Month: November 2025

The New Zealand General Practice Podcast

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

Clinical Snippets November 2025

https://open.spotify.com/episode/0rVqbjPu8l1vJOM2qJMYQP?si=eQu5gna5QjuRSaz0zcas5A

1. NZ Doctor prescribing Spotlight series

NZ Doctor have been publishing a Spotlight series of snapshot reports using hazard detection data from the Conporto Event Detection & Mitigation service that automatically analyses the patient’s medical records and identifies if a risk of harm is likely. 

(i) The first report looked at sodium valproate prescribing in women of childbearing potential without documented history of hysterectomy. Sodium valproate is contraindicated in girls and women of childbearing potential, unless other treatments are ineffective or not tolerated, and effective contraception is in place. It should not be prescribed in pregnancy for epilepsy unless no alternatives exist, or in pregnancy at all for bipolar disorder. Between 14 and 27 April 2025, 187,608 patient interactions were captured and a total of 474 new harm events were detected across 307 medical centres. Over these two weeks, 56 females aged 10–59 years were identified as being prescribed sodium valproate without a history of hysterectomy recorded in their notes. Of these, 29 women did not have any history of epilepsy.  ACC have developed a resource on benefits and risks of anti-seizure medicine prescribing for healthcare professionals to discuss with anyone who could get pregnant. 

(ii) A second report run between 19 May and 1 June 2025 focussed on the “triple whammy” combination – the concurrent use of an NSAID, an ACE inhibitor or angiotensin II receptor blocker, and a diuretic in patients with impaired renal function (eGFR <60).  This combination significantly increases the risk of AKI, especially in patients with impaired renal function, but can also cause harm in those with previously normal renal function.  Māori, Pacific peoples and older adults are particularly vulnerable due to higher rates of chronic kidney disease, heart disease and multimorbidity.  Over the observation period there were 191,140 patient interactions a total of 491 new harm events were detected across 299 medical centres.  Over these two weeks, 57 patients with impaired renal function prescribed all three components of the triple whammy. The event detection system indicates the combination has been newly initiated in patients with renal impairment.  It is important to note that only prescribed NSAIDs are captured – patients may also be taking over-the-counter NSAIDs, which are not recorded and could further increase risk. Advice is to avoid prescribing the triple whammy combination in patients with already impaired renal function and educate patients with impaired renal function of the potential risk of OTC NSAIDs.  

(iii) Another report run between 16 and 29 June 2025 looked at co-prescribing of macrolide antibiotics (particularly erythromycin or clarithromycin) with simvastatin, a known high-risk interaction that is contraindicated.  Macrolides strongly inhibit cytochrome P450 3A4, the enzyme that metabolises simvastatin. This can lead to a 10-fold increase in simvastatin exposure and four-fold increase in atorvastatin exposure, significantly raising the risk of myopathy and rhabdomyolysis. Risk increases with age ≥65 years, higher statin doses and concurrent medicines (eg, azole antifungals, ciclosporin) or comorbidities such as diabetes or renal impairment.  Over the observation period there were 209,108 patient interactions across 295 medical centres, with 517 new harm events identified. Among these, 25 patients were prescribed a macrolide antibiotic while also taking simvastatin.  Advice: Before prescribing or dispensing a macrolide antibiotic check for concurrent statin use, particularly simvastatin or atorvastatin. If a macrolide cannot be avoided, one of the following is recommended:

  • Temporarily withhold simvastatin or atorvastatin during the course of macrolide treatment.
  • Consider using a statin not metabolised by CYP3A4, such as pravastatin or rosuvastatin.
  • Select a macrolide with a lower interaction risk, such as roxithromycin, with caution – warn patients to promptly report symptoms of myopathy, such as muscle pain or weakness.

2.  Carotid artery POCUS

Issue 261 of GP Research Review includes review of a cross-sectional study published in BMC Primary Care investigating the sensitivity and specificity of POCUS for identifying carotid atherosclerosis in primary care, and the prevalence of carotid atherosclerosis in apparently healthy individuals with high or very high cardiovascular disease risk. A total of 199 participants aged 40–69 years with high or very high calculated CVD risk and no prior treatment with antilipemic drugs underwent POCUS of the carotid arteries. The prevalence of carotid atherosclerosis was 69.5%, with higher rates in males and older patients. The sensitivity and specificity of POCUS for detecting carotid atherosclerosis were 96.4% and 90.0%, respectively.  The reviewer’s take home message was that using POCUS in primary care can significantly improve early cardiovascular disease risk assessment and prevention and is another effective point-of-care procedure that can be accurately undertaken in general practice.  I note all family medicine practitioners taking part in the study took part in a 5-step individual carotid artery POCUS course, which took from 2 to 6 months (depending on prior ultrasonographic experience of the practitioner).

3.  Insomnia study

The same issue of GP Research Review summarised the randomised controlled DREAMING study from the Netherlands published in the British Journal of General Practice which aimed to asses the effectiveness of low-dose mirtazapine (7.5-15mg) and amitriptyline (10-20mg) in patients with insomnia disorder. Insomnia Severity Index (ISI) scores were assessed at baseline and again at 6, 12, 20, and 52 weeks.  The conclusions: Compared with placebo, low-dose mirtazapine provided a statistically significant and clinically relevant reduction of insomnia severity at 6 weeks, but not at later time points. Low-dose amitriptyline resulted in a statistically significant but not clinically relevant reduction at 6 weeks. The results do not support the prescription of low-dose amitriptyline and mirtazapine for several months in patients with insomnia disorder in general practice. Based on the results, GPs may consider prescribing off-label low-dose mirtazapine for a period of about 6 weeks in cases where non-pharmacological treatment is insufficient. BPAC has excellent resources on management of insomnia.  

4.  Sepsis

HQSC has released the Clinical Guide to Sepsis management in New Zealand.  There is a section on sepsis management outside the acute hospital setting together with tables of red and amber assessment criteria.  Take home points include relevant to primary care include: 

(i) Refer all people with suspected sepsis outside acute hospital settings for emergency medical care by the most appropriate means of transport (usually via ambulance) if:

• they meet any high-risk (RED FLAG) criteria (see relevant tables) or

• there is a concern that the person would be unable to return with new or worsening symptoms

• one or more moderate- to high-risk criteria are present and there is increased concern for sepsis and/or lack of improvement after a period of observation.

(ii) If a definitive diagnosis is not reached, or the person cannot be treated safely outside an acute hospital setting, refer them urgently for care.

(iii)  For people with infection who do not have any high or moderate- to high-risk criteria who are being treated for infection, provide information about sepsis symptoms and how to access medical care if they are concerned (use dedicated written patient resources).

5. SA updates

Pharmac has announced the requirement for some Special Authority renewals is to be removed from some products from 1st December, 2025. New patients will still require an initial Special Authority application.  Pharmac states they we will work with Health New Zealand to extend the expiry dates for people with an existing Special Authority approval for these products. 

The affected products include:

  • Insulin pumps and continuous glucose monitors (interoperable and standalone) for type 1 diabetes
  • Long-acting muscarinic antagonists with long-acting beta2-agonists (LAMA/LABA inhalers) for respiratory conditions
  • Febuxostat for gout
  • Budesonide capsules for Crohn’s disease and microscopic colitis
  • Epoetin alfa for chronic renal failure

6.    Alzheimer’s Disease advances 

(i) A recent NZ Doctor article noted that new blood tests for biomarkers of Alzheimer disease pathology can allow earlier diagnosis and improve its accuracy.  Biomarkers such as p-tau217 are being used to assist diagnosis in countries like the US, Japan, the UK, and China, and have shown “good agreement” with PET imaging, CSF biomarkers, and postmortem diagnosis, the experts say.  The diagnostic accuracy of these blood tests sits at 90–95 per cent, well above the 60–70 per cent with a purely clinical approach, and they can reduce the need for CSF biomarkers and PET scans by approximately 80–90 per cent. Results are being validated in primary care and real-world settings overseas although the tests are not yet available in New Zealand. 

(ii) Their uptake is expected to grow with a rise in the availability of new disease-modifying treatments for Alzheimer disease.  These expensive anti-amyloid monoclonal antibodies require biomarker-based diagnosis to identify possible candidates for treatment, and their use is controversial due to their modest effectiveness, frequent IV infusion regimen, and serious potential side effects that require regular monitoring with MRIs.  They are not licensed in New Zealand, but they are in clinical use or available in a growing number of territories, including the UK, EU, US and China.  Donanemab and Lecanemab have been licensed in Australia this year but are not subsidised.  Donanemab currently costs approximately $A 4700 per infusion every four weeks over the 18-month treatment course.  

(iii) Advances in diagnosis and management of Alzheimer’s disease are discussed in a recently published  three-part  on-line Lancet series if you are interested in more detail.   In the meantime, your local Health Pathways has a section on Cognitive Impairment that includes available assessment, management and support services advice.    

7.  Interesting bits from Research Review

(i) A New Zealand study NZ comparing NT-proBNP levels in Pacific peoples, Māori, and NZ Europeans with heart failure found that after adjustment for ethnicity, age, sex, body mass index, estimated glomerular filtration rate, ejection fraction and presence of AF, while levels in European and Māori were not statistically different, For each decade of life over 60 years, plasma NT-proBNP levels in patients with HF were a mean 67% lower in Pacific peoples than in aged-matched NZ Europeans suggesting we might have to use different normal ranges according to ethnicity. 

(ii)  A US study looking at varenicline (Champix) for youth nicotine vaping cessation used the standard smoking cessation varenicline regime or placebo with either text messaging support or weekly counselling plus text messaging support in a 12 week trial.  Continuous abstinence rates in the last month of treatment were 51%(V) vs 14%(P) and at 6-month follow-up 28%(V) vs 7%(P).  Results were similar for the text only versus text + counselling groups.  Treatment-emergent adverse events did not differ significantly between groups. Conclusion: Varenicline, when added to brief cessation counselling, is well tolerated and promotes nicotine vaping cessation compared with placebo in youth with addiction to vaped nicotine. Note this would be off-label prescribing in NZ and NZF includes a warning to monitoring for neuropsychiatric adverse effects including suicidality in patients prescribed varenicline.  

(iii) A multicentre, double-blind randomised controlled trial from China published in JAMA Internal Medicine  compared vitamin K2 (185mcg nocte) with placebo for management of nocturnal leg cramps.  The medication was taken every day for eight weeks and those in the K2 arm experienced a significantly lower number of weekly nocturnal leg cramps versus placebo with significantly greater reductions in cramp severity and duration.  There were no reported adverse events.  Vitamin K2 is readily available over the counter or on-line.  There is a possible interaction between Vitamin K2 and warfarin with potential to decrease the INR. 

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare, rural, Uncategorized , , , , , ,

https://open.spotify.com/episode/5zPf8bAGVqeeIKF9sGd7zT?si=xGcqfnVjRaGp8jhaCPrbeg

Clinical Snippets October 2025

Clinical Snippets October 2025

1. Suicide prevention

(i) A recent Goodfellow Gem drew attention to the NHS guidance Staying safe from suicide (2025) which includes references to NICE Guideline NG225: Self-harm: assessment, management and preventing recurrence.  Of note, the NICE guideline strongly advises against the use of risk assessment tools and scales, or global risk stratification into low, medium, or high risk, to predict future suicide or repetition of self-harm or to determine who should or should not be offered treatment or be discharged. 

(ii) The NHS guidance has 10 key principles:

  • relational safety: build and maintain trusting, collaborative therapeutic relationships. These are the strongest predictor of good clinical outcomes
  • biopsychosocial approach: address safety as part of a broad biopsychosocial approach aimed at improving overall well-being by considering biological, psychological and social aspects
  • safety assessment and formulation: reach a shared understanding with the individual about safety and changeable factors that may affect this
  • safety management and planning: consider the need for immediate action and work with the individual to navigate safety and the factors impacting this over time.
  • dynamic understanding: regularly assess and adapt formulations and safety plans based on the individual’s changing needs and circumstances
  • evidence-based practice: base work on the latest research and understand population-level risk trends
  • involving others: encourage the involvement of trusted others, where possible and as appropriate
  • inclusivity: Ensure practices are inclusive and adaptable, particularly for marginalised and high-risk groups
  • clear communication: use simple language tailored to the individual and don’t use jargon. Use interpreters or approaches like drawing, if needed
  • continuous improvement: regularly review and refine approaches based on outcomes and feedback

(iii) A written, prioritised list of coping strategies and/or sources of support that the person who has self-harmed can use to help alleviate a crisis. Components can include recognising warning signs, listing coping strategies, involving friends and family members, contacting mental health services, and limiting access to self-harm methods.  The NZ Mental Health Foundation provides an editable Personal Safety Plan which is also available as hard copy.  Other suicide related resources are also available.   

(iv) Community Health Pathways has sections on Suicide Prevention in Adults and Suicide Prevention in young People.  The Pathways do currently include risk stratification but also emphasise the most important priorities are to engage the patient, provide hope, and look at ways to keep them safe. Hopelessness has a high correlation with eventual suicide.  The Pathway also emphasises the importance of building a strong therapeutic alliance by:

  • Communicating empathy and understanding for patient’s extreme suffering.
  • Providing reassurance that recovery is possible.
  • Reinforcing the patient’s help-seeking behaviour in coming to see you for treatment.

2. Ondansetron in pediatric gastroenteritis

Issue 259 of GP Research Review looked at a double blind study published in NEJM in which just over 1000 children between the ages of 6 months to <18 years with acute gastroenteritis associated vomiting whose carers were provided with 6 doses of oral ondansetron or placebo at the time of ED discharge, with instructions to use in the case of ongoing vomiting. Outcomes were measured in symptom continuation and deterioration, duration, total number of vomiting episodes and the need for further medical intervention. In the 7 days after enrolment, those prescribed ondansetron had significantly less chance of deterioration and reduced episodes of vomiting. Adverse events were balanced between study arms. Take-home message: Ondansetron is effective in reducing vomiting from gastroenteritis in those aged between 6 months and 18 years. NZFC notes acute gastroenteritis-related vomiting associated with dehydration is an indication for a single dose of ondansetron in children. 

3.  HIPC Rule 11

A recent issue of NZ Doctor contained an article from the office of the Privacy Commissioner on Rule 11 of the HIPC which links to last month’s discussion around suicide prevention.   

The question is presented: When a patient insists that their parents not be told about what’s going on in their life, but you think their mental health is at risk and parental support could lessen that threat, what should you do?  If a patient refuses consent to share their health information, but a GP believes their safety is at risk, Rule 11 of the Health Information Privacy Code may allow the doctor to act.

Rule 11 of the HIPC permits the disclosure of health information if it is necessary to prevent or lessen a serious threat to the life or health of any person, or to public health or safety (the serious threat exception). In each case, specific requirements must be met for the serious threat exception to apply. If another piece of legislation requires or allows you to share the health information in question, you should rely on that legislation rather than Rule 11. For example, if sharing is permitted by the Oranga Tamariki Act 1989 you should rely on that as your authority. You don’t need to also make an assessment under Rule 11.

If no other piece of legislation applies, you need to assess the disclosure under Rule 11. There are four steps to work through.

(i) Has the person authorised you to share their health information?  If yes you can release information as agreed with the person.  

(ii) If you do not have authorisation, it reasonably practical to seek authorisation? For the serious threat exception to apply, you need to have reasonable grounds to believe that it is not desirable or practical to seek the individual’s authorisation. If you request authorisation to disclose the information but the individual does not grant it, you must consider why the authorisation was not granted and whether it is appropriate to proceed with the steps. If the threat is serious enough, you might find that it outweighs the need for authorisation. If it is not desirable or practicable to seek authorisation, go to step three.

(iii) Is there a serious threat to the life or health of a person?

The serious threat exception applies to serious threats to the life or health of the person whose information it is, that of any other person, or public health or safety. When considering whether there is a serious threat, you need to use your clinical judgement to assess the likelihood of the threat occurring, the seriousness of the threat and the harm that could eventuate and the imminence of the threat. If the threat does not meet the “serious threat” threshold, you cannot rely on this exception. If there is a serious threat, go to step four.

(iv) Is the disclosure to someone who can help lessen or prevent the threat?

You can only disclose health information under this exception if you are sharing the information with someone who can help lessen or prevent the threat, and only as much information as is needed to do so. For example, if you have gone through these four steps and concluded that involvement from a patient’s loved one in their care would lessen the threat, you should still only share as much information as is necessary to do that.

As always, it will be crucial to document your decision-making process. It may help to record the answer to the four steps sequentially in your notes as you are deciding on the best course of action, as well as your rationale for these answers.  The full guidance on this exception is available in the resources and learning section at privacy.org.nz.

4. Long-acting insulin

  • A recent Tools for Practice from the College of Family Physicians of Canada looked at the evidence comparing once-weekly insulin icodec (Awiqli) compared to daily long-acting insulins in type 2 diabetes?  The bottom line was that once-weekly insulin icodec is as effective as daily long-acting insulin (glargine or degludec) in lowering HbA1c. Safety and hypoglycemia risk appear similar, though data are limited for patients or situations at risk for hypoglycemia such as sick days or in frail patients. 
  • Insulin icodec is not yet approved for use in New Zealand but is approved in Australia for type 2 diabetes in adults and adult type 1 diabetes with some restrictions.   Insulin icodec (Awiqli™ 700 units/mL, 2100units/pen) is an ultra-long-acting insulin.  In insulin naive patients, initial recommended dosage is 70 units once per week, equivalent to 10 units daily. Maximum dose per injection 700 units. When switching from another long-acting insulin, use the equivalent total weekly dose but a one-time 50% higher loading dose may be considered.  However, it may be a while before it is approved in New Zealand – it is more expensive than other long-acting insulins.  Approximate costs per month for 40 units/day or 280/week: Glargine: $70; Degludec: $100; Icodec: $115  NZD equivalent. 

5. Insomnia medication

The Research Review Educational Series has published an update on recent advances in the management of insomnia.  Behaviour therapy is the recommended first line treatment for insomnia with hypnotics being used as adjunctive or alternative therapy. Health Pathways has a comprehensive summary of accepted insomnia management practices. 

The publication reviews the various available hypnotics including dual orexin receptor antagonists (DORAs) which are a newer class of hypnotic. In December 2024, the Minister of Health consented to the distribution of the DORA lemborexant (Dayvigo®) in New Zealand for treatment of insomnia in adults. The following ‘take home’ messages relate to lemborexant. 

  • RCTs, meta-analyses and network analyses have shown lemborexant has favourable efficacy and side effect profiles compared to placebo and benzodiazepine receptor agonists. Lemborexant significantly reduced time to sleep onset and increased overall sleep time compared to placebo and zolpidem at 1 month, and compared to placebo at 6 months with these effects maintained to 12 months.
  • Discontinuation of lemborexant therapy was not associated with rebound insomnia and lemborexant did not significantly impair next-day memory or driving, compared to placebo and benzodiazepine agonist receptors.
  • Lemborexant was well tolerated with a TEAE (treatment emergent adverse event) rate similar to placebo.  TEAEs most commonly associated with lemborexant are somnolence, headache, nightmares and/or abnormal dreams. A single retrospective study found Lemborexant was associated with a lower rate of falls in hospitalised patients compared to benzodiazepine receptor agonists.
  • Information on dosing and precautions is available in NZ Formulary and the Medsafe data sheet.  The drug is not currently subsidised and is an unapproved medicine (s29).   The Better Sleep Clinic website has a page dedicated to comparing the various medications used in insomnia management which might be a useful resource for patients.  The cost of a four week supply of Lemborexant in NZ (Pharmacy Direct) is $113 for the 5mg tab and $143 for the 10mg tab. 
  • There is a recent Goodfellow Gem briefly summarising relevant prescribing data 

6. Triple therapy for COPD

A recent NZ Doctor article on triple therapy for COPD  includes the following take home points:

  • For mild COPD, monotherapy with a bronchodilator is usually adequate; start a regular LAMA early; if symptoms increase, add a LABA.
  • An eosinophil count ≥0.3×109/L helps identify people with frequent exacerbations who are most likely to respond to an ICS.
  • If an ICS is indicated, it should be part of triple therapy (ICS + LAMA + LABA not ICS + LABA).
  • Strongly recommend vaccinations (encourage the unfunded vaccines, especially pneumococcal) and pulmonary rehabilitation (refresher course every two to three years).
  • The debate around the benefits and risks of therapy for COPD involves the place of inhaled corticosteroids. When we had limited inhaled therapy options for COPD, many people with COPD were initiated on an ICS + LABA combination. Subsequently, different phenotypes of COPD have been identified, and those with frequent exacerbations (two or more exacerbations in 12 months) have been shown to have fewer exacerbations when on an ICS. Those without frequent exacerbations derive no benefit but are at increased risk of adverse effects from ICS therapy, such as pneumonia.

7. Resource – iron studies and anaemia

A recent Research Review Educations Series titled What the ferritin? Is well worth an hour of CME.  It covers the basics of iron metabolism and then the various blood test used to asses iron status.  There is a very helpful table to aid distinguishing iron deficiency from anaemia of chronic disease and an acute phase reaction, and algorithms aiding differentiation of absolute versus functional iron deficiency.  The importance of investigating an underlying cause of absolute or functional iron deficiency is emphasised.  Take home messages include:

  • Low serum iron is not a reliable indicator of depleted iron stores (diurnal variation and inter-individual variation, sensitive to recent iron intake, acute and chronic illness.
  • Low transferrin saturation (TSAT) with low ferritin is consistent with iron deficiency (ID). High TSAT with high ferritin indicates iron overload. TSAT alone is not a reliable marker of iron status.
  • A normal or raised serum ferritin level does not necessarily exclude ID; it is important to distinguish between absolute and functional ID, especially in patients with inflammation or chronic disease.  However, serum ferritin is a sensitive and specific test for ID.  Low ferritin levels are highly specific for ID; high ferritin levels do not necessarily indicate iron overload.
  • The reticulocyte haemoglobin equivalent RET-He test is a rapid, inexpensive indicator of ID in chronic disease.
  • If patients are started on oral iron replacement therapy, they should be checked at 6 weeks to ensure the medication is being tolerated and that haemoglobin levels are increasing.  Patients who receive IV iron replacement therapy should have a full blood count at 2–3 months post-infusion to check for haemoglobin normalisation. 

8.  Follow-ups

(i)  Adult ADHD management:  MyHealthHub has hosted a webinar ADHD in Adults – the Primary Care Perspective by Auckland psychiatrist Dr Sidesh Phaldessai.  The hour-long webinar is eligible for PD points and explores explore the diagnosis, referral, management and long-term care of adult ADHD.  Dr Phaldessai is also hosting an online Adult ADHD GP Masterclass which is a series of six webinars 7.30pm-8.30pm every Wednesday from 22 October until 26 November 2025 covering all aspects of adult ADHD diagnosis and management.  It is RNZCGP endorsed (12 CME points) and if you are unable to attend on the given date and time – the webinar will be recorded and you can access it later. 

(ii)  Further to a discussion in the last Snippets regarding medications that can affect the QTc interval, Christchurch Medicines Information Service have recently published a succinct 2-page bulletin on the issue including predisposing risk factors, culprit drugs and drug interactions and how best to manage the risk.   There are links to the CredibleMeds website which enables you to search individual medications and categorises them as:

  • Known Risk of Torsade de Pointes (TdP) – These drugs prolong the QT interval AND are clearly associated with a known risk of TdP, even when taken as recommended.
  • Possible Risk of TdP – These drugs can cause QT prolongation BUT currently lack evidence for a risk of TdP when taken as recommended.
  • Conditional Risk of TdP – These drugs are associated with TdP BUT only under certain conditions of their use (e.g. excessive dose, in patients with conditions such as hypokalemia, or when taken with interacting drugs) OR by creating conditions that facilitate or induce TdP (e.g. by inhibiting metabolism of a QT-prolonging drug or by causing an electrolyte disturbance that induces TdP).
  • Drugs to Avoid in Congenital Long QT Syndrome (cLQTS) – These drugs pose a high risk of TdP for patients with cLQTS and include all those in the above three categories (KR, PR & CR) PLUS additional drugs that do not prolong the QT interval per se but which have a Special Risk (SR) because of their other actions.