Month: October 2025

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , , , , ,

Clinical Snippets September 2025

https://open.spotify.com/episode/5i9wUuxH5kdEXCzrK0pgjQ?si=3uXdYDZxQM6nMjlenuMYOQ

Clinical Snippets September 2025

1. Malnutrition

A recent issue of NZ Doctor reviewed detection and management of adult malnutrition (Malnutrition Awareness Week ran from 8-12 September), noting it can be difficult to detect and is often overlooked in primary care. 

(i) Key risk factors include:

  • older age (especially 75+)
  • chronic conditions (eg, chronic obstructive pulmonary disease, heart failure, cancer, inflammatory bowel disease, liver disease, dementia)
  • polypharmacy and medication side effects
  • poor appetite or early satiety
  • chewing or swallowing difficulties
  • living alone, poverty or reduced mobility, especially in older adults
  • recent hospital admissions or unexplained weight loss.

(ii) Start with the basics – ask patients:

  • Have you lost weight without trying in the last three to six months?
  • Have you been eating less than usual?
  • Have you noticed your clothes or belts fitting more loosely?

(iii) Routinely document:

  • weight and height so it is easy to see if weight has changed over time
  • changes in appetite, energy or function
  • illness or social factors affecting food intake (eg, living situation, money to buy food).

(iv) Use a validated screening tool

  • Malnutrition Universal Screening Tool (MUST) assesses BMI, unplanned weight loss and acute disease effect, and is available online. It categorises risk as low, medium or high.
  • MNA-SF is designed for older adults (65+) and includes six questions on appetite, mobility, recent illness, weight loss and BMI. It can be completed by health professional or patients

(v) Refer to a registered dietitian if the patient is:

  • identified as being at high risk of malnutrition (using a validated screening tool)
  • experiencing unintentional weight loss of greater than 5 per cent in three to six months
  • eating poorly due to illness, nausea, swallowing issues, poor dentition or depression
  • recently discharged from hospital after a nutrition-impacting condition
  • living with a long-term condition that affects eating or nutrient absorption
  • unable to meet nutritional needs with food alone.

Do not wait for laboratory results. Malnutrition is a clinical diagnosis, and blood tests are not required to refer.

(vi) Health Pathways have a dedicated section Weight and Nutrition in Older Adults

2. Breast Screening Extension

Te Whatu Ora has announced an extension to the national breast screening programme.

(i) Extending the age for breast screening across New Zealand in year one will only apply to 2 age groups: 70 and 74-year-olds (except for the pilot district of Nelson and Marlborough which started 1 October 2024)

As of 1 October 2025:

  • Women who turn 70 on or after 1 October 2025 are eligible for free mammograms every 2 years (from their last screen) until aged 75.  Note: some women may have screened at 69 and won’t be due again at 70
  • Women who are 70 to 74 before 1 October 2025 are eligible for one final screen at age 74, if booked before turning 75

(ii) Extending the age (to include all women up to the age of 74) will be fully in place by the end of 2029. This phased approach will enable breast screening and cancer treatment services to progressively meet the additional demand.

(iii) Women aged 70 and 74 will be automatically identified through the new online breast screening system called Te Puna .  A BreastScreen Aotearoa provider will then send them a personalised link to enrol/re-enrol and to book a mammogram. This is a shift away from an opt-in to an opt-out enrolment approach.

(iv) Design and construction work for three additional fixed locations is expected to be ready in time for the age extension national rollout, and another two in 2026. Mammography, ultrasound machines and three additional mammography semi-trailers are also on order. Additional funding for treatment costs related to the age extension are planned.

(v)  The Te Puna website notes GPs and primary care professionals are encouraged to talk with their patients aged 45 to 69 (and women aged 70 and 74 from 1 October 2025) to enrol/re-enrol and to book a mammogram when they receive their secure personalised link.  GPs are also requested to keep referring their patients aged 45 – 69 years (plus women aged 70 and 74 from 1 October 2025*) through current processes to ensure all eligible women are invited.

3.  Serum oestradiol

The BMS Tool for Clinicians, released in July 2025 by the British Menopause Society (BMS), provides guidance on measuring serum estradiol in the menopause transition, emphasizing that a single estradiol level is not sufficient to gauge menopause hormone therapy (MHT) effectiveness or manage symptoms.  Some points from the 13-page document summarised in GP Notebook include:

4. Equity focus – anticoagulant monitoring

Issue 116 of Maori Health Review examined a recent NZMJ article on anticoagulation management and poor clinical outcomes in tamariki and rangatahi with rheumatic heart disease following mechanical valve replacement surgery in Counties Manukau

  • This was an observational study conducted in the Counties Manukau region between 2016 and 2021. A total of 53 individuals were included, of whom 19% were Māori and 81% were Pacific peoples. Median age at time of first mechanical valve surgery was 15 years (range 4-23 years), and the median duration of anticoagulation was 4 years (range 0.5-18 years). Monitoring was most commonly carried out via the community laboratory service and general practitioner.
  • Overall, 38 individuals had at least one anticoagulation-related hospitalisation. Reasons for the 80 anticoagulation-related hospitalisation events were subtherapeutic INR without clinical complication (52%), supratherapeutic INR without clinical complication (15%), haemorrhage (14%), stroke (9%), other thromboembolic event (6%), and prosthetic valve thrombosis (4%). Five deaths occurred over the study period.
  • The authors concluded that urgent efforts are required to improve services for anticoagulation monitoring and management in young adults following mechanical valve surgery for rheumatic heart disease.  What are the barriers to optimum INR management in this group and how might they be best addressed?

5.  Prostate cancer screening and DRE

Best Practice Bulletin 128 includes an interesting Practice Focus on the question Prostate cancer screening – to DRE or not to DRE?

  • Prostate cancer is the most common cancer in males in New Zealand, and the second most common cause of cancer-related mortality. Performing a digital rectal examination (DRE) for prostate cancer screening is often considered best practice in New Zealand, alongside PSA testing. However, recommendations vary between international guidelines.
  • An article published in the British Journal of General Practice (BJGP) last year questioned the value of DRE in prostate cancer screening and raised concerns about the procedure representing a barrier to males seeking care for prostate-related issues. The British Association of Urological Surgeons in association with Prostate Cancer UK, has since issued a statement (June, 2025), that DRE is no longer considered a useful screening test for prostate cancer. There have been no changes to the recommendations in New Zealand at this stage.
  • The statement states evidence shows that fear of rectal exams is the greatest barrier to men taking action by talking to their GP about the PSA blood test. Different research from Prostate Cancer UK found that in a group of more than 2,000 men, 60% were concerned about having a rectal exam. Of those, 37% would not speak to a GP about prostate worries because they feared the DRE.  Even worse, Black men — who have twice the risk of getting prostate cancer and dying from it — report that they feel an even greater stigma about rectal exams.
  • My favourite AI source states DRE is not recommended as a primary screening test for prostate cancer due to its poor diagnostic accuracy and limited impact on cancer-related morbidity or mortality. Systematic reviews and meta-analyses demonstrate that DRE has low sensitivity (approximately 51%) and specificity (approximately 59%) for prostate cancer detection, and its positive predictive value is particularly poor in men with low or normal PSA levels.

6.  Release of 16 optimal cancer care pathways

The Cancer Control Agency | Te Aho o Te Kahu has published 16 Optimal Cancer Care Pathways (OCCPs) for eight solid tumours and eight blood cancers that affect people in Aotearoa New Zealand.

 The OCCPs are pathways that describe contemporary best practice for the delivery of optimal cancer care by tumour type. Each OCCP has been designed in partnership with the sector:

  • With the needs of the person and their whānau (family) at the heart
  • To reflect the best service capabilities available in New Zealand
  • To provide a national expectation of equitable, high-quality, timely, and evidence-based cancer prevention and care for all New Zealanders.

7.  FIT Symptomatic Pathway

  • The implementation of the FIT for Symptomatic clinical pathway in the Waikato District went live last month.  The pathway is a new model of care for patients referred from primary care with bowel symptoms.  Patients will be triaged and graded by a clinician as usual, and will be graded for urgent colonoscopy, non-urgent colonoscopy, to be seen in clinic, or declined. Some of the patients graded as non-urgent will be sent a FIT test kit as part of the triage process.  Patients who are triaged as urgent or not suitable for the FIT test will proceed to colonoscopy or clinic without the requirement to complete the FIT test.
  • Patients with a negative FIT result, unless otherwise stated at the initial triage by the grader, will be returned to primary care without being offered a colonoscopy. They will receive a discharge letter advising them that if their symptoms become more severe or persist for more than six weeks, they are to make another appointment promptly with their GP/ health care provider.
  • Within the FIT for Symptomatic Register, patients will be flagged if they have been sent a bowel screening kit or are due to be sent one in the next 30 days.  Within the FIT for Symptomatic pathway there are patient touch points to support the patient to return the FIT KIT if a result is not received.
  • The National Bowel Screening Programme FIT threshold for a positive test result is ≥200ng Hb/ml buffer while the threshold for the FIT for Symptomatic clinical pathway is ≥50ng Hb/ml. When tested on the New Zealand population the diagnostic accuracy was comparable to previous studies in the UK.  Using a threshold of 50ng Hb/ml buffer the sensitivity was 91% and the specificity was 83%. The negative predictive value is 99.6% for a threshold of ≤50ng Hb/mL buffer with the number needed to scope to identify one bowel cancer if the FIT threshold is ≤50ng Hb/mL buffer being 280. 
  • You need to advise the patient that they are being referred for a bowel assessment and they may be offered a FIT test.
  • Provide them with the patient information sheet that will be available on HealthPathways and on HealthEd (various languages and print sizes), confirm their address and identify any support needs on referral.
  • Please also advise the patient that if they receive a negative FIT result but continue to have persistent symptoms to return to you, their GP or nurse practitioner.
  • Please consider if the practice needs to actively contact a FIT negative patient at six weeks (having received a discharged letter). There are many barriers to symptom presentation and being advised you don’t need a colonoscopy may subtly add to these.

8.  Oral iron tablets

  • Pharmac has announced a supply issue affecting ferrous sulfate 325 mg modified-release tablets (Ferrograd) due to a change in manufacturer and price. Ferrograd tabs are expected to go out of stock in early September and no alternative equivalent brand is available. No new patients can be prescribed ferrous sulfate tablets from 1st September, 2025, and this formulation will be delisted from the Pharmaceutical Schedule on 1st March, 2026.
  • Ferrous fumarate 200 mg (Ferro-tab) is an alternative oral iron supplement although it is an immediate-release formulation and lower elemental iron dose than Ferrograd, and some patients may require dosing up to three times daily, as opposed to once daily with Ferrograd (see NZF for dosing instructions). However, ferrous fumarate may be better tolerated by some patients.

9.  Standing orders for adrenaline for authorised vaccinators

  • A recent statement from the Immunisation Advisory Centre confirms that while there has been no change to the Medicines Regulations 1984, authorised vaccinators administering adrenaline for post-vaccination anaphylaxis require a prescription or a Standing Order.
  • Vaccinator authorisation is enabled under the Medicines Regulations 1984 (44A), which does not include authorisation to administer adrenaline. Previously, administration of adrenaline by authorised vaccinators was understood to have been covered by vaccinator authorisation.
  • Adrenaline is not a prescription medicine; however, it is a restricted (pharmacist-only) medicine and its administration by non-prescribing registered healthcare professionals (other than pharmacists) requires a prescription or a Standing Order.

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , , , , , , ,

August 2025 Clinical Snippets

Clinical Snippets August 2025

1. Desmopressin in nocturnal enuresis in children

A recent PEARL from the Cochrane organisation  looked at the effectiveness of desmopressin for treating nocturnal enuresis in children.  It was noted the overall quality of evidence in the studies reviewed was low to very low. 

  • The bottom line was thatdesmopressin may reduce the mean number of wet nights per week by 1–2 compared with placebo, with higher doses potentially offering greater benefit. Its effectiveness compared with alarm therapy or tricyclics is unclear. Combining desmopressin with alarm training probably reduces the number of wet nights per week compared with desmopressin alone.
  • Desmopressin probably results in an increase in the number of children achieving 14 consecutive dry nights by the end of treatment compared with placebo. Its effectiveness compared with alarm therapy or tricyclics remains uncertain for this outcome. Combining desmopressin with alarm training or anticholinergics may increase the number of children achieving 14 consecutive dry nights by the end of treatment compared with desmopressin alone.
  • Health Pathways have a helpful Enuresis in Children pathway that notes medications for primary nocturnal enuresis are rarely indicated.  With respect to desmopressin, the Pathway notes:
  • 60 to 70% of patients will respond
    • Response not sustained on drug withdrawal
    • Safety concerns regarding water intoxication: Hyponatraemia, cerebral oedema, convulsions; Small number of deaths in the USA occurred in otherwise healthy children on desmopressin for nocturnal enuresis.  Oral formulation safer than intranasal
    • Minimise risk by using lowest effective dose and restricting fluid from 1 hour prior to 8 hours post-dose
    • Consider for short-term use on nights away from home: 1 to 2-week trial period at home is suggested first to determine if response is adequate.
    • Discrete use of padded pull-up underpants may prove a safer and more effective alternative.
    • Desmopressin tablets and wafers are fully funded without special authority
    • For longer term use, a specialist review is suggested. An alarm programme should either have been trialled first or considered inappropriate due to child or family circumstances.
  • The NZ Formulary for Children emphasises the potential risk of hyponatraemia due to fluid overload noting patients being treated for primary nocturnal enuresis or nocturia should be warned to avoid fluid overload (including ingesting water during swimming) and to stop taking desmopressin during an acute illness with fever, vomiting or diarrhoea (until fluid balance is normal). The risk of hyponatraemia can also be minimised by keeping to the recommended starting doses.

2. Prescriber Update

The September 2025 issue of Prescriber Update includes a few pertinent reminders:

(i)  Fluoroquinolones: There is another reminder that fluoroquinolones have been associated with prolonged, disabling, and potentially persistent/irreversible serious adverse reactions, including tendonitis/tendon rupture, peripheral neuropathy and psychiatric reactions including psychosis or depression leading to suicidal ideation.  Only prescribe fluoroquinolones when other antibiotics normally used for the infection are inappropriate and advise patients to promptly report any symptoms/signs of an adverse reaction.

(ii) Macrolides: At the June 2025 meeting it was recommended all macrolide antibiotics should include the increased risk of adverse cardiovascular outcomes on the Medsafe data sheet (currently only listed for clarithromycin). Meta-analyses and large cohort studies indicate that macrolide use is associated with a 2- to 3-fold increased risk of sudden cardiac death or ventricular tachyarrhythmia compared to non-macrolide antibiotics, with an absolute risk increase of approximately 118 additional events per 1 million treatment courses.  The risk is highest during the first week of therapy and is largely confined to the duration of treatment. It is most pronounced with erythromycin and clarithromycin, while azithromycin also carries risk but to a lesser extent. Roxithromycin appears to have a lower risk profile.  Patients with underlying cardiac disease or those taking concomitant QT-prolonging medications are at increased risk. 

(iii) Adult ADHD medication:    There is a several page section on adult ADHD medication noting psychiatric effects, cardiovascular effects, and risk of seizures should all be considered when prescribing these medicines.  Some specific statements include:

  • Treatment of ADHD with stimulants should not be initiated in patients with acute psychosis, acute mania, acute suicidality or signs of suicidal tendency. Monitor patients for onset or exacerbation of aggressive behaviour which may occur during treatment.
  • Do not use lisdexamfetamine in individuals with tics or Tourette’s syndrome.  Methylphenidate is associated with the onset or exacerbation of motor and verbal tics, including worsening of Tourette’s syndrome. There have been reports of tics with atomoxetine.
  • Adults with structural cardiac abnormalities or other serious cardiac problems (eg, cardiomyopathy, heart rhythm abnormalities) should not be treated with these medicines.  Some patients can have clinically relevant increases in blood pressure or heart rate so regularly review blood pressure and cardiovascular status during treatment.
  • Additional potential adverse effects mentioned include lowered seizure threshold, risk of serotonin syndrome when co-administered with other serotonergic agents, risk of abuse and (with atomoxetine) risk of liver injury. 

(iv)  Pisa Syndrome:  Pisa syndrome refers to an abnormal posture characterised by involuntary leaning to one side when upright (>10 degrees constant lateral flexion). The person may have difficulty walking and standing up straight. 

  • Anticholinesterase inhibitors and antipsychotics are the most frequently reported medicines associated with Pisa syndrome.  Some antidepressants, anti-Parkinson agents, lithium and valproate have also been implicated.
  • Medicine-induced Pisa syndrome may appear months to years after starting the medicine. It usually resolves after stopping the suspected medicine or lowering the dose. 

3.  ADHD resources

4.  National Community Referral Criteria for Imaging

Te Whatu Ora has introduced mandatory national criteria for Community Referred Radiology (CRR) from 1 September 2025, replacing the previous regionally adapted framework. These changes aim to standardise access and improve equity nationwide. Key changes include:

  • national, non-modifiable criteria
  • expanded referral eligibility (now includes GPs, urgent care doctors, and nurse practitioners)
  • defined priority timeframes (e.g. acute, urgent, 2–6 weeks)
  • new triage and liaison roles to support referrals
  • digital tracking and integration with ERMS, BPAC, and HealthLink
  • clear responsibilities for follow-up and service provision

The 114 page document is available here with a supporting explanatory document  for primary care also available. 

There is a Goodfellow Unit webinar Navigating radiology: Referral to result taking place on Tuesday evening 30 September.  This is advertised as:  Learn about the new Community Radiology Programme and Regional Hubs, including the tools and context to confidently refer under the new system.

5.   CT Imaging and Cancer Risk

Issue 20 of GP Practice Review included a study published recently in JAMA  on the projected lifetime cancer risks from current CT imaging in the USA.  The review notes that CT is an extremely useful medical imaging test however the risk of cancer associated with the exposure to ionising radiation used to perform the procedure is unknown. These researchers estimated the number of future cancers that could result from the 93 million CT scans performed in the United States in 2023. The risk model projected that CT scans in 2023 could result in approximately 103,000 future cancers. The per-examination cancer risks were higher in children and adolescents, but higher CT utilisation in adults meant that most of the projected cancers would occur in adults. These findings suggest that if current CT utilisation practices continue in the United States, CT-associated cancers could potentially comprise 5% of all new cancer diagnoses annually. Lung cancer and colon cancer were projected to be the two cancers to be increased the most due to CT scan exposure.  The reviewer notes This study provides interesting information regarding the cancer risk associated with CT scans. Many patients are unlikely to consider the risks associated with medical imaging, including of incidental findings. This paper will help to guide discussions with patients by emphasising that medical imaging is not a benign intervention and that careful consideration regarding how any result will guide management is required before referring a patient for any imaging procedure.

6.  Covid-19 antiviral eligibility

Pharmac has announced that from 1 September 2025, the COVID-19 antivirals nirmatrelvir with ritonavir (branded as Paxlovid) and remdesivir (branded as Veklury) will be funded for people aged 50 years or over with an active COVID-19 infection who are at high risk of hospitalisation or death from COVID-19.

This decision will improve access to these COVID-19 antivirals for people aged between 50 and 65 years who are high risk and not already eligible under the other access criteria. People who can currently access funded antivirals will continue to have access to them under the updated criteria and the Pharmac Paxlovid access criteria assessment tool has been updated to reflect the new criteria.

BPAC have recently released a supporting article that discusses what patients may be at increased risk of hospitalisation, with a table of various morbidities that might be considered.  The article concludes:

In general, consider COVID-19 antivirals in a patient aged 50 – 64 years if they have any of the following factors:

  • Māori or Pacific ethnicity
  • Socioeconomic deprivation that means they do not have a stable setting in which to recover from COVID-19, or a reliable means of caring for themselves, seeking help or responding to follow up
  • Are not fully vaccinated against COVID-19 (primary course) and never had COVID-19 before
  • One or two of the medical co-morbidities from Table 1 if there is clinical concern about the effect on recovery from COVID-19

7. Reminder re hyperkalaemia

A recent NZ Doctor article reviewed causes of hyperkalaemia.

(i) Impaired renal function – for individuals with pre-existing impaired renal function, serum potassium levels may be elevated. These individuals are more susceptible to hyperkalaemia if they become dehydrated or take medicines that have a detrimental additive effect on serum potassium levels.

(ii) Dietary factors – it is worth exploring whether any dietary changes could increase serum potassium levels, particularly during the fruit seasons (eg, bananas, oranges, avocados and tomatoes).

(iii) ACE inhibitors and ARBs – these are among the most commonly recognised potential causes of hyperkalaemia, particularly if a person is unwell and reduces fluid intake, leading to dehydration.  Additionally, there are possible interactions with other medicines, such as NSAIDs, trimethoprim/co-trimoxazole and potassium-sparing diuretics (eg, amiloride and spironolactone).

(iv) Potassium-sparing diuretics – potassium-sparing diuretics such as amiloride reduce the passive renal excretion of potassium. It is important to note that this action differs from that of spironolactone (and eplerenone), which is an aldosterone antagonist. Importantly, in heart failure, the renin–aldosterone–angiotensin system is activated, highlighting the specific benefit of spironolactone and its lesser risk of hyperkalaemia in heart failure.

(v) Beta-blockers – This adverse effect is primarily seen with non-selective beta-blockers Carvedilol is non-selective, and although metoprolol is a selective beta-blocker, hyperkalaemia has been observed with it. Bisoprolol is usually considered the most cardioselective beta-blocker. The hyperkalaemia seen with beta-blockers is usually mild and dose related.

(vi) Trimethoprim – reduces the passive renal excretion of potassium. The interaction between trimethoprim/co-trimoxazole used for over 10 days and ACE inhibitors/ARBs or spironolactone is significant and may be overlooked.

(vii) NSAIDs – can cause hypoaldosteronism, and hence reduce potassium excretion, but may also contribute by reducing kidney function.

8. Widened access to meningococcal B vaccine

Pharmac has announced that from 1st September, 2025, access to the meningococcal B vaccine (Bexsero) will be widened to include all children aged under five years. Currently, meningococcal B vaccination is funded for children up to age 12 months as part of the childhood immunisation programme; it is scheduled to be given as three doses, usually at ages three, five and 12 months. The timing of administration remains the same. A catch-up meningococcal B vaccination programme has also been available for children aged 13 – 59 months since March, 2023 but ends on 31st August, 2025. This change will replace the current catch-up programme, and means that all children aged under five years will be able to complete the full meningococcal B vaccination course if it was not done within the first 12 months of life.

Eligibility criteria for funded meningococcal B vaccination for older children and adults at high risk remain the same; click here for funding criteria.

9.  Resources