chronic-pain

The New Zealand General Practice Podcast

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

Clinical Snippets August 2026

1. Peptides

  • Medsafe has recently published a consumer advisory on the potential risks of using unapproved peptide products and selective androgen receptor modules (SARMs).  There is an increasing number of unapproved products being promoted on-line with some of the commonly advertised products being BPC‑157, CJC-1295, GHRP‑6, Ipamorelin, Kisspeptin, KLOW, melanotan II, retatrutide, sealank, seamax, TB‑500 and thymosin.
  • Medsafe has NOT assessed these products for quality, safety or efficacy. They are unapproved products and it is illegal to import, use or sell the products. There is a very real risk that these products may be of poor quality, not contain the substance claimed on the label (if they are labelled), contain other harmful substance not on the label or not be sterile (and so may contain substantial quantities of germs or mould).  Because some are injected, it means there is a high risk of a life-threatening infection from using them.
  • There is a specific warning regarding retatrutide with international reports having linked black‑market retatrutide to fatal overdose, contamination, severe neurological symptoms, hair loss, and other serious adverse effects.  Another commonly obtained peptide is melanotan II (often called the Barbie peptide) which comes as injections or nasal sprays and is used to promote tanning. It has been associated with sudden increase in atypical pigmented skin lesions and melanoma risk, AKI, hypertension, cerebral oedema and priapism.  
  • Comprehensive consumer information on peptides (licit and illicit) is available from thelevel.org.nz website including how to stay safer if using unprescribed peptides

2.  Methotrexate monitoring

  • BPAC had published an update on methotrexate safety noting that while the drug is often initiated in a specialist care setting specialist involvement is not a requirement for funded treatment and clinicians who are confident about prescribing methotrexate can initiate it in primary care if it is safe and appropriate to do so.
  • Pre-treatment screening recommendations include baseline FBC, LFT and renal function (exclusion of pregnancy) identification and treatment of any active infections including latent TB and hepatitis B where relevant and ensuring immunisation status is up to date. Avoid live vaccines during treatment, unless dose is ≤ 0.4 mg/kg/week.  It is important to asses respiratory history and consider reparatory function testing and chest X-ray f respiratory symptoms or knew respiratory condition or risk factors (eg smoker aged  40 yrs).  Review toxicity risk factors (medicine interactions, alcohol intake – advise no more than 1-2 std drinks per week). 
  • The importance of providing clear written information to the patient is emphasised together with co-prescribing of folic acid to reduce risk of adverse effects – 5 mg, once weekly, to be taken on a different day to methotrexate [“Methotrexate Monday, folic acid Friday”]
  • Methotrexate can cause bone marrow suppression, liver and pulmonary toxicity and a variety of other adverse effects. Toxicity can occur at therapeutic doses and it is important to monitor for symptoms such as mouth ulcers, nausea, vomiting, infection, sore throat, bruising, dyspnoea which may represent toxicity.  There is an increased risk of non-melanoma skin cancer related to cumulative dose and more common in psoriasis treatment.  Monitor laboratory parameters regularly (FBC, LFTs, serum creatinine). Initially, every two to four weeks, and then less frequently depending on risk factors.  
  • A recent instalment of the NZ Doctor Spotlight series  focused on methotrexate prescribing without recent blood test monitoring.  Over the fortnight of prescribing reviewed (200,000 patient interactions) 164 people were dispensed methotrexate without a recorded blood count or liver function test. This suggests laboratory monitoring may not always be completed before methotrexate prescription renewals, creating potential gaps in safe prescribing practices.

3.  HPV vaccination delivery

  • Health New Zealand Te Whatu Ora has announced an important change to how human papillomavirus (HPV) vaccination is being delivered through the School Based Immunisation Programme.  Since 27 July 2026, children will be offered one dose of the HPV vaccine (Gardasil9) at school, with parent or caregiver consent. HPV dose 2 will no longer be offered in schools from this date.
  • The approved HPV vaccination course in New Zealand is currently two doses for children aged 9 to 14 years. However, international studies show that a single dose provides 97-98% protection against HPV infection and HPV-related cancers. Based on this evidence, the World Health Organization now recommends a single-dose HPV vaccination schedule. Many countries, including Australia and the United Kingdom, have already adopted this approach.
  • Note, a second HPV dose remains free and available through GPs, pharmacies and community health providers at least six months after the first dose, should it be requested by whānau. This change will enable schools to prioritise increasing the uptake of HPV dose 1 (which is currently low) and other catch-up immunisations to address existing immunity gaps and maximise the impact of the programme.
  • You may start to receive requests for HPV vaccination from August 2026, particularly from whānau with children in Year 7 and 8 wishing to complete their HPV vaccination course. Note that:
  • Primary and community care providers will not be expected to proactively recall or follow up for HPV dose 2 for students in Years 7 and 8 (ages 10 to 13 years)
  • PHOs will not be performance‑managed on delivery or coverage of HPV dose 2 within enrolled populations
  • Demand for HPV dose 2 in general practice is expected to be limited
  • Over 500 pharmacies currently offer HPV vaccination. This is expected to mitigate demand for HPV dose 2 and reduce pressure on general practice
  • GPs are strongly encouraged to offer catch-up HPV vaccination to young people aged 14 to 26 years, focusing on those who have not received any HPV doses. It is estimated that ~370,000 young people aged 14 to 26 years have not had any doses of the HPV vaccine. Achieving high coverage in this cohort is essential to accelerate progress towards cervical and other HPV cancer elimination in Aotearoa New Zealand.

4.  IBS and TCAs

  • The CFPC Tools for Practice #416 summarised the evidence around efficacy of antidepressants in improving irritable bowel syndrome symptoms.  The bottom line was that tricyclic antidepressants (TCAs) improve overall IBS symptoms and abdominal pain in ~55% of patients versus ~35% with placebo at ~2-6 months. Mirtazapine shows similar, based on 1 small randomized, controlled trial (RCT). About 25-55% experience adverse effects (examples: drowsiness, dry mouth) with TCAs or mirtazapine compared to 5-35% with placebo.
  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) achieve similar pain relief but without consistent overall improvement. Limited evidence to suggest differing efficacy based on IBS subtype. Many guidelines and pathways recommend TCAs or SSRIs regardless of comorbid depression or anxiety.
  • Largest TCA RCT suggests possible preferential benefit for diarrhoea-predominant IBS, but overall support for this theoretical benefit is weak.  Indirectly, dietary interventions (examples: FODMAP, Mediterranean diet) may have comparable efficacy to antidepressants. Evidence for antidepressants appears stronger than for antispasmodics, probiotics, or opioid receptor modulators.

5.  Briefs

(i) BNP testing:  GP Research Review #273 reviewed a study on NT-pro BNP testing for heart failure diagnosis in people with atrial fibrillation and found that NT-proBNP was substantially higher in people with AF, reducing its diagnostic accuracy for heart failure. There was very high sensitivity but poor specificity for diagnosing heart failure in patients with AF at the usual 125pg/mL threshold suggesting a higher threshold may be appropriate for those patients. 

(ii) Rosuvastatin:  Pharmac has announced  that rosuvastatin tablets will be available without restrictions from 1 October 2026. This means people will no longer need to meet specific eligibility criteria to access the medicine although SA criteria still apply until 30 September. For further information on the role of rosuvastatin in lipid-lowering treatment there is a 2022 BPAC article that will be updated to reflect the funding changes.  The article includes dosing considerations, pre-initiation assessment and monitoring.  

(iii) Glucosamine:  A Medscape review of a study published in Nature Metabolism notes that glucosamine, a popular joint-pain supplement, may worsen outcomes in people with mild cognitive impairment (MCI), due to a newly identified metabolic pathway involving excessive protein glycosylation.  The study found that glucosamine use was associated with a 25% increase in MCI → dementia progression over 5 years and a 25% increase in 10-year mortality in patients with Alzheimer’s disease and related dementias.  The investigators note this was an observational study and causality is unproven but glycan metabolism is a candidate target.

(iv)  Augmentin plus amoxicillin:  Health New Zealand | Te Whatu Ora has provided information on the co-prescription of amoxicillin + clavulanic acid PO 625mg with amoxicillin PO 500mg, explaining that this oral combination is recommended for treatment of some conditions in adults patients in the national antibiotic guideline, Te Whata Kura, and is increasingly used in practice, particularly in management of diabetic foot ulcers.

(v)  PMOS:  BPAC Bulletin 148 notes Polycystic Ovary Syndrome (PCOS) will now be known as Polyendocrine Metabolic Ovarian Syndrome (PMOS). The name change comes following a multistep global consensus process spanning 14 years, with input from thousands of people, including those with lived experience, clinicians and medical and academic professional organisations. Transition to the new name is anticipated to occur over the next three years. It is felt the new name better reflects the multi-system nature of the condition, i.e. abnormalities in endocrine, metabolic and ovarian function, and aims to support earlier detection and treatment.

(vi) Perindopril (Coversyl):  Pharmac has announced changes to the formulation of Coversyl which is being changed from perindopril erbumine to perindopril arginine.  The new formulation comes as 2.5mg, 5mg and 10mg tabs equivalent to the current 2mg, 4mg and 8mg tabs.  Advice is to transition your patients currently on Coversyl 2 mg and 8 mg tablets to the equivalent perindopril arginine (Coversyl 2.5 mg and 10 mg) from 1 September 2026.

Coversyl 4 mg tablets will remain available longer. Please transition these patients to the equivalent Coversyl 5 mg tablets from October.

6.  NZTA research – Cognitive screening for fitness to drive

This report, commissioned by the NZ Transport Agency (NZTA) Waka Kotahi and the Office for Seniors, was developed to support health professionals in understanding the utility of cognitive assessment within medical office-based driving assessment process.  The report notes there is no universally accepted protocol for a general practice medical office-based driving assessment or for the use of cognitive tests in fitness to drive assessment. There is also no universally accepted cognitive test for the purpose of assessing fitness to drive.  Relevant research findings include:

  • For older people who are considered to be physically and mentally healthy, current evidence does not support the routine use of cognitive assessment as part of fitness to drive assessment.
  • Global cognitive assessments (e.g. Montreal Cognitive Assessment (MoCA), MiniAddenbrooke’s Cognitive Examination (mini-ACE)), while giving an indication of general cognitive ability, do not accurately predict on-road driving performance.
  • Trail Making Test (TMT), Maze assessment and reaction time tests are moderately associated with on road driving performance. 
  • When the assessor has concerns about cognitive ability, the Trail Making Test (TMT) could be an alternative to more global cognitive assessment tools, such as the Mini-Mental State Examination (MMSE), MoCA or Mini-ACE to reflect driving performance. Consideration of a test of reaction times may aid prediction of on road driving safety. Trail Making Test administration and scoring references are available online.
  • Recognising there is no perfect office-based test, if there is uncertainty of cognitive or functional ability to drive, an On Road Safety Test or, if appropriate, an Occupational Therapy Driving Assessment will add useful information.

It is well worth reviewing the report in its entirety. 

7.  Clarification

There was some confusion following an article in last month’s Snippets regarding Work and Income certification and use of telehealth.  It can be clarified that telehealth may be an acceptable form of patient contact, depending on the patient’s health condition or disability, whether or not the provider has access to the patient’s medical records, and what support is being applied for. See Telehealth for MSD Certificates in the Work and Income Funding section of your local Health Pathways.

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