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.