Published: 21st February, 2025
Contents
New from bpacnz: Recovery at Work case study quiz
bpacnz recently published a comprehensive guide for supporting primary care clinicians to help patients navigate the ACC Recovery at Work process, including considerations when conducting an initial medical certification consultation, medical certificate definitions, as well as the ACC-mediated supports available if further assistance is required. Read the full article here. A B-QuiCK summary is also available.
We have now developed a case study quiz with interactive feedback for this topic. The quiz follows two different cases through the Recovery at Work framework and includes a final “extra for experts” question:
- Case 1: Āwhina, a 22-year-old female, has a left rotator cuff sprain after an incident walking her dog. She is struggling with the pain and is very anxious about going back to work. What can you do to help her?
- Case 2: Mike, a 48-year-old male, presents in primary care with back pain following a workplace accident. What is your assessment of his injury and how will you complete his ACC45?
- Extra: Alice, a 55-year-old female, falls off a scooter in Fiji – will she be covered when she gets back home?
Go on, give it a go! Complete the case study quiz here.
N.B. you will need to log-in to your “My bpac” account.
Quizzes are endorsed as a professional development activity by the RNZCGP (two CPD credits) and InPractice. Quizzes may also be completed by any “My bpac” user. Register here for a free account.
In case you missed it: Management of stable angina pectoris
Stable angina pectoris is defined by predictable or reproducible chest pain (or discomfort) caused by transient myocardial ischaemia that occurs when cardiac oxygen supply cannot meet demand. Angina has typically been considered a manifestation of obstructive coronary artery disease; however, the understanding of angina pathophysiology is changing.
This is a revision of our previously published article, and includes a general update of terminology and evidence based on recent international coronary artery disease guidelines and studies, and the addition of new sections on the clinical diagnosis and ongoing monitoring of stable angina.
Read the full article here. A B-QuiCK summary is also available.
Medicine news: Liraglutide, venlafaxine, dipyridamole, bevacizumab
The following news relating to medicine supply has recently been announced. These items are selected based on their relevance to primary care and where issues for patients are anticipated, e.g. no alternative medicine available or changing to the alternative presents issues. Information about medicine supply is available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
New patients can be initiated on liraglutide from 1st March
Pharmac has announced the “no new patient” restriction on liraglutide (Victoza) will be removed from 1st March, 2025, as supply has now stablised. Therefore, new patients with diabetes who meet Special Authority criteria will be able to be initiated on funded liraglutide. Due to increased demand, worldwide supplies of GLP-1 receptor agonists have been limited and since May, 2024, no new patients could be initiated on funded dulaglutide or liraglutide in New Zealand. The restriction will still apply to dulaglutide; only existing patients can currently access funded dulaglutide. An associated news release is available here.
For information on prescribing liraglutide for diabetes, see: https://bpac.org.nz/2021/diabetes.aspx
Venlafaxine temporary packaging change
In January, 2025, dispensing of venlafaxine was temporarily switched to monthly due to supply issues (as reported in Bulletin 115). From 1st March, 2025, Pharmac is listing an alternative Enlafax XR product for the 75 mg and 150 mg strength capsules from Australia (Viatris). Patients can be reassured that there is no change to the active ingredient, manufacturer or manufacturing method, however, the packaging will look different. The blister sheets are for seven days (instead of 14), and the boxes come in a pack of 28 (instead of 84). Pharmac expects the New Zealand packaging for the 75 mg and 150 mg capsules to be available again sometime in April. No alternative product is being sourced for the 37.5 mg strength capsules, as stock is expected to arrive by the end of February.
Dipyridamole tablets to be discontinued
Dipyridamole tablets (Pytazen SR) are being discontinued by the supplier due to problems with accessing the active ingredient. Current supplies will expire at the end of July, and Pharmac expects stock to be exhausted from May/June. Dipyridamole is used in the secondary prevention of ischaemic stroke and TIA (unapproved indication), usually in combination with aspirin. Patients taking this medicine will need to be switched to an alternative product; there is currently no alternative brand available, however, other antithrombotic medicines may be suitable for some patients, e.g. clopidogrel.
Decision to widen access and fund bevacizumab (Vegzelma)
Pharmac has announced a decision, following consultation in December/January, to widen access to and fund bevacizumab (Vegzelma) for a range of conditions, including liver and ovarian cancer (subject to Special Authority approval).
From 1st March, 2025, bevacizumab (Vegzelma) will be funded for patients with:
- Unresectable hepatocellular carcinoma
- Advanced ovarian cancer
- Recurrent respiratory papillomatosis
- Ocular conditions
Access to atezolizumab will also be widened to include patients with unresectable hepatocellular carcinoma, and lenvatinib for patients who experience adverse effects from atezolizumab with bevacizumab. An associated news release is available here. In a separate announcement, Pharmac has advised that from 1st March, 2025, lanreotide will be funded for a range of conditions, including malignant bowel obstruction, acromegaly and neuroendocrine cancers; read more here.
Coeliac New Zealand primary care checklist
Since 1973, Coeliac New Zealand has worked to support children and adults who have been diagnosed with coeliac disease. Its aim is to raise awareness, provide information and resources, to support research and education and to assist those working in healthcare with guidance regarding diagnosis and treatment.
Coeliac New Zealand has developed a checklist designed for primary care clinicians to rapidly refresh their knowledge on some key points regarding this condition. It provides clarification on questions such as “When should a person stop consuming gluten?” (if the diagnosis is suspected) and “Can patients have a ‘diet holiday’?”
The checklist can be found here with the bpacnz 2022 article on “Coeliac disease: investigation and management”. It is also available as a printable PDF.
Providing patients access to their clinical record: MCNZ guidance
The Medical Council of New Zealand, in its latest newsletter, has responded to frequently asked questions about patients requesting copies of their medical records. In summary, the Medical Council has clarified that:
- Patients have the right to access their health information, regardless of the reason
- Practices should be guided by the patient’s preference as to the format of the copy of their record, i.e. electronic or hard copy
- However, discuss the potential risks of a hard copy, e.g. more likely to be lost, misplaced or accessed by someone unintended compared to electronic records. Raising awareness of possible risks can help patients to make an informed decision about how they would like to receive their records.
- Patients cannot generally be charged by practices for providing their medical records (including hard copies), unless:
- The patient has requested the same information within the past 12 months; or
- The request involves making copies of X-rays, video recordings, MRI scans, PET scans, or CAT scans due to the associated costs
View the questions and full responses, here.
Further information is available from the Medical Council, here.
New ACC45 claim numbers introduced
New ACC45 claim numbers are being introduced, replacing the previous format of two letters, followed by five numbers (e.g. AB12345). This change has occurred because the possible combinations in the previous format are almost exhausted; the previously allocated ACC45 claim number format will continue to be accepted. New ACC45 claim numbers will be either:
- Five numbers, followed by two letters, e.g. 12345AB
- Four numbers, followed by three letters, e.g. 1234ABC
Upcoming webinars: Winter immunisations, menopause
Immunisations. IMAC and Health New Zealand, Te Whatu Ora, are hosting a webinar on the 2025 winter immunisation programme: “Flu and friends” (influenza, COVID-19 and RSV). The webinar will be held on Tuesday, 25th February, from 5.30 pm – 6:30 pm. Click here to register. A recording will be available at a later date.
Menopause. HealthPathways is hosting a national webinar on navigating menopause. This free webinar coincides with the update of the menopause and MHT pathways that were made across regional HealthPathways and is expected to cover topics including indications for MHT, prescribing guidelines and evidence about risks and contraindications of MHT. The webinar will be held on Wednesday, 19th March, from 7 pm – 8 pm. Click here to register (a certificate of attendance and two CPD points are available). A recording will be available at a later date.
February is Ovarian Cancer Awareness Month
This month is Ovarian Cancer Awareness Month (following Cervical Cancer Awareness Month in January). Ovarian cancer is the second most common gynaecological cancer, after endometrial, and has a higher mortality rate than all other gynaecological cancers in New Zealand combined.
There is no effective screening test for ovarian cancer; diagnosis relies on the prompt recognition and investigation of suspicious symptoms. While ovarian cancer was historically considered to be a silent disease in its early stages, evidence suggests that 90 – 95% of people diagnosed are symptomatic. However, a key diagnostic challenge is that symptoms are often vague and non-specific. There should be a low threshold for initiating further investigations (including serum CA-125) in patients with suspicious symptoms and risk factors.
Symptoms of ovarian cancer may include:
- Abdominal bloating or distention
- Abdominal or pelvic pain
- Early satiety or loss of appetite
- Increased urinary frequency or urgency
- Changes in bowel habit
- Fatigue
- Unexplained weight loss
- Post-menopausal bleeding
Symptoms are more likely to be associated with ovarian cancer if they are in a post-menopausal female and/or if they are new, severe, unusual, recurrent or persistent, e.g. occurring 12 or more days per month. New symptoms suggestive of irritable bowel syndrome, e.g. changes in bowel habit, in females aged > 50 years are unusual; consider the possibility of ovarian cancer in these patients (among other potential diagnoses such as bowel cancer).
bpacnz published a series of gynaecological cancer articles in 2022 and 2023 with support from Te Aho o Te Kahu, Cancer Control Agency. This collection covers the early detection and diagnosis of ovarian cancer, as well as cervical, endometrial, vulval and vaginal cancers, managing follow-up and ongoing surveillance in primary care. Click here to browse these resources.
Vaping and smoking in adolescents in New Zealand
A New Zealand-based study of electronic lifestyle and mental health data from YouthCHAT has found that one in five adolescents have vaped. The analysis was based on responses to a self-report questionnaire from just under 3,500 adolescents aged ≤ 14 years between 2019 and 2024. Vaping (22% have tried at least once) was more frequent than smoking (12%) and rates were higher among females and those of Māori or Pacific ethnicity. Most adolescents who vaped had not smoked (7% reported vaping for smoking cessation); 38% of current smokers reported vaping for smoking cessation. More than two-thirds (68%) felt the need to reduce or stop vaping, and almost half (49%) felt the need to reduce or stop smoking. Over one in five wanted help with quitting vaping (22%) and smoking (28%).
The authors note that vaping is largely replacing smoking in young people; do you opportunistically ask adolescent patients if they have ever vaped or smoked? If so, typically how willing are they to engage in help to reduce this?
The Asthma and Respiratory Foundation NZ published guidelines in 2023 for healthcare professionals on supporting young people and adolescents to quit vaping, covering screening and assessment, behavioural support, pharmacotherapy and follow-up. Read the full guideline here.
Patients can also be referred to a website produced by the Asthma and Respiratory Foundation NZ: “Don’t Get Sucked In”, which encourages young people not to take up vaping and smoking, and hosts a wide range of vaping-related information and educational resources.
Medical Factorium: Why is stroke called stroke?
Every now and then, patients ask “why?” and the answer eludes us. In this occasional bulletin segment, we attempt to answer some of those curious questions.
The question: We are all familiar with the term “stroke” and arguably use it more often than the clinical terminology of cerebrovascular accident (CVA). But where did the term actually come from and why do we call it “stroke”?
Determining the origin of the word “stroke” is equally a journey into the history of the understanding and definition of stroke itself. Hippocrates first used the term “apoplexy”, a Greek word meaning struck down by violence, to describe the various symptoms and signs associated with fast-onset cerebral dysfunction. These features can now be attributed to a number of clinical events including acute cerebral events, myocardial infarction, pulmonary embolism and other vascular and non-vascular disorders. It is believed that a layman’s description of apoplexy was “a stroke of God’s hand”, leading to the common term of “stroke” to describe a sudden onset of symptoms that caused a person to fall to the ground.
During the 17th Century, the physician Johann Jakob Wepfer discovered that people who died from apoplexy had evidence of brain haemorrhage. In later years, with further advances in pathology, the causes of apoplexy were divided into “sanguineous” (haemorrhagic) and “serous” (ischaemic). Apoplexy was now accepted to be a vascular disease.
In the 1920s, “arteriosclerosis with cerebral lesion” was added to the International List of Causes of Death (ILCD) and the term apoplexy was removed from the ILCD in 1938. In the 1950s, transient ischaemic attack was introduced as a term to describe temporary vascular-related episodes of cerebral dysfunction.
The term stroke (cerebrovascular) first appeared in the ICD-9 in 1968 (replacing the term apoplexy) and was defined by the World Health Organization in the 1970s. It remains slightly murky as to why the layman’s term was adopted, but it could be because “apoplexy” had fallen out of favour due to its non-specific definition and, well, everyone was calling it stroke, so the name stuck.
The modern-day definition of stroke is still dependent on pathological findings (haemorrhagic and ischaemic) that were rooted in early medical history, but now also includes “silent” infarctions and cerebral haemorrhage where the “stroke of God’s hand” is not so obvious.
For further reading, see:
View previous Medical Factorium items here.
Do you have a clinical oddity that you would like us to investigate, or better yet, can you share a fascinating medical fact with our readers? Email: editor@bpac.org.nz
Podcast of the Week: An overview of rosacea
A recent episode of The Good GP, an Australian podcast series, in collaboration with DermNet and New Zealand Dermatologist Dr Louise Reiche, discusses an overview of rosacea. Rosacea can sometimes be challenging to manage in general practice, but there are certain dietary and lifestyle changes and treatments available that are effective for many patients.
Avoiding or reducing exposure to known triggers for individual patients (e.g. spicy food, caffeine, alcohol, certain skincare products), following a Mediterranean diet for its anti-inflammatory effects and practicing sun-safe behaviours can improve symptoms. Application of a topical retinoid is the most effective pharmacological treatment option; oral retinoids may be considered after a few months of unsuccessful topical treatment. Topical azelaic acid or topical ivermectin (unapproved indication) may also help to reduce inflammation. Antibiotics (topical or oral) are no longer routinely recommended.
Listen to the podcast here (nine minutes).
Further information on rosacea is available from DermNet, here.
Paper of the Week: Three’s a crowd - how long to continue triple antithrombotic therapy after ACS (if indicated)
Determining the most beneficial combination and duration of preventative pharmacological treatment for a patient after an acute coronary syndrome (ACS) can sometimes be complex. Especially when the patient has multiple co-morbidities. The regimen is individualised for each specific scenario, and determined by the cardiology team, based on bleeding and ischaemic risks. Once the patient is discharged, their primary care team, including community pharmacy, are integral in monitoring for complications and adverse effects, and ensuring that treatment is stepped down appropriately, depending on the recommended duration of each medicine they have been prescribed.
In an article in the latest edition of Australian Prescriber, the authors discuss triple antithrombotic therapy which is increasingly being prescribed in patients who need both antiplatelet and anticoagulant treatment following an ACS. Triple antithrombotic therapy is the combination of an oral anticoagulant (e.g. dabigatran, rivaroxaban, apixaban, warfarin) with dual antiplatelet treatment (aspirin and either clopidogrel or ticagrelor). This combination is used in patients who have had an endovascular or cardiac intervention in which dual antiplatelet treatment is indicated (e.g. coronary artery stent), but they also have an ongoing need for anticoagulant treatment (e.g. atrial fibrillation, mechanical heart valve or venous thromboembolism). The benefits of triple therapy need to be carefully weighed against the risk of adverse outcomes, and this analysis changes with time. The article outlines the rationale for treatment, the typical medicines used in the regimen, how long they are used for and how to step-down treatment in the community.
In your experience, do discharge summaries usually contain sufficient information to direct duration of antiplatelet and/or anticoagulant treatment, or do you have to determine this for a patient? What tools or parameters do you use to assess bleeding risk? Does this differ depending on what combination of medicines a patient is taking? Do you feel confident about stepping down antithrombotic treatment?
Read more
When is triple antithrombotic therapy indicated?
Following an ACS, antiplatelet treatment is necessary to prevent future atherosclerotic cardiovascular events. If a patient has a stent placed, the need for dual antiplatelet treatment is even greater, as there is a risk of stent thrombosis which can present as ST-elevation myocardial infarction (STEMI). This risk is highest immediately following the procedure and reduces as the stent endothelialises. The risk of stent thrombosis is also influenced by other factors such as the size of the stent, the number of stents and patient co-morbidities.
Some patients who have an ACS and require a stent, are already taking oral anticoagulant treatment, e.g. for atrial fibrillation, or atrial fibrillation is diagnosed at the time of their event. Therefore, these patients have an ongoing need for oral anticoagulation in addition to dual antiplatelet treatment. Oral anticoagulants alone are not effective in preventing stent thrombosis and dual antiplatelet treatment alone is not sufficient to prevent thromboembolic complications in people with atrial fibrillation.
What are the risks?
The need for both anticoagulant and dual antiplatelet treatment in this patient group is clearly established, however, combining these treatments significantly increases bleeding risk, therefore, the benefits must outweigh this risk on a case-by-case basis. Evidence shows that there is a statistically significant greater risk of any bleeding event (but not major bleeding events alone) with triple treatment compared to antiplatelet + anticoagulant treatment or either treatment alone. To reduce this risk for patients taking triple treatment, a proton pump inhibitor is added to their regimen, and medicines that increase bleeding risk (e.g. NSAIDs) are avoided.
Which medicines are used?
Local protocols and preferences may differ, but guidelines generally recommend using:
- Dual antiplatelet treatment: aspirin and clopidogrel
- Oral anticoagulant: any direct-acting oral anticoagulant (dabigatran, rivaroxaban, apixaban) or warfarin if mechanical heart valve
Ticagrelor is usually recommended in preference to clopidogrel after stent placement, but in the context of the triple treatment regimen, there is more evidence to support clopidogrel.
How long should triple treatment be continued?
New evidence suggests that a short duration of triple treatment balances ischaemic protection with bleeding risk, e.g. one week for most patients and one month for those with additional ischaemic risk factors. Previously, guidelines suggested one month for most patients and up to six months for those at highest risk. Ischaemic risk factors include STEMI, previous stent thrombosis, complex coronary procedures and prolonged cardiac instability.
How should treatment be stepped down?
After the individually specified period of triple treatment, the first step is to stop one of the antiplatelet medicines – usually aspirin. Most patients will continue on single antiplatelet treatment for 12 months, but those with a high bleeding risk may stop after six months. The oral anticoagulant is continued indefinitely and reinstated to the patient’s standard dosing if it was temporarily reduced during triple treatment.
Evidence shows that for patients initially prescribed triple treatment, stopping one antiplatelet after one month and the next one after six months, and continuing the oral anticoagulant did not increase the risk of ischaemic events (MASTER DAPT trial). For patients who do not have a high bleeding risk, with stable coronary artery disease, continuing antiplatelet treatment beyond 12 months, while taking an oral anticoagulant, increases all-cause mortality compared to taking the oral anticoagulant alone (AFIRE trial).
The HAS-BLED tool, familiar to most clinicians in New Zealand, may be useful for assessing bleeding risk for patients taking combined antiplatelet and anticoagulant treatment (although it is not validated for this use).
What else can primary care do?
In most cases, the patient’s pharmacological regimen and durations for each treatment will be set out in their discharge treatment plan. If insufficient information is provided, it is essential to communicate with the secondary care team to ensure that a step-down plan is put in place. Reminders can be added to the patient’s record to ensure they are assessed at appropriate intervals. Dispensing of repeat prescriptions is also an opportunity to enquire about adverse effects, such as bruising, and ensure the patient knows when to seek medical help.
Ziser K, Rahman S, Soro R, et al. The role of triple antithrombotic therapy in patients with atrial fibrillation and coronary stent insertion. Aust Prescr 2025;48:18-22. DOI: 10.18773/austprescr.2025.009
Watch this space: we will be updating our article on acute coronary syndromes in 2025.
For further information on antithrombotic medicines click here. (N.B. This article was published in 2015 and some information may be out of date including medicine funding status and latest clinical trial evidence.)
This Bulletin is supported by the South Link Education Trust
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