventions. 3 Funding changes to diabetes management products announced 6 Medicines interactions: using the New Zealand Formulary 44 Correspondence Guidance for stopping alendronate, Corrections facebook.com/bpacnz All web links in this journal can be accessed via the online version: www.bpac.org.nz 2 BPJ Issue 46 Funding changes to diabetes management products announced On 1 September 2012, three new blood glucose meters were listed on the Pharmaceutical Schedule: CareSens II, CareSens N and CareSens N POP. Key dates for the changes 1 September 2012 – CareSens range of blood The CareSens brand will replace previously funded diabetes glucose meters and testing strips listed for meters, however, changes will be phased in over six months, subsidy on the Pharmaceutical Schedule so there is no need for patients or health professionals to take 1 December 2012 – only CareSens range of urgent action or initiate additional patient visits to change blood glucose meters will be subsidised. Other meters. currently funded brands of blood glucose meters (Accu-Chek Performa, Optium Xceed, On PHARMAC is working with the supplier and health Call Advanced, FreeStyle Lite) will no longer be professional groups to run a nationwide meter swap funded campaign, to demonstrate the meters to patients and provide 1 March 2013 – only CareSens range of testing environmentally safe disposal of old meters. strips will be subsidised. Other currently funded brands of testing strips (Accu-Chek Performa, The changes may also provide an opportunity to review Optium 5 second test, On Call Advanced, patients’ current testing regimens and educate on appropriate FreeStyle Lite) will no longer be funded testing. Funding of existing meters continues for some patients: For patients using the Accu-Chek Performa meter with an Accu-Chek Combo insulin pump prior to 1 June 2012, there will be continued funding, via Special Authority, for the Accu-Chek testing strips for the life of the Accu-Chek Combo insulin pump For patients using a Freestyle Optium (Optium Xceed) meter as their only meter for both blood glucose and ketone testing prior to 1 June 2012, there will be continued funding, via Special Authority, of the Optium blood glucose test strip BPJ Issue 46 3 CareSens meters Key messages: There are a few key differences between the meter PC Software is available free of charge – a USB cable is people are using now and the new meters: available from Pharmaco – For most patients, no calibration step is required Key information about the meters, including patient – There is no ability to “top up” the blood sample on information in multiple languages, is available from: test strip www.caresens.co.nz Test strips need to stay in their storage container and the For any meter queries, contact Pharmaco on: 0800 expiry date should be checked GLUCOSE (0800 458 2673) CareSens II The CareSens II has a large screen and large numerals useful for vision impaired people with diabetes. It stores 250 records on the meter or records can be downloaded to the PC Care software. CareSens N The CareSens N is a simple, no-coding meter, which calculates and displays the 14-day average of total test results, as well as pre- and post- meal test results. This meter is ideal if people need to test frequently or require alarms to remind them to test at meal times. The meter stores 250 records which can be downloaded to the PC Care software. CareSens N POP The N POP meter includes more advanced functions such as LCD backlighting, plus strip expiry indicator alarm and no manual coding. The meter stores 500 records which can be downloaded to the PC Care software. 4 BPJ Issue 46 Insulin pumps As well as changes to blood glucose testing equipment, PHARMAC is now funding insulin pumps and consumables. The Animas 2020 insulin pump and a range of insulin pump consumables are available via Special Authority for those people who meet the criteria. The application form can be completed online and eligibility against the Special Authority criteria will be assessed by a panel of clinicians. A further competitive process is currently underway to identify a second insulin pump for funding – this process is hoped to be completed by the end of 2012. Online form available from: www.pharmac.govt.nz/SAForms For further information about these changes, see: www.pharmac.govt.nz/diabetes Chronic Care Module The new bestpractice Decision Support Chronic Care Module combines cardiovascular risk assessment, chronic kidney disease and diabetes management all in one simple intuitive decision support form.