Year: 2026

The New Zealand General Practice Podcast

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

Clinical Snippets May 2026

https://open.spotify.com/episode/36kWoqOhzJqdOdVy1lvsp0?si=oFfT4qOmS_SJJoS1E_u1Cw

Clinical Snippets May 2026

1.  Youth issues

(i)  Choking: A recent NZ Doctor article noted that strangulation during sex (often euphemistically labelled “choking”) is on the rise, especially among young people. The widespread access to pornography and influence of social media depicting “vanilla” sex as somehow shameful or boring is influencing sexual practice. There are new “norms” and some people think strangulation during sex is to be expected.  There is reference to a recent study of Australians aged 18–35 found 57% had been strangled during sex (61% of women, 43% of men, 79% of trans or gender-diverse people). Participants most commonly reported becoming aware of “sexual choking” during ages 16–18. Pornography was the most common source by which those reported first hearing about it (35%). There was a general perception that strangulation during sex can be safe and expected behaviour, and the authors highlighted this is contrary to the numerous and potentially significant harms that can result from strangulation.  The issue of consent is discussed in some detail and it is noted the concept of “consent” is a moot point when being strangled – how can you have informed consent and continue to consent when the practice reduces oxygen to your brain and your cognitive capacity?  The study concluded that results indicate the need for developing strong sexual health education around consent, harms, and normative expectations around sexual strangulation.  When talking about safe sexual practices with youth the issue of sexual choking should probably be included together with pregnancy and STI prevention.  

(ii)  Sexual violence disparities: A recently published study on sexual violence and unwanted sexual experiences among adolescents in Aotearoa New Zealand using Youth 2000 data and reviewed in issue 120  Maori Health Review found significant disparities between various ethnic and minority groups.  Māori adolescents experience a greater burden of sexual violence than the general adolescent population. The overall prevalence of sexual violence among adolescents was 12.4% in 2019, an increase from 9.5% in 2012. Prevalence was higher in girls (19%), Māori (15.3%), and those in socioeconomically deprived schools (15.3%) and neighbourhoods (13.4%). However, even higher rates of sexual violence occurred in transgender adolescents (31.9%), those involved with statutory child protection (26.7%), those with long-term conditions (23.4%), and sexual minorities (22.1%). The reviewer comments include: This study showing the extent of sexual violence among rangatahi Māori is deeply concerning because (1) this type of violence destroys rangatahi flourishing and (2) it reflects the fact that we aren’t adequately protecting Māori young people. Addressing this requires prevention and support approaches that are Māori-led – grounded in kaupapa Māori values and tackling broader determinants.

(iii)  Looksmaxxing:  A Medscape article titled ‘The Extremely Risky Trend That Should Be on Family Doctors’ Radar’ discussed the looksmaxing social media trend aimed mainly at teen and young adult males with influencers promoting a narrow and idealized version of masculinity centred on the belief that real men must have specific physical traits like a square jawline, tall stature, muscular build, perfect hair, and clear skin.  The article notes a growing number of men are taking cosmetic procedures into their own hands, injecting themselves with neuromodulators, fillers, fat dissolving products, and peptides, and some even taking mallets to their faces to reshape their bone structure. Followers are encouraged to use techniques like mewing and bone-smashing (repeatedly hitting the face with a blunt object) to reshape their face. Mewing, where the tongue is repeatedly pressed to the roof of the mouth, was developed by US orthodontist John Mew and is a looksmaxxing practice aimed at achieving a more defined jawline. He encouraged up to 8 hours of mewing daily and lost his license in 2017 due to unproven claims. The American Association of Orthodontists (AAO) advised against the practice in 2024, warning it carries risks for loosened teeth, misaligned bite, and speech impediments, all of which may require “complicated treatment” to resolve. Looksmaxxing is felt likely to be a risk factor for the development of an eating disorder or muscle dysmorphia.  The article recommends physicians become familiar with Looksmaxxing, pay closer attention to self-esteem and self-image among young men and boys, and provide body positivity resources (Link to some NZ resources here) . Validating that people are treated differently based on their appearance — a form of bias known as “looksism” — can also be a starting point for discussions about looksmaxxing, and it is important to push back or provide counterfactuals against looksmaxxing’s “really limited notions of what it means to be a man” and “derogatory opinions” of both women and other men.

2. Insulin update

(i)  A reminder that there are ongoing changes to availability of some insulin preparations.   Eli Lilly is stopping supply of some insulin products in 2026. This only affects the 10 mL vial presentation of the following products (the penfill versions remain available) with supplies ending at end of June 2026 for most:

  • Humalog
  • Humulin NPH
  • Humulin 30/70
  • Humulin R

Novo Nordisk has added two products to the discontinuation list (supplies end at end of 2026):

  • Actrapid Penfill 3mL
  • Protaphane Penfill 3mL

Details on insulin discontinuation and supply dates is available on the Pharmac website.

(ii)  There is an excellent resource on use of Ryzodeg, including case studies, on the Goodfellow Unit site, with further information on use of pre-mixed and co-formulated insulins available on the NZSSD website (also a great algorithm for initiating and adjusting insulin in patients with type 2 diabetes).    

(iii)  Patient information on insulin is available on Healthify and Starship Hospital has a link to a Ryzodeg patient leaflet with a more formidable consumer information sheet available from Medsafe. 

3.  Assessment and management of Abnormal Uterine Bleeding

Health New Zealand | Te Whatu Ora have shared the new national Assessment and management of Abnormal Uterine Bleeding (AUB) guideline which has been endorsed by the RNZCGP. It provides clear evidence-based best practice on the management of AUB in non-pregnant women of reproductive age.  Regional Health Pathways are being aligned with the guidelines and will be kept updated so worth consulting these in the first instance although the guideline document contains more detail on various aspects of management.   Health Pathways has additional sections on post-coital bleeding and post-menopausal bleeding,    Health Pathways in conjunction with Te Whatu Ora have made available an accompanying hour long webinar titled Abnormal Uterine Bleeding (AUB): What general practice needs to know. 

4.  MHT and all-cause mortality

A Danish registry-based cohort study recently published in BMJ aimed to assess whether menopausal hormone therapy increases the risk of all-cause mortality.  Almost 900,000 women born between 1950 and 1977 were involved in the study with follow-up from age 45 years ending on 31 July 2023 (median follow-up time 14.3 years).   Exclusion criteria included history (at time of entry) of thrombophilia, liver disease, arterial thrombosis or venous thrombosis, breast cancer, endometrial cancer, ovarian cancer, previous use of menopausal hormone therapy, or previous bilateral oophorectomy. Just under 12% of women received a prescription for MHT during the study period.  The principal findings were summarised as:

  • There was no epidemiological evidence of excess mortality following menopausal hormone therapy use.
  • Women who had undergone bilateral oophorectomy between age 45 and 54 years, were associated with a significant survival benefit when using menopausal hormone therapy, corresponding to a 27-34% decrease in mortality hazard.
  • Stratified analyses found the lowest mortality among women predominantly using transdermal menopausal hormone therapy formulations, oestrogen monotherapy, cyclic progestogen regimens, and among women initiating menopausal hormone therapy aged 52 years or older, although these findings should be interpreted with caution and await scrutiny in future studies.
  • No unambiguous changes in cause-specific mortality were found between groups.

5.  That’s interesting

(i)  Dry eye and vitamin D:  In a study recently published in the American Journal of Ophthalmology researchers conducted a retrospective cohort study involving about 12 million adults to evaluate whether adults with a deficiency of vitamin D were at an increased risk of developing dry eye disease.  During a median follow-up period of around 3.5 years there was a new diagnosis of dry eye disease in 3.3% of adults with a deficiency of vitamin D compared with 2.7% of those without the deficiency corresponding to a 28.6% higher risk of developing dry eye disease in those with the vitamin deficiency.   The authors concluded that in patients with dry eye disease, “identifying and correcting low vitamin D levels may be a reasonable adjunct to standard…therapies, while recognizing that supplementation should be guided by general medical indications rather than used as a stand-alone treatment” for the condition. 

(ii)  Topical lignocaine for IUD placement:  A College of Family Physicians of Canada ‘Tools for Practice’ addressed the question: Does topical lidocaine decrease pain during tenaculum placement and intra-uterine device (IUD) insertion? The ‘botom line’ was that topical lidocaine-prilocaine 2.5% cream (EMLA – 2mL applied with cotton swab 5 minutes before procedure) reduces pain with tenaculum placement and copper/levonorgesterel IUD insertion by about 2-3 points more than placebo on a 10-point scale (minimum clinically important difference for pain is 1.3-2). Lidocaine 10% spray reduces the proportion of women experiencing moderate/severe pain to 6% versus 41% on placebo, but ~55% experience vaginal irritation.  Topical lidocaine 2% is likely ineffective. 

(iii)  Jess’s Rule:  Jess’s Rule is a NHS England initiative launched in September 2025 that mandates a “three strikes and rethink” approach for GPs. The rule is named after 27-year-old Jessica Brady, who died of cancer in 2020 after over 20 GP consultations over six months with no clear diagnosis.  The stated purpose of the initiative is to prevent avoidable deaths by ensuring persistent, unexplained symptoms are not dismissed, particularly in young or, minority ethnic patients who may face diagnostic delays. Patients are encouraged to mention “Jess’s Rule” if they have seen a doctor three times for the same issue without improvement. The core approach is the three Rs: Reflect, Review, Rethink.

  • Reflect: Think back on previous consultations, particularly if they were remote, and invite the patient for a face-to-face, physical exam.
  • Review: Discuss the case with peers and check for “red flags,” disregarding assumptions based on young age.
  • Rethink: If appropriate, refer onwards for further tests or for specialist input.

6.  Paediatric asthma

A recent Research Review educational series article on treating small airways dysfunction with extrafine inhaled corticosteroids in children with asthma included the following take home messages:

  • The small airways are a major source of airway limitation in many children with asthma, across all levels of disease severity
  • The use of extrafine ICS (inhaled corticosteroid – MMAD ≤2 μm) improves medicine deposition in the peripheral airways compared to larger-particle ICS, which may result in better lung function, reduced exacerbations and better asthma control in children with small airways involvement
  • Extrafine BDP (beclomethasone diropionate) (Qvar®) is the only fully funded extrafine ICS available as a single product inhaler in New Zealand and low dose therapy (100 mcg/day) is recommended by local and international guidelines for maintenance treatment in children with asthma from age 5 years
  • Extrafine BDP has a higher potency than budesonide and other formulations of BDP in New Zealand and is taken at half the dose, resulting in less systemic exposure and potentially fewer adverse effects (comparative tables available in the original article and Medsafe data sheet together with advice to take care to educate whānau when a change in inhaler translates to different practice.)
  • Stepping up to extrafine BDP from a larger-particle inhaler appears to be as effective as adding on a LABA
  • Extrafine BDP is most likely to benefit paediatric asthma patients with:
    • An increased exacerbation risk
    • Nocturnal symptoms
    • Increased bronchial hyperresponsiveness
    • Exercise-induced asthma
    • Reduced QoL.

7.  Post-vaccination observation time

  • BPAC Bulletin 142 notes the standard post-vaccination wait time now 15 minutes for all publicly funded vaccines in New Zealand.  This change applies to all age groups and all vaccines, whether administered alone or at the same time as other vaccines.
  • A shortened wait time of five minutes can also be considered in people who meet all of the following criteria:
  • No known history of severe allergic reactions
  • Has been assessed for immediate post-vaccination adverse reactions (after five minutes)
  • Knows when and how to seek post-vaccination advice
  • An adolescent or adult will be with them for the first 15 minutes post-vaccination
  • Agree not to drive, skate, scoot, ride a bike or operate heavy machinery until 15 minutes post-vaccination
  • Can contact emergency services if required
  • Vaccinators may consider advising post-vaccination observation wait times longer than 15 minutes, in some clinical situations, e.g. history of allergy, syncope. IMAC has produced a flow chart for vaccinators. 

The New Zealand General Practice Podcast

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

Clinical Snippets April 2026

Clinical Snippets April 2026

1.  Diabetes

As part of the recently released National Diabetes Roadmap Te Whatu Ora has published a notice stating they will align New Zealand’s diagnostic threshold for diabetes and pre-diabetes with international standards to facilitate timely and appropriate diagnosis of diabetes and to minimize the risk of overdiagnosis of pre-diabetes.

Effective 1 July 2026 the national diagnostic thresholds for HbA1c are changing to:

  • Diabetes: HbA1c ≥ 48 mmol/mol (lowered from the current ≥ 50 mmol/mol).
  • Prediabetes: HbA1c 42 – 47 mmol/mol (previously 41 – 49 mmol/mol)
  • Normal: HbA1c < 42 mmol/mol.
  • No confirmatory test required if HbA1c > 53 mmol/mol.
  • Confirmatory test required as soon as practical if HbA1c 48 – 52 mmol/mol eg. repeat HbA1c, fasting glucose or random glucose (if symptomatic)

It is worth keeping in mind that diabetes exists on a spectrum. Microvascular risk begins to increase above an HbA1c of 39 mmol/mol, which is the threshold used for prediabetes in some countries. At the borderline range, diabetes is not usually symptomatic. 

2.  Whole body scanning

An excellent article by Dr Orna McGinn in a recent issue of NZ Doctor examined the risks of consumer driven health testing including whole body scanning which is being promoted on social media and by some imaging providers.  About the same time, the Canadian primary care evidence summary service Tools for Practice  released their summary #410 titled Whole-Body MRI for Cancer Screening: Many findings, little benefit with the clinical question   What are the potential benefits and harms of performing whole-body MRI for cancer screening in asymptomatic adults?  The bottom line was that systematic reviews of observational studies found that 94% of patients who undergo whole-body MRI will have a radiologic abnormality and up to 30% require additional investigations. Ultimately, 1.1-1.6% will have a pathologically confirmed cancer (most commonly prostate, renal, lung, thyroid). No data on mortality exists. Whole-body MRI for cancer screening in asymptomatic individuals should not be encouraged.  The summary notes that patients who undergo whole-body MRI have higher downstream health care costs, primarily from additional imaging and speciality consultations.  The time to perform whole-body MRI depends on machine, sequences captured and protocols, but typically 60-90 minutes which is about three times as long as a body-specific MRI (eg brain or knee). 

3.  Sepsis 

A recent NZ Doctor article on sepsis promoted the new pre-hospital and primary care sepsis screening and action tools we have discussed previously in Snippets and which are available from the NZ Sepsis website and the HQSC clinical guide.  The article emphasises the four principles of screen, stratify, act immediately and use critical language, and notes that clinical judgement remains central. The HQSC clinical guide accepts that while not every person with amber flags needs transfer to hospital, this is warranted where there is persistent whānau concern or acute functional decline, or when people lack the ability to return for assessment in the event of deterioration.  Three primary care cases are presented and there is a list of practical points:

  • Build a sepsis habit.  Note normal temperature does not exclude sepsis. 
  • Communicate clearly and transfer early [use terms such as red flag sepsis]
  • Antimicrobials (prompt administration of IV ceftriaxone or other available broad spectrum antibiotic – antibiotics are first priority and while blood cultures are very helpful they can remain positive for up to 30 minutes after antibiotics are given, so can follow a dose of antibiotics if IV access is initially difficult)
  • Safety netting vital if the patient is believed suitable for observation in the community
  • Embed the tools locally. Add the sepsis pathways PDFs to your practice intranet, put laminated copies in triage rooms, and run a short huddle to rehearse the flags.

4.  1 May Privacy Act updates

 From the April issue of GP Pulse is a reminder that the Privacy Amendment Act 2025 will introduce a new Information Privacy Principle (IPP 3A) which will come into effect on Friday 1 May. From this date, if your organisation collects personal information from third parties (i.e. not from the individual concerned) you must take reasonable steps to ensure the individual is aware.  The Privacy Commission has published updated guidance on application of the principle

Essentially, under the existing principle IPP3, agencies (businesses or organisations) must already inform people when they collect their personal information from them. Under IPP3A, if an agency collects a person’s personal information from someone other than the person themselves (i.e. indirectly), then that agency is required to tell the person, unless an exception applies.

If an agency has collected personal information indirectly, IPP3A requires them to take reasonable steps to make sure that the person concerned is told:

  • that the information has been collected
  • the purpose of the collection
  • the intended recipients of the information
  • the name and address of the agency that is collecting the information and the agency that holds the information
  • whether the collection is authorised or required by law and which particular law
  • their right to access and correct their information.

MPS has developed guidance for members on what these changes mean for clinicians and explains what your practice should think about and implement before 1 May.  It is expected the majority of practice obligations under IPP3A will be met by an update of the practice’s existing Privacy Statement. The Privacy Statement needs to describe the types of information collected and the purpose for which it is collected. This means that if a practice receives information from a source not explicitly mentioned in their Privacy Statement, they will not generally need to re-notify the patient, provided the information is of the same type and collected for the same purpose.  The guidance gives specific advice on what the Privacy Statement should contain and discusses exceptions to IPP3A requirements and the issue of receipt of unsolicited third-party information.  

5.  Smartphones and kids

A study recently published in Pediatrics and reviewed in Issue 269 of GP Research Review looked at health outcomes at age 12 associated with smartphone ownership.   Researchers analysed data from 10,588 participants in the Adolescent Brain Cognitive Development (ABCD) study.  Compared with non‑owners, 12‑year‑olds with smartphones had higher odds of depression, obesity, and insufficient sleep after adjustment for socioeconomic, developmental, and monitoring factors. Earlier acquisition was additionally associated with obesity and insufficient sleep. Among youth without a smartphone at 12, those who obtained one by age 13 showed increased clinical‑level psychopathology and insufficient sleep even after controlling for baseline status. Findings were robust across sensitivity analyses. Overall, smartphone ownership – particularly earlier ownership – was consistently associated with adverse mental and physical health indicators in early adolescence, with implications for caregivers and policy.

6.  MPS Resource

MPS has released the Safe Prescribing podcast series – a five‑episode, practical, medicolegal resource designed to help you reduce risk, streamline decision‑making, and feel more confident in everyday prescribing.

  • Episode 1: 12‑month prescriptions: What the law change means in practice, how to decide on prescription length, and strategies to minimise complaints.
  • Episode 2: Prescribing by telehealth and narrow‑scope clinics: The rise of telehealth brings new risks. We explore how to keep patients safe and protect yourself when consulting remotely.
  • Episode 3: Prescribing by proxy: when care is shared:  Shared care is now the norm. We unpack the medicolegal implications of prescribing for patients you haven’t personally assessed, and how to stay aligned with Medical Council expectations.
  • Episode 4: Standing orders:  A clear, practical look at your obligations when using standing orders, and how to ensure you’re meeting regulatory requirements.
  • Episode 5: Dangerous drugs: focus on Methotrexate – Using a real case example, we highlight why methotrexate remains a high‑risk medication and how to avoid the errors that lead to serious harm.

7.   Spotlight Series

The NZ Doctor Spotlight series looking at prescribing data analysed using the Conporto Health Event Detection & Mitigation service has reported on several prescribing issues:

(i)  Co-prescribing of PDE5 inhibitor and nitrates.  There were 10 events over a fortnight amongst 196k interactions.

  • avoid concurrent use of nitrates (this is a contraindication – concurrent use may cause potentially life-threatening hypotension and, in severe cases, can precipitate myocardial infarction).
  • if nitrates must be given, allow a minimum of 24 hours after sildenafil or 48 hours after tadalafil, and consider a longer interval in anyone with factors that could raise PDE5 inhibitor levels (eg, interacting medicines)
  • review patient medicine histories to identify any prescription of a nitrate (eg, glyceryl trinitrate, isosorbide mononitrate)
  • counsel patients to tell emergency or ambulance staff when they last used a PDE5 inhibitor, so nitrates are avoided in acute care
  • check for cardiovascular disease – ask about angina, chest pain, shortness of breath, palpitations or syncope, even if the patient is not on nitrate therapy

(ii) Prescribing of metformin in patients with severe renal impairment, defined as an eGFR below 15ml/min/1.73m2. At this level of kidney function, metformin is generally contraindicated because the risk of metformin-associated lactic acidosis increases significantly. Lactic acidosis carries a high fatality rate and can be difficult to recognise early because symptoms are often non-specific.  There were 5 episodes of such prescribing over a fortnight amongst 227k interactions.

  • stop metformin in patients with an eGFR <15ml/min/1.73m2
  • review the most recent renal function results before issuing a new or repeat prescription or adjusting the dose
  • check for episodes of acute illness (eg, dehydration, vomiting or infection) that may reduce kidney function, and consider temporarily withholding metformin
  • assess for risk factors that increase susceptibility to lactic acidosis, including poorly controlled diabetes, heart failure, liver disease or alcohol misuse
  • consider alternative glucose-lowering therapies more suitable for patients with severe renal impairment
  • discuss sick day management and the need to pause metformin during acute illness, and reinforce the importance of regular renal monitoring
  • advise patients to seek medical attention promptly if they develop symptoms such as unusual fatigue, muscle pain, abdominal discomfort, rapid breathing or nausea, as these may indicate lactic acidosis or acute kidney injury.

(iii) First prescriptions of allopurinol at doses >200mg per day in patients with severe renal impairment, defined as an eGFR below 30ml/min/1.73m2.  There were 9 episodes of such prescribing detected over a fortnight amongst 212k interactions. 

  • Allopurinol and its metabolites are renally excreted, and impaired kidney function leads to accumulation. This increases the risk of serious adverse reactions, including allopurinol hypersensitivity syndrome and drug reaction with eosinophilia and systemic symptoms (DRESS), which can be life-threatening. Renal impairment has an additive effect on genetic susceptibility to these reactions, making cautious initiation and slow titration essential.
  • The New Zealand Formulary advises caution in renal impairment and suggests the following dosing for gout prophylaxis:
    • eGFR 30–60: start at 50mg once daily and increase by 50mg every four weeks, if tolerated, until target serum urate level (<0.36mmol/L) is reached
    • eGFR <30: start at 50mg every second day and increase by 50mg every four weeks, if tolerated, until target serum urate level (<0.36mmol/L) is reached.
  • Before initiating allopurinol, check renal function and document baseline eGFR. Start at the lowest recommended dose and titrate slowly, monitoring serum urate and renal function. Advise patients about hypersensitivity reactions. Patients should be counselled to stop taking allopurinol at the first sign of a rash (even if mild) or if they develop other symptoms of an allergic reaction (eg, swelling of the lips or mouth, difficulty breathing, fever) and to seek urgent medical help. Consider alternative urate-lowering strategies and/or specialist input for patients with significant renal dysfunction.

8.  Post Script

One of our listeners, Dr Andre Bonny from Nelson, took up the challenge to produce a Medsafe-type information sheet for alcohol (see below).  Perhaps a bit light on the social harms including family and relationship damage, crime, accidents and injuries, and economic and workplace issues.  From an economic perspective, a 2024 report to the Ministry of Health/Manatu Hauora included the following statistics for the 2023 year:

  • $9.1b estimated total cost of alcohol harm based on disability-adjusted life years
  • $4.8b associated with disability-adjusted life years from Fetal Alcohol Spectrum Disorder (FASD)
  • $1.2 b associated with disability-adjusted life years from alcohol use disorder
  • $281m – intimate partner violence (for alcohol use disorder alone)
  • $74m – child maltreatment (for hazardous drinking alone),
  • $2.1b in societal cost of road crashes where alcohol was a factor
  • $4b in lost productivity associated with alcohol use, including FASD, crimes and workplace absenteeism
  • $810m, predominantly in health and ACC spending

Ethanol (Ethyl Alcohol) – One Page Safety Summary (Medsafe■Style)

Overview

Ethanol is a psychoactive central nervous system depressant commonly present in alcoholic beverages and some medicinal preparations. While widely consumed socially, ethanol has no routine therapeutic indication and is associated with significant health risks, particularly when used regularly or combined with other medicines. It affects brain neurotransmitters including GABA and glutamate, leading to sedation, reduced inhibition, impaired coordination, and altered judgement.

Key Health Risks

Short■term: impaired judgement, reduced coordination, slurred speech, nausea, vomiting, slowed reaction time, injury risk.

Serious acute effects: respiratory depression, hypoglycaemia, seizures, loss of consciousness, alcohol poisoning.

Long■term: liver disease (fatty liver, hepatitis, cirrhosis), cardiovascular disease, increased cancer risk, cognitive impairment, and alcohol dependence.

Adverse Effects

Common: headache, fatigue, dehydration, sleep disturbance, mood changes. Less common: gastric irritation, memory impairment, anxiety or depression. Serious: severe intoxication, cardiac arrhythmias, acute pancreatitis, liver failure.

High■Risk Groups

Young people and adolescents; pregnancy (risk of Fetal Alcohol Spectrum Disorder); people with liver disease; people with mental health disorders; individuals taking sedating medicines.

Interactions With Medicines

Medicine TypeInteraction Risk
BenzodiazepinesExcess sedation, respiratory depression
Opioid pain medicinesIncreased overdose risk
Sleeping medicinesSevere drowsiness and impaired breathing
AntidepressantsIncreased sedation and impaired cognition
AntipsychoticsEnhanced CNS depression
Warfarin / anticoagulantsIncreased bleeding risk

Dependence and Withdrawal

Regular heavy use may lead to tolerance and physical dependence. Withdrawal symptoms may include tremor, anxiety, sweating, agitation, and seizures in severe cases requiring medical supervision.

Key Safety Message

Ethanol significantly increases the risk of sedation, overdose, injury, and drug interactions, especially when combined with other central nervous system depressants.

The New Zealand General Practice Podcast

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

Clinical Snippets – March 2026

https://open.spotify.com/episode/0UG8gzNIsEMYMBqg7unimr?si=08fPJi4CQR-SrQP559gahg

Clinical Snippets March 2026

1.  UTI in children

BPAC have published an update on managing urinary tract infection in children.  For rapid reference there is a B-Quick summary available that includes a useful dipstick interpretation algorithm.  Some relevant points include:

(i) Symptoms

  • UTI symptoms in young children may be non-specific, e.g. fever, irritability, poor feeding, vomiting
  • Older children may report urinary symptoms, e.g. frequent or painful urination, changes to urine colour or smell, abdominal or back pain
  • Suprapubic or flank tenderness, palpable bladder or stool in the bowel, abdominal distension, dehydration and/or fever may be present on physical examination

(ii) Red flags for paediatric advice or referral

  • Seek paediatric advice for children with a suspected upper UTI, i.e. with UTI symptoms accompanied by fever ≥ 38°C and/or loin or flank pain/tenderness
  • Acute paediatric referral is indicated for children:
    • Aged under three months
    • With symptoms or signs of significant systemic illness or sepsis
    • With complicating factors, e.g. an abdominal or bladder mass, impaired renal function, anatomic urinary tract abnormalities, previous renal surgery/implants

(iii) Urinalysis

  • Urinalysis is indicated for all children with a suspected UTI. Mid-stream or clean catch urine samples are preferred.  The full article and Starship guidelines describe various methods to facilitate sample collection including the Quick wee method, bladder percussion and the Perez reflex
  • Urine dipstick testing can support the diagnosis. However, urine microscopy, culture and sensitivity analysis is required to confirm a UTI and determine microbial sensitivity.
  • In children aged over three months, a UTI is unlikely with a negative dipstick test result for both leukocyte esterase and nitrite; consider alternative diagnoses
  • In children aged three months to three years, a positive dipstick test result for either leukocyte esterase or nitrite is sufficient to initiate empiric antibiotic treatment and send the sample for microscopy, culture and sensitivity analysis

(iv) Treatment

  • Initiate oral empiric antibiotic treatment while awaiting laboratory urinalysis results.  Review antibiotic choice once results are available. If symptoms are not improving and the pathogen is resistant to the empiric choice, select an alternative.  Seek paediatric advice if symptoms do not respond to appropriate antibiotic treatment within 48 hours
  • Order of preference for empiric treatment (three-day course standard, up to seven days may be considered in children with more severe symptoms but no red flags for secondary care referral) is cefalexin then nitrofurantoin (can be compounded into a suspension) then if bacteria are known to be sensitive amoxiclav then co-trimoxazole. 

(v) Follow-up:  Request a renal ultrasound (ideally to be performed six weeks after presentation) for:

  • Children aged < 12 months with their first UTI
  • Children of any age with an atypical UTI who have not previously been investigated with a renal ultrasound 
    • Poor response to antibiotics after 48 hours
    • Poor urine flow/suspected urinary obstruction
    • Abdominal or bladder mass
    • Raised creatinine
    • Hypertension
    • Infection with a non-E. coli organism
  • Children of any age with recurrent UTI   (≥ 2 culture-proven UTIs within one year, or ≥ 3 if the symptoms were only mild) who have not previously been investigated with a renal ultrasound

2. Prescriber Update

Some updates from the March Prescriber Update include:

(i)  Gynaecomastia

  • Has been reported in association with a wide range of medicines (27 listed as a representation) including omeprazole, digoxin, spironolactone, amlodipine, most statins, isotretinoin, methotrexate, antipsychotics, sertraline, fluoxitene, methyphenidate.  Atomoxetine is currently on the reporting list.
  • Onset can be delayed – gynaecomastia can develop weeks to years after starting treatment or adjusting the dose. Dose reduction or discontinuation of the suspect medicine may lead to improvement, particularly when gynaecomastia is identified early. Persistence beyond 12 months may be less likely to resolve without intervention.
  • Consider a medicine-related cause in male patients presenting with breast enlargement or other breast tissue changes.

(ii) Fournier gangrene

  • Fournier gangrene (necrotising fasciitis) is a rapidly progressive infection affecting the soft tissue and fascia of the perineal, perianal or genital areas.
  • Fournier gangrene has been known to occur in patients treated with empagliflozin for type 2 diabetes mellitus and is now known to occur with the use of empagliflozin in patients who do not have type 2 diabetes mellitus (eg when used in heart failure).

(iii) Zoledronic acid in the elderly

  • Elderly patients receiving zoledronic acid infusions are at higher risk of adverse reactions and may experience more severe adverse reactions or find them more disabling than younger people.  In particular, acute phase reactions are noted as a cause of concern including fever, joint pain and swelling, myalgia, influenza-like illness and gastrointestinal symptoms (abdominal pain, vomiting and diarrhoea). These usually occur within the first three days after zoledronic administration. Ocular inflammation, such as uveitis, can rarely occur and requires prompt ophthalmologist review.  Administering paracetamol shortly after the zoledronic acid infusion may reduce symptoms (some clinicians recommend a dose 60 mins prior to the infusion and regular administration for up to three days post-infusion).
  • Consider the following prior to the zoledronic infusion:
  • Inform the patient that acute phase reactions are common and usually resolve in a few days. However, patients should seek medical attention if symptoms are serious or prolonged. 
    • Ensure the patient is adequately hydrated and measure their serum creatinine. Maintain adequate hydration following the infusion.
    • Treat pre-existing hypocalcaemia with adequate intake of calcium and vitamin D.

(iv)  GLP-1 receptor agonists

GLP-1 receptor agonists can cause altered skin sensations.

  • Semaglutide (Wegovy) is associated with dysaesthesia, paraesthesia, hyperaesthesia, burning sensation, allodynia and sensitive skin.
  • Tirzepatide (Mounjaro) is associated with dysaesthesia.
  • Consider GLP-1 receptor agonists as a possible cause in patients presenting with altered skin sensations.

NB Healthcare professionals and consumers are encouraged to report any suspected acute persistent visual loss associated with use of GLP-1 receptor agonists per Medsafe monitoring communication in January 2026.   Cases of retinal vein occlusion and non-arteritic anterior ischaemic optic neuropathy (NAION) have been described in patients taking GLP-1 receptor agonists although the significance of this association is yet to be determined. 

3.  In other news…

(i)  Coffee:  The DECAF randomised clinical trial is a study of 200 patients with persistent AF and baseline coffee intake of 7 cups per week in which patients were randomly assigned in a 1:1 ratio to either regular caffeinated coffee consumption or complete abstinence from coffee and caffeine for 6 months following successful cardioversion.  The consumption group was encouraged to drink at least one cup daily, while the abstinence group avoided all caffeinated and decaffeinated coffee and other caffeine products.  In the primary analysis, AF or flutter recurrence occurred in 47% of the coffee group versus 64% of the abstinence group, with a 17% absolute difference.

(ii)  Paracetamol:  Two recent analyses of reviews and metanalyses regarding prenatal paracetamol exposure and child neurodevelopment, one published in the BMJ and another in The Lancet, have both concluded that current evidence does not indicate a clinically important increase in the likelihood of autism spectrum disorder, ADHD, or intellectual disability in children of pregnant individuals who use paracetamol as directed.  This is in contrast to the Trump administration proclamation in September last year.  The BMJ authors note Any apparent effect observed after in utero exposure to paracetamol on autism and ADHD in childhood might be driven by familial genetic and environmental factors and unmeasured confounders. 

(iii)  Morphine:  Issue 239 of Respiratory Research Review included comment on the Morphine for chronic breathlessness (MABEL) trial undertaken in the UK with results published in The Lancet late last year.  Adults with chronic breathlessness due to cardiorespiratory conditions were randomised to receive oral long-acting morphine 5–10mg twice daily with a laxative (evaluable n=73) or placebo (evaluable n=67) for 56 days.  At 28 days, 88% in the active arm and 99% in the placebo arm had regime adherence of >90%.  However, there was no significant difference between morphine versus placebo for the primary outcome of worst breathlessness at day 28 or at other time points.  There was improved cough at day 56 favouring morphine.  There were more adverse events in the morphine arm than in the placebo arm.  The authors concluded we did not show a benefit of morphine for our primary outcome of breathlessness. However, secondary outcome findings taken together (some evidence of benefit [eg, cough, physical activity], some evidence of no difference [eg, morphine-related neurocognitive or respiratory harms], and newer insights into morphine-related harms [eg, morphine withdrawal, persistence of constipation despite resolution of nausea and vomiting]) alongside acceptable tolerability indicate that further research is needed to fully understand the role of morphine in people living with chronic breathlessness. 

4.  Equity focus

(i)  Issue 118 of Maori Health Research Review examined a recently published observational study on CVD risk assessment by ethnicity in Aotearoa New Zealand.  People aged 25-74 years living in New Zealand on 31 March 2018 who were eligible for CVD risk assessment (n = 1,476,747) were analysed. Between 1 April 2018 and 31 March 2023, 67.1% of men and 65.5% of women had CVD risk assessments undertaken. After adjustment for socioeconomic deprivation and residential district, the odds of CVD risk assessment when compared with Europeans was lower in Māori men with diabetes (aOR 0.77) and without diabetes (aOR 0.73), and in Maori women with diabetes (0.93) and without diabetes (0.89).  The odds of CVD risk assessment was also lower in Pacific men (aOR 0.86 [95% CI 0.78-0.94] with diabetes (aOR 0.86) and without diabetes (aOR 0.72) and Pacific women without diabetes (aOR 0.95) compared with Europeans. The reviewer notes With CVD being a leading cause of avoidable premature death for Māori, this study has importantly quantified an often-invisible step in the CVD prevention continuum. Targeted strategies that redress equity in the wider determinants, in system design and in clinical practice, rather than simply increase screening overall, are needed.

(ii)  Goodfellow Gem #253 summarised a recent NZMJ study looking at cancers potentially attributable to excess body weight in Aotearoa New Zealand from 2019 to 2023.  The authors express concern that excess body weight (EBW) contributes to many cancers in New Zealand and compounds health inequities, with higher proportions of EBW-attributable cancers within Māori and Pacific populations.  Pacific peoples had the highest population attributable fraction (11.8%), and this was highest among Pacific females (16.1%). Māori also had a higher PAF (6.9%) than European/other (4.5%). The cancers most commonly attributable to EBW were colorectal cancer, followed by uterine cancer and breast cancer among postmenopausal females.  The authors conclude A pro-equity, anti-stigmatising approach to prevention, early detection and treatment of EBW is important. Ultimately, sustained reductions in EBW-attributable cancers will depend on preventing EBW.

5.  Recent releases

(i) The Medical Council of New Zealand has recently published Guidance on using artificial intelligence in patient care.  It is important to review the statement in its entirety but some clauses include:

  • AI is not a substitute for your clinical judgement, and you remain responsible for all your clinical decisions and actions. AI can make mistakes or reflect bias and may produce inaccurate or fabricated information. Therefore, as far as is reasonably practicable, you should check the accuracy of any AI output and confirm it is appropriate for the individual patient before using it for patient care or including it in patient records.
  • Patients should know when AI is being used in their care. For low-risk AI, this can be explained in a simple statement that describes how AI is used in their care and how their data is protected. For high-risk AI that influences clinical decisions, you must explicitly inform the patient.
  • There are some specific situations where you need to obtain informed consent for the use of AI, including when:
    • using an AI tool to record the consultation, such as a transcription tool (scribe)
    • the patient’s personal details are shared outside of the primary medical record or used for AI training in a way that could identify them
    • the AI technology plays a significant role in diagnosis, treatment or delivery of care.

In these situations, let the patient know how their care will be affected if they decide against the use of AI. Always document in the patient’s records whether informed consent was obtained.

(ii)  GP2GP:  Some recent reporting in NZ Doctor highlighted potential good news on the horizon for those concerned with clinical notes transfer between practices. 

  • PMS providers Medtech and Valentia Technologies say testing and rollout of an upgraded GP2GP patient file-transfer system is underway.
  • Medtech expects the upgrade to be available to its customers by the end of June, while Valentia says its rollout to Indici users could be completed by May.

(iii) Meningococcal disease:  The reporting earlier this month of two cases of meningococcal disease in tertiary students in Dunedin has led to a reminder from IMAC that now is a good time to check meningococcal immunisation status for school and university students.   

  • The vaccinations Bexsero (B strain) and the quadrivalent MenQuadfi (A,C,W and Y strains) are recommended and funded for those aged 13-25 years inclusive who are entering within the next three months, or are in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, Youth Justice residences or prisons.  Funding covers individuals who turn 13 years of age while living in boarding school hostels.
  • IMAC notes that the MeNZB vaccine used in NZ from 2004 to 2011 targeted one type of meningococcal group B disease. Those who received MeNZB are no longer expected to have protection against this type of group B disease.  IMAC provides an FAQ resource on meningococcal vaccines including information on co-administration and duration of effectiveness. 

(iv)  Season 2 of The Pitt was released in NZ in January (Neon) and a Medscape emergency medicine article has several doctors rating the accuracy of the clinical presentations or procedures dominating each episode.  These include:

  • A hilar flip during an emergency clamshell thoracotomy to stop a catastrophic lung haemorrhage (realistic)
  • Hypokalaemic periodic paralysis masquerading as traumatic paraplegia (zebra)
  • Intrarectal manipulation for a coccygeal fracture (without anaesthetic!)
  • Management of medication related priapism (OK except for the gentle massage and no 3-way stopcock (for phenylephrine injection and aspiration)

The New Zealand General Practice Podcast

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

Clinical Snippets – February 2026

https://open.spotify.com/episode/7JILezv6hONlRH6v8j9Jnc?si=zerXvOiBSMuc5HFOEDBvaw

1. Dengue Fever

(i) At the end of January 2026 Te Whatu Ora released an alert noting there is an ongoing dengue outbreak in the Pacific, particularly affecting the Cook Islands, with continued transmission in Samoa, American Samoa, Kiribati, Nauru, and Tuvalu. To date, 86 confirmed and probable dengue cases have been reported in New Zealand, most associated with recent travel to the Cook Islands.  There is a Health Pathway section on dengue that includes the following advice: 

(ii) Consider dengue fever if the patient has recently travelled overseas to a country where there is a risk of dengue or a known outbreak.  Infection may be asymptomatic. In patients with symptoms, clinical presentation can range from a mild febrile illness to a life‑threatening shock syndrome.  Symptoms include: sudden onset of high fever although that not all patients present with fever; Severe headache and retro‑orbital pain; Myalgia or arthralgia; Rash, which may be itchy or hypersensitive; Anorexia with foul or metallic taste; Nausea and diarrhoea; Abnormal bruising and bleeding.

(iii) Severe dengue often presents after a few days of being mildly unwell with symptoms including: significant bleeding (gums, nose, GI, vaginal) and bruising/petechiae; hypotension causing dizziness; abdominal swelling (ascites); SOB (pleural effusion); persistent vomiting; impaired cognition and level of consciousness.   Severe disease is more likely with recurrent dengue, age <1 year and >65yrs; pregnancy; patients with chronic comorbidities or who are immunocompromised.   Increasing haematocrit, rapid decrease in platelet count, AST or ALT > 3 times ULN and fall in albumen are all warning features of impending severe dengue.

(iv) Fever usually lasts 2-7 days and if the fever has been present for more than 3 days, the critical phase may occur at any time.  In a patient presenting with positive travel history and history consistent with dengue examine the patient noting the potential signs of severe dengue discussed and consider alternative diagnoses.  Appropriate testing includes Dengue NS1 Ag (day 1-9 of illness), CBC and LFTs with other investigations as indicated by your differential diagnosis.  Write the date of onset of symptoms and note any recent overseas travel on pathology request to enable the laboratory to run correct confirmatory tests.

(v) If suspected severe or impending severe dengue fever resuscitate as required and refer to hospital.  Refer also if there is a rise in haematocrit 20% or more above baseline or a platelet count less than 50,000 in adults or 100,000 in children.  Seek paediatric medicine advice for any child in whom you suspect the diagnosis. Notify Public Health if dengue is confirmed on testing (no isolation required while awaiting the result) or immediately in suspected cases where there is no history of international travel (may mean the Aedes mosquito has penetrated the NZ border).

(vi) There is no specific management other than supportive care (paracetamol – avoid NSAIDs/aspirin), fluid replacement,  bed rest), patient education (English and Samoan) regarding warning symptoms, and regular review depending on the patient’s risk factors for severe disease and initial assessment findings.  Check platelets and haematocrit from the third day of the illness until 1 to 2 days after the fever subsides (frequency depending on results and risk of severe disease). 

2. Monitoring for psychostimulants

With the recent changes in restrictions on psychostimulant prescribing, I note the following recommendations in NZ Formulary regarding pre-treatment screening and monitoring during treatment.  

(i) Pre-treatment screening

Before starting a psychostimulant medicine, a physical health assessment should be undertaken including psychiatric and medical history, current medicines, height and weight, and a cardiovascular assessment (including heart rate and blood pressure). A 24-hour ECG and cardiology referral is recommended if the person has a history of congenital heart disease or cardiac surgery, a history of sudden cardiac death in a first-degree relative under 40 years, shortness of breath or fainting on exertion, palpitations, chest pain, or heart murmur.  Baseline symptoms and level of functioning should be recorded.

(ii) The following monitoring has been suggested by the New Zealand Clinical Principles Framework for Attention Deficit Hyperactivity Disorder Ministry of Health, 2025. Follow-up is likely to be more frequent (usually weekly), early on in treatment and during titration, and will settle over time to longer intervals of months. Individual requirements for monitoring will vary (depending on how well the ADHD core symptoms are managed and co-existing conditions) and more frequent monitoring may be necessary.

During treatment

  • A review to monitor progress and adverse effects (using standardised assessment scales) should be conducted two to four weeks after initiating treatment or changing the dose. Thereafter, symptoms, level of functioning, and adverse effects should be regularly assessed and recorded at least every 6 months or at each dose change.
  • An additional clinical follow-up for cardiac and mental health review after 6–12 months.
  • An annual review of medication efficacy and tolerability, including weight, heart rate and blood pressure checks (more frequently if there are dose changes)
  • Review the need for continuing medication every two to four years (see Treatment duration below).

Undertake reviews more frequently if there are any concerns and refer to a specialist if needed.

3. Statin side effects

A recent BMJ news article commented on a meta-analysis of double blind RCTs examining adverse effects attributed to statins published earlier this month.  The study analysed 19 trials involving 123 940 participants that compared statins with placebo, with a median follow-up of 4.5 years. Findings include:

  • For 62 of the possible side effects listed in package leaflets, the study found similar numbers of reports among people taking statins and those taking the placebo.
  • Statin therapy was associated with a significant excess risk for four of 66 prespecified outcomes: abnormal liver transaminases, other liver function test abnormalities, urinary composition alteration, and oedema and the absolute annual excesses for each of these outcomes was below 0.1%.
  • The study did not look at muscle symptoms or diabetes, as the same team had previously examined those two potential side effects, finding that statin therapy caused muscle symptoms in only 1% of people during the first year of treatment, with no excess thereafter and that statins can cause a small increase in blood sugar concentrations, the majority occurring in people with glycaemic markers already close to the diagnostic threshold for diabetes at the time of starting statins.
  • Comment in the BMJ article includes:  In an era of social media driven debate, this study strengthens the evidence base needed to counter misleading claims about drug harms, communicate actual risk clearly, and prevent avoidable discontinuation or non-use of statins among patients who would benefit.

4. Cardiometabolic issues with antidepressants

Goodfellow Gem #254 summarised a 2025 systematic review in The Lancet  on the cardiometabolic issues with antidepressants.

There were a few surprises:

  • None caused significant QT interval issues.
  • Systolic blood pressure went up with amitriptyline, fluoxetine, imipramine and venlafaxine, and down with nortriptyline.
  • Weight loss was observed with bupropion, citalopram, fluoxetine, moclobemide, paroxetine, sertraline and venlafaxine.
  • Weight gain was found with amitriptyline (1.6kg relative to placebo) and mirtazapine (0.87kg).
  • Heart rate (beats per minute) increased by 13.77 with nortriptyline, 9.74 with clomipramine, 9.44 with imipramine and 9.25 with amitriptyline

5. Chronic Kidney Disease

I regularly see complaints regarding management of CKD, usually related to the patient being unaware they have ever had abnormal renal function tests, and around inadequate testing (including ACR which is important in staging) and monitoring. 

The Chronic Kidney Disease Health Pathway has been aligned nationally across most New Zealand HealthPathways regions, supporting the work of the Renal National Clinical Network. There are quick links on the right of the Health Pathways Chronic Kidney Disease webpage providing access to a one-page Chronic Kidney Disease Quick Guide and At Home Sick Day Advice.  The Pathway contains advice on diagnosing, modifying reversible causes, maximising lifestyle efforts, modifying disease progression and cardiovascular risk, and when and how to escalate for further support. There is an hour long webinar recording available. You will also find the recording in the ‘for health professionals’ section at the bottom of the CKD pathway.

BPAC has previously published a comprehensive article on identifying and managing CKD together with an easy to follow detection and diagnosis algorithm. 

6.  Adult sinusitis update

Issue 22 of GP Practice Review looks at an updated  Clinical Practice Guideline for adult sinusitis update published by The American Academy of Otolaryngology/Head and Neck Surgery Foundation. The guideline contains the following key recommendations:

1. Acute bacterial rhinosinusitis (ABRS) should be distinguished from acute rhinosinusitis due to other causes. ABRS should be diagnosed when

  • symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without improvement for ≥10 days beyond the onset of upper respiratory symptoms, or
  • symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (strong recommendation).

2. Radiologic imaging should not be obtained for patients meeting the diagnostic criteria for ABRS, unless a complication or alternative diagnosis is suspected.

3. Analgesics, topical intranasal steroids, and/or nasal saline irrigation may be recommended for symptomatic relief of viral rhinosinusitis.

4. Watchful waiting without antibiotics should be offered for adults with uncomplicated ABRS with assurances of follow-up.

5. If a decision is made to treat ABRS with antibiotics, amoxicillin for seven days is the first-line therapy for most adults.  [Te Whata Kura suggests 1000mg amoxicillin TDS for 5 days]

7. Resources

(i) Sepsis:  One-page algorithms for recognition and initial treatment of sepsis have been published by Sepsis Trust NZ, Te Whatu Ora and HQSC. Separate community algorithms, which are being incorporated into Health Pathways, are available for 

(ii)  Methylphenidate prescribing (NZF)

(iii) 12-month prescribing aid

An Auckland GP Dr Ryo Eguchi, has a website clinicpro.co.nz with tools he has developed including a 12-month prescribing aid in the form of an e-algorithm that facilitates a logical approach to choice of prescribing interval for patients.  There are also links to additional useful 12-month prescribing resources. 

8. That’s interesting

An interesting article published in Issues in Mental health Nursing was titled  … 5, 6, 7, 8: The Many and Interrelated Benefits of Line Dancing – A Scoping Review.   The authors note Line dancing has been the subject of many studies, with research focusing on particular areas of health and the impact line dancing can have in these areas. The authors findings indicate that line dancing enhances physical health by improving balance, coordination, and cardiovascular fitness. In relation to mental health, it contributes to reduced depression and anxiety symptoms. Socially, line dancing fosters community engagement and friendships. Cognitively, participants experience improvements in memory and executive functions. The authors conclude This review highlights the health benefits of line dancing, with evidence suggesting that line dancing is an effective health intervention with benefits for physical, mental, social, and cognitive health across various age groups… line dancing can be considered an effective, adaptable and accessible intervention that could be promoted to patients of all ages and abilities.

The New Zealand General Practice Podcast

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

https://open.spotify.com/episode/6aKRuhi5cOFKyqpFkssFJE?si=XKvV_tmqQ0O-AXN7KtqttA

Shownotes

Clinical Snippets January 2026

1.  Measles refresher (from NZ Doctor)

  • A characteristic maculopapular rash and Koplik spots are the key clinical signs of measles infection.
  • Koplik spots:  may appear at the end of the prodromal period; are quite specific for measles; have a “grain of salt” on a bright red background appearance.
  • Maculopapular rash: appears after a prodromal period; usually appears on the face first, then descends downwards; eventually turns brown and fades; may be less apparent on people with dark skin.
  • Notify Public Health immediately if there is a clinical suspicion of measles and advise the patient to isolate while awaiting test results (PCR takes up to 2-3 days). The Medical Officer of Health will guide confirmation testing.
  • Measles PCR on a nasopharyngeal or throat swab is the test of choice. It is most sensitive in the prodromal period or during the first few days of rash. Sensitivity is high enough to exclude infection if negative in the first seven days after the rash appears.  It is very important to include the date of onset of rash and the measles vaccination history in the clinical details on the laboratory request form.  Do not send the patient to the lab!
  • If measles transmission in the local community is low, then the pre-test probability of any individual patient being diagnosed with measles will be low and other diagnoses should also be considered. Parvovirus, enterovirus, adenovirus, scarlet fever and infectious mononucleosis (among other infections) may all mimic measles to some extent and should all be considered in the New Zealand setting.
  • Complications of measles include: otitis media (7 to 9% cases); pneumonia (1 to 6% cases); croup; encephalitis (1 per 1,000 cases – fatal in 15%, and 1 in 3 have permanent brain damage); possible miscarriage or premature delivery in pregnant patients (frequency unknown); diarrhoea (8% cases).  If referring to hospital ensure ambulance staff (if used) and ED staff are aware of potential measles.  The process in the Waikato is to phone paediatric on-call registrar, arrange for immune or vaccinated family member to present to ED reception ahead of case if possible, masks for everyone, the case will then be directed to negative pressure room. 
  • If a high-risk close contact has presented to primary care, contact the Medical Officer of Health and follow the local process for arranging urgent post-exposure prophylaxis with immunoglobulin.
  • Offer measles vaccination to people born after 1969 with unknown or no history of measles vaccination (and no contraindications).
  • Further details are available on your local Health Pathways including Medical Officer of Health contact details.  RNZCGP publishes updates and has developed resources to assist practices to prepare for arrival of measles cases.   

2.  NZ Doctor Spotlight series

Two further reports from the NZ Doctor Spotlight series using reporting from the Conporto Event Detection & Mitigation service that automatically analyses the patient’s medical records and identifies if a risk of harm is likely:

A.  NSAID use in CKD

 (i) Background: In people with an eGFR below 45ml/min/1.73m2, NSAIDs should be avoided as their use is associated with worsening renal function, acute kidney injury, electrolyte disturbances and increased cardiovascular risk. Safer alternatives for pain management are preferred, such as paracetamol or topical NSAIDs. Māori, Pacific and Indo-Asian peoples are at higher risk of developing chronic kidney disease, with rates up to three times higher than in other populations. Advanced CKD is also more common, occurring up to five times more often. Because of this, NSAID prescribing and over-the-counter supply carry greater potential for harm in these ethnic groups.

(ii) Over two weeks in August 2025 the event detection system recorded 226,285 patient interactions across 245 practices, identifying 468 potential harm events. Of these, 51 detections were NSAIDs prescribed to patients with an eGFR <45ml/min/1.73m2.

(iii) Before prescribing or dispensing an NSAID:

  • check renal function – confirm the patient’s most recent eGFR result
  • avoid NSAIDs in patients with an eGFR <45ml/min/1.73m2, unless under specialist advice
  • consider alternatives for analgesia in those with CKD (eg, paracetamol, topical agents, non-pharmacological)
  • review for polypharmacy risks – avoid concurrent use of an NSAID, an ACE inhibitor or angiotensin receptor blocker, and a diuretic (the “triple whammy”).

Additionally, all patients with newly diagnosed CKD should have their medicines reviewed for nephrotoxic risk. Patients with CKD should be advised to avoid over-the-counter NSAIDs and to check with their healthcare team before using any new medicines.

B.  Methotrexate without folic acid

(i) Background: Between 7 and 30% of patients discontinue methotrexate within the first year due to toxicity, and some of these cases are likely related to folate antagonism. Methotrexate toxicity includes minor adverse effects such as mouth ulcers, nausea and vomiting, and major effects such as bone marrow suppression and liver function abnormalities. Folic acid supplementation reduces the frequency and severity of these adverse effects, decreases treatment discontinuation, and may improve adherence and long-term response to therapy.

(ii) Over two weeks in September 2025, the event detection system recorded 176,334 patient interactions across 240 medical centres, with 506 new harm events identified. Among these, 15 patients were prescribed methotrexate without an accompanying folic acid prescription.

(iii) Before prescribing or dispensing methotrexate, check folic acid is also prescribed and that patients understand how to take it correctly – commonly, 5mg once weekly, taken on a different day to methotrexate. Alternative regimens may be used in some situations. For example, if adverse effects occur, it is possible to increase folic acid to 10mg weekly. Doses above 10mg have no proven additional benefit. Continue folic acid for as long as methotrexate therapy is given as the risk of adverse effects remains throughout treatment. Encourage adherence to folic acid to support ongoing methotrexate use and reduce the risk of adverse effects. Advise patients to report early signs of toxicity, such as mouth ulcers, sore throat, bruising or nausea.

3.  Disability Allowance updates

(i) New disability allowance special food information form

If a patient has extra costs for special food or diet due to their medical condition, MSD may be able to support them through the Disability Allowance. Patients can print out the new ‘Disability Allowance – special food information’ form to record what their extra food costs are.  You will still need to complete a Disability Allowance medical certificate for your patient confirming that they have additional costs related to purchasing special foods, and that these costs are ongoing and directly related to their disability or ongoing health condition. There is a separate form for StudyLink beneficiaries. 

(ii)  For people who do not meet Pharmac funding criteria for continuous glucose monitors (CGMs):

The ongoing costs of CGMs can be considered in Disability Allowance (DA) for patient who meet the eligibility criteria for DA, do not meet Pharmac funding criteria (usually people with type 2 diabetes), and whose life or health would be placed at risk, or their disability aggravated if they did not receive assistance.  Additional information will also be required for these requests:

  • How well controlled is the patient’s diabetes?
  • Do you (the medical/nurse practitioner) support this request and consider the use of a CGM to be essential?
  • Has there been instances when the patient’s condition has been compromised despite good diabetic management, for example ongoing high blood glucose levels, hospitalisation due to very high/low glucose levels?
  • The type of CGM preferred (if there is a preference).  Use of the lowest cost device is encouraged (comparison table available here)

4.  Cremation Regulations exemption extended

The Ministry of Health has advised work on amending the Cremation Regulations 1973 is still ongoing. In the meantime, the partial exemption from complying with Cremation Regulation 7 has been extended until 30 April 2026. Details of the exemption can be found on the Health NZ website.  The exemption applies to the requirement for a medical practitioner or NP to see and identify the body after death for the purpose of completing the cremation certificate in situations when:

  • the death occurs in rest homes, residential care facilities, and other long-term in-patient facilities; and
  • the death is not unexpected; and
  • where the medical history and current conditions of the deceased are known by a medical or nurse practitioner.

This exemption does not apply to deaths in public hospitals, hospices, private homes, or other settings and where a medical practitioner does not know the medical history of the individual. Certifying practitioners are still required to view the body of a person who dies outside of a residential care facility in order to issue a cremation certificate. Under this authorisation a medical referee must receive advice from a trusted source, who has a reasonable level of assurance of the cause of death to verify the identity of the deceased and that the deceased died of natural causes.

5. Concussion Guidelines

Australia and Aotearoa New Zealand Concussion Guidelines were published on-line in November 2025 and are worth reviewing.  There is a dedicated ‘toolbox’ section with links to evidence-based assessment tools for various components of mTBI assessment and management.  The guideline notes that the use of a standardised tool with concussion-specific measures allows for consistent and standardised assessment, with the ability to follow and monitor the progression of recovery and the Toolbox includes links to the Brain Injury Screening Tool (my favourite) as well as numerous other assessment resources.  Ther guideline is organised into manageable sections both general and symptom specific and includes practical guidance on issues such as when is imaging indicated, return to work and sport after mTBI, and management of repeated mTBI. 

6. RNZCGP position statement on 12-month prescribing

The Royal New Zealand College of General Practitioners (RNZCGP) has released a position statement on Twelve-month prescribing in general practice, ahead of amendments to the Medicines Regulations 1984 that will increase the period of supply limit from three months to 12 months, from 1st February, 2026. Clinicians are expected to use clinical judgement when making prescribing decisions, and this should include a risk/benefit assessment for each patient. The College recommends that practices adopt their own in-house policy to guide their clinicians, always consider equity and access when deciding on a prescribing period and to work collaboratively with pharmacists. 

A poster and FAQ sheet for patients have also been produced to help explain the changes.

7.  Resources

(i) Angina Action Plan 

New Zealand Heart Foundation has available a simple Angina Action Plan which can be printed off for patients in any of  English, Te Reo Māori, Samoan, Tongan, Chinese, Korean

(ii) Birth trauma screening tool

The UK’s City University recently developed a scale which can be used to assess for post-traumatic stress symptoms related to birth experience. The tool (City Birth Trauma Scale) is based on DSM-5 criteria for post-traumatic stress. The tool includes a short scale involving five questions and a longer, more in-depth scale, both of which can be completed on-line and saved as a PDF or printed off for manual completion and scanning.  The website includes information on scoring and interpreting the results.   The tools hold great value for whānau including facilitation of accurate diagnosis of distress and guidance towards appropriate treatment and support. Support for whānau can be found on the Birth Trauma website. 

(iii) Online learning modules for bowel screening

Health New Zealand, Te Whatu Ora, has announced that four new learning modules for bowel screening are now available on regional learning sites (listed on the main website).  The modules are designed to give clinical staff the information needed to clearly and confidently discuss bowel screening with patients. The module content includes bowel cancer and screening, the faecal immunochemical test (FIT), culturally safe communication and advice on responding to different situations when discussing bowel screening including real-life scenarios.  The modules take a total of around 75 minutes to complete and are relevant for any staff that might be involved in bowel screening discussions with patients.  

(iv)  Antibiotic stewardship

The Te Whata Kura website has been developed by a multidisciplinary team from across Aotearoa to provide nationally unified antibiotic prescribing guidance.  It is accessible via web or as an app on your mobile device and is designed to promote both prudent use and equitable access to best-practice prescribing.  Website information notes Te Whata Kura will provide a consistent national standard, allowing all prescribers access to the same expert advice, and enabling more informative monitoring of appropriate and inappropriate antibiotic prescribing.  It comes with the disclaimer that these are educational guidelines and do not supplant clinical judgement or Infectious Diseases/Clinical Microbiology consultation.   There is regional information on how to access infectious diseases expertise for complex cases.  The guidelines are organised by where you prescribe antibiotics (community, hospital or surgical prophylaxis), adult versus child then by anatomical region. 

(v)  Adult ADHD   

There is a live webinar scheduled for 7pm on 17 February 2022 run by Health Pathways Education and RNZCGP covering the changing role of primary care in diagnosing and managing adult ADHD.   Topics include:

  • New prescribing rules and boundaries
  • Key expectations under the Clinical Principles Framework
  • Practical steps for screening, referral, titration, and managing supply issues
  • Training options and Health Pathways updates
  • What to do if you choose not to provide comprehensive ADHD diagnostic care