Author: opotikigp

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

The New Zealand General Practice Podcast

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

Clinical Snippets December 2025

https://podcasts.apple.com/nz/podcast/the-new-zealand-general-practice-podcast/id1457506728

Clinical Snippets December 2025

1.  Restless leg syndrome in adults

(i) Best Practice Bulletin 127 commented on an updated international guideline from the American Academy of Sleep Medicine published earlier this year that has recommended a new treatment hierarchy for managing patients with severe symptoms of restless legs syndrome. One of the most significant changes is that dopamine agonists, previously first line for patients with severe symptoms, are no longer recommended due to concerns with augmentation syndrome (worsening of restless legs symptoms over time). The importance of iron supplementation in people with low ferritin levels is also strongly emphasised.

(ii) Good practice statements include:

  • The first step in the management of RLS should be addressing exacerbating factors, such as alcohol, caffeine, antihistaminergic, serotonergic, antidopaminergic medications, and untreated obstructive sleep apnoea.
  • In all patients with clinically significant RLS, clinicians should regularly test serum iron studies including ferritin and transferrin saturation (calculated from iron and total iron binding capacity). Testing should ideally be administered in the morning avoiding all iron-containing supplements and foods at least 24 hours prior to testing. Consensus guidelines, suggest supplementation of iron in adults with oral or IV iron if serum ferritin ≤ 75 mcg/L or transferrin saturation < 20%, and only with IV iron if serum ferritin is between 75 and 100 mcg/L.  Note that Special Authority criteria for funded access to IV iron supplementation in New Zealand requires a diagnosis of anaemia and a serum ferritin level ≤ 20 mcg/L (or a serum ferritin level between 20 – 50 mcg/L and CRP ≥ 5 mg/L), therefore people with restless legs syndrome may not qualify.
  • RLS is common in pregnancy; prescribers should consider the pregnancy-specific safety profile of each treatment being considered.

(iii)  gabapentin and pregabalin are now regarded as first line pharmacological treatment for adult RLS (off-label use in NZ) with dipyridamole and low dose opioids conditionally recommended as second line agents.  There are conditional suggestions against the standard use of dopamine agonists (ropinirole, pramipexole) with the qualifying remark: [the drug] may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use (particularly augmentation).  [Note potential adverse effect of impulse control disorders also].  There are also conditional suggestions against the use of bupropion, carbamazepine, clonazepam, valproate and valerian.  Health Pathways acknowledges the new guidance with the RLS pathway to be updated as resource allows. 

2. Pregabalin prescribing

A recent NZ Doctor article looked at prescribing of pregabalin in neuropathic pain.  This was presented as a case study and comment from various health providers.  

  • There is reference to the ‘black box’ warning which notes the drug  poses risks of misuse, abuse and dependence which can lead to overdose and death especially when used concomitantly with opioids and other CNS depressants.
  • Dosing is renal function dependent. 
  • Withdrawal symptoms are common and can occur even when stopping relatively low doses of pregabalin. NZF notes that, dose reduction should be individualised as tolerated; a suggested regimen is to reduce the daily dose of pregabalin at a maximum rate of 50–100mg every week, but the tapering rate may need to be considerably slower, e.g. smaller dose reductions over a longer time.  Gradual withdrawal allows for monitoring, and appropriate management of withdrawal symptoms. In those taking high doses for long periods of time, complete withdrawal may take several weeks or months.
  • Pregabalin use in the first trimester of pregnancy may cause major birth defects in the unborn child. Pregabalin should not be used during pregnancy unless the benefit to the mother clearly outweighs the potential risk to the fetus. Women of childbearing potential must use effective contraception during treatment – ideally long-acting reversible contraception (LARC) is preferred; alternatively, two complementary forms of contraception including condoms should be used.

Comments from a specialist pain physician regarding issues experienced in her practice include:

  • lack of informed decision-making – patients unaware of the indication, mechanism and ‘off label’ nature of the gabapentinoid use, potential side effects and difficulty weaning in future
  • not having been advised of the potential risks to a developing pregnancy, and thus not using effective contraception 
  • cognitive impacts – including one older gentleman who was unable to complete the crossword in his daily paper as he usually could, and a young woman who had a near-miss car accident with her children in the car
  • mood effects – including low mood and new-onset suicidal ideation
  • discontinuation syndrome – many of my patients have experienced severe symptoms (eg, mood destabilisation, insomnia, suicidality) when trying to wean from gabapentinoids, and I have had two who needed to do so slowly over a year.

3. Ryeqo

(i) The drug company Gedeon Richter Australia has announced registration in July 2025 of their product Ryeqo for the treatment of endometriosis symptoms, including endometriosis pain, for adult women of reproductive age who have previously tried medical or surgical treatment for their endometriosis. It was initially approved in October 2023 for the treatment of moderate-to-severe symptoms of uterine fibroids in adult women of reproductive age.

(ii) Ryeqo is an oral treatment which contains the combination of a GnRH (gonadotropin-releasing hormone) receptor antagonist, relugolix 40mg, and a hormone add-back therapy, estradiol 1mg and norethisterone acetate, 0.5mg in a single, once-daily tablet. The main component, Relugolix works by reducing the hormone oestrogen that drives endometriosis symptoms including pain, whilst the estradiol and norethisterone acetate add-back therapy components help to maintain hormonal balance.

(iii) Ryeqo is not currently funded on the Pharmaceutical Schedule – patients will need to pay for the medicine (around $NZ250 per month) and any associated healthcare professional fees.  

(iv) A comprehensive prescribing summary, including recommendations regarding informed consent and monitoring, has been developed by Cheshire and Merseyside NHS and although this reflects current prescribing restrictions in the UK, it provides an excellent overview of use of the drug.  Medsafe have published Consumer and Health Professional prescribing data sheets.

  
3. Nortriptyline reminder

Health Pathways recommends nortriptyline as a first-line pain modifying agent in management of chronic non-malignant pain and I often see it prescribed appropriately for this indication.   However, I have also received several complaints relating to adverse reactions (often stated by the complainant to be serotonin syndrome) occurring at what appear to be fairly modest doses of the drug although often in combination with other serotonergic medications such as tramadol.  Health Pathways incudes the following advice with respect to prescribing of nortriptyline for chronic non-malignant pain: 

  • Best taken as a single evening dose 3 to 4 hours before bed.
  • Start at 10 to 25 mg.
  • Due to variations in CYP2D6 enzyme and metabolism of nortriptyline, there is a lot of individual variation in dose response.
  • Nortriptyline needs to be titrated, guided by measurement of plasma level after at least 10 days on a new dose.
  • Aim for a trough (late afternoon) plasma of between 200 to 400 nmol/L.
  • Trial for at least 6 weeks at a therapeutic level.
  • Typical effective dose is 50 to 75 mg, but some patients will require either much smaller or much higher doses.

4. Signs in ACS

Issue 262 of GP Research Review reported on a recently published meta-analysis evaluating the diagnostic accuracy that 13 symptoms and signs had in patients with suspected acute coronary syndrome (ACS) and acute myocardial infarction (AMI).  The results suggested that the included symptoms and signs had limited utility for the detection of both conditions. The symptoms with the highest diagnostic accuracy for ACS were an absence of chest wall tenderness (diagnostic OR 7.73) and pain radiating to the right arm (OR 3.9). The most accurate symptoms for AMI were sweating, pain radiating to the right arm, absence of chest wall tenderness and pain radiating to both arms.  Chest pain on exercise was also important in ACS. The reviewer’s take-home message was Symptoms have limited value in diagnosis of AMI and ACS, and objective testing remains essential for accurate diagnosis.  

While we are on diagnosis of chest pain it is important to remember spontaneous coronary artery dissection (SCAD) as a cause of ACS.  SCAD is often underdiagnosed, partly because it occurs in younger individuals (average age 51yrs, 80-90% female) without typical cardiovascular risk factors and clinicians may fail to consider ACS in a young female.  It is the cause of around a third of heart attacks in women under 50 and half of all heart attacks in pregnancy and the post-partum period. The majority of patients (around 70%) present with non-ST-segment elevation myocardial infarction (NSTEMI), while 30% have ST-segment elevation MI (STEMI), with chest discomfort reported by around 90% of the subjects. Less common symptoms included nausea, vomiting, light headedness, and dyspnoea. I have also seen a recent case where a middle-aged woman without traditional CV risk factors presented with shortness of breath and chest tightness on exertion and was found to have 95% stenosis of her left main coronary artery due to radiotherapy she had undertaken several years previously for left sided breast cancer.    

5.  HQSC Cultural Resource:  

To support the 2023 publication RN frailty care guide ‘Guide for health professionals caring for kaumātua’ HQSC has developed a series of short videos on cultural considerations when caring for kaumātua (Māori older adults) and their whānau in aged residential care and other health settings.  The series covers key concepts of Māori identity, whanaungatanga (relationships), mana and manaakitanga (dignity and respect), tapu, noa and whakamā (sacredness, balance, and shame), and holistic care. Each video encourages reflection and offers practical ways to weave tikanga Māori into everyday care [2-3 minutes each].  

6. Reminder:  Staff checks

  • A recently published investigation by the Ombudsman launched found Health NZ had not been following the proper vetting processes required by law for nine years.
  • It is a requirement in the Children’s Act 2014 for all non-core children’s workers to have passed an appropriate check to work with children, and this check requires updating every three years.  
  • Details relating to the legislation requirements and checking process can be found on the Te Whatu Ora website.  

7. Resources

(i)  STI Patient Info  

The Sexually Transmitted Infections Education Foundation has a series of patient pamphlets available, which cover a range of topics related to herpes and human papillomavirus. Topics include HPV vaccination, cervical screening and results, HPV and throat cancer, and breaking down herpes myths. These resources are available electronically (herpes.org.nz and hpv.org.nz) and hard copies can be ordered and posted out free to general practices and sexual health clinics.

(ii) Herpes guidelines 

STIEF and the New Zealand Herpes Foundation have also published updated clinical guidelines for the management of genital herpes in Aotearoa. Access them for free online (guidelines.stief.org.nz).  The guidelines include genital herpes management flowcharts for clinicians covering first episodes, recurrent genital herpes and herpes in pregnancy. There is also key information to provide to patients at the time of diagnosis. [A reminder that dosing of acyclovir and valaciclovir is renal function dependent – important to avoid neurotoxicity associated with elevated serum levels, particularly in the elderly being treated for shingles]

(iii)  Cyber security guide for primary care

Health New Zealand, Te Whatu Ora, has published guidance on managing cyber security incidents for primary care organisations. Strengthen Your Digital Defence: A Guide to Cyber Security Incident Response for New Zealand Primary Health Sector is one of several resources developed to help healthcare organisations prepare for and respond to worst-case cyber security incidents. This includes reducing cyber security risks, preparing for future incidents, responding to a cyber security incident and how to recover and return to normal operations in the aftermath. The guide is intended as an educational tool and does not contain exhaustive advice; it should not replace any legal, technical or professional cyber security advice your organisation already has. 

(iv)  Miscarriage Matters websiteThe Miscarriage Matters website presents the organisation’s mission as To improve the experience of miscarriage in New Zealand by empowering people with information, advocacy and support.  To do this by raising awareness, connecting existing services, providing information, delivering care packages, supporting midwives (and other maternity carers), supporting research, and advocating for positive change.  There are extensive written resources on all aspects of miscarriage and miscarriage support (including a FAQ section), and a pamphlet that can be ordered by practices to provide to women following a miscarriage.  The organisation also makes and delivers personal Care Packages for women in Canterbury, the West Coast, North Shore (Auckland), South Auckland and Wellington who experience miscarriage.

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.

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Clinical Snippets September 2025

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

Clinical Snippets September 2025

1. Malnutrition

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

(i) Key risk factors include:

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

(ii) Start with the basics – ask patients:

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

(iii) Routinely document:

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

(iv) Use a validated screening tool

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

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

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

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

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

2. Breast Screening Extension

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

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

As of 1 October 2025:

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

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

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

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

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

3.  Serum oestradiol

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

4. Equity focus – anticoagulant monitoring

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

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

5.  Prostate cancer screening and DRE

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

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

6.  Release of 16 optimal cancer care pathways

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

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

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

7.  FIT Symptomatic Pathway

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

8.  Oral iron tablets

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

9.  Standing orders for adrenaline for authorised vaccinators

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

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August 2025 Clinical Snippets

Clinical Snippets August 2025

1. Desmopressin in nocturnal enuresis in children

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

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

2. Prescriber Update

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

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

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

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

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

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

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

3.  ADHD resources

4.  National Community Referral Criteria for Imaging

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

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

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

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

5.   CT Imaging and Cancer Risk

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

6.  Covid-19 antiviral eligibility

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

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

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

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

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

7. Reminder re hyperkalaemia

A recent NZ Doctor article reviewed causes of hyperkalaemia.

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

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

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

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

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

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

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

8. Widened access to meningococcal B vaccine

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

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

9.  Resources