Published: 7th March, 2025
Contents
New from bpacnz: Management of fungal nail infections
Fungal infection of the nail, or onychomycosis, is a common clinical problem, especially in older adults. However, it is not just a cosmetic concern - in some cases it can cause significant distress, pain and reduced mobility, impacting a person’s quality of life. Laboratory confirmation of fungal infection is recommended before initiating treatment, even when clinical suspicion is high. This is because many other conditions can have similar symptoms and ruling out a fungal cause would prevent months of unnecessary antifungal treatment. Conversely, prior antifungal treatment can inhibit nail culture growth, making it difficult to subsequently confirm infection if symptoms do not improve.
After confirming infection, an antifungal treatment should be initiated and will often need to be continued for several months or even years. Oral antifungal treatment is more effective (terbinafine for dermatophyte onychomycosis and itraconazole for candidal onychomycosis), but the choice between oral and topical treatment is also determined by patient-specific factors, e.g. severity of infection, co-morbidities, potential for medicines interactions. The recent emergence of dermatophyte species resistant to standard treatment options in New Zealand is cause for concern.
Read the full article here. A B-QuiCK summary is also available for this topic.
In case you missed it: Recovery at Work case study quiz
bpacnz recently published an interactive case study quiz on the ACC Recovery at Work process. Test your knowledge with the case study quiz here* and earn CPD points. For an overview of the Recovery at Work programme, read the main article here. A B-QuiCK summary is also available.
* You will need to log-in to your “My bpac” account to complete the quiz; sign up for a free account, here
New Zealand-based online CBT course for substance harm
Just a Thought is a New Zealand organisation that offers free online cognitive behavioural therapy (CBT) courses and other resources for a range of mental health conditions. A new series of online CBT courses have been released, in partnership with Health New Zealand, Te Whatu Ora, for people experiencing harm from alcohol or drugs: Alcohol and drug support – thinking about change, taking action and getting back on track. These are the first free online courses on substance harm available in New Zealand.
The courses use CBT and incorporate lived experience stories to support people experiencing substance harm, providing them with the necessary knowledge, skills and strategies to overcome such challenges. Courses can be completed in a self-guided manner or through prescription by a clinician; patient progress can be monitored through the clinician dashboard. View all the courses available from Just a Thought, here.
Medicine news: Oxycodone, methylphenidate, scalp applications, inhalers
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.
Supply issue affecting oxycodone 5 mg tablets
There is a supply issue affecting stock of 5 mg oxycodone immediate-release tablets (Oxycodone Amneal). Supply of other strengths is currently unaffected. Pharmac advise that halving the 10 mg immediate-release tablets may be a suitable strategy, however, a new prescription will be required for this option. Otherwise, clinicians could consider prescribing an alternative analgesic.
Reminder: Morphine is the first-line strong opioid for moderate to severe pain. Oxycodone is a second-line option if morphine is contraindicated or not tolerated. A range of opioid resources are available from bpacnz, including:
Methylphenidate: supply and Special Authority update
Pharmac has advised that the ongoing supply issues affecting stock of methylphenidate are likely to continue throughout 2025. The latest stock information is available here. Clinicians are being asked to:
- Prioritise prescribing methylphenidate for children and adolescents as these groups are most at need of this medicine because it is more tolerable than some of the alternative ADHD medicines
- Consider prescribing other brands of methylphenidate or alternative medicines for patients with ADHD or narcolepsy
- Review guidance from Medsafe on switching between brands of long-acting methylphenidate
Since 1st March, 2025, Special Authority applications have been updated for new patients prescribed methylphenidate which allows them to be dispensed Concerta or Ritalin LA if other brands are not available. Previously, patients were only eligible for funded Concerta or Ritalin LA after trialling other brands of methylphenidate (i.e. Methylphenidate ER - Teva, Rubifen, Rubifen SR, Ritalin) and meeting additional criteria. Two Special Authority numbers (SA2446 and SA2411) for methylphenidate are still required to allow patients to have funded access to all brands.
N.B. This change is only for new patients and does not currently apply to patients with existing Special Authority approval. Pharmac expects to provide an update on this soon.
The Goodfellow Unit, University of Auckland, is hosting an upcoming webinar: Navigating ADHD treatment: Strategies for prescribing and transitions, presented by Dr David Codrye. This webinar is free to attend and will be held on Tuesday, 1st April from 7.30 pm. Click here to register.
Scalp applications and Duolin HFA inhaler back in stock
Supply issues for the following medicines have been resolved and stock should arrive in pharmacies within one to two weeks: betamethasone valerate (Beta Scalp) and clobestasol propionate (Dermol) scalp applications*, salbutamol with ipratropium bromide (Duolin HFA) inhaler.
* Hydrocortisone butyrate (Locoid) scalp application is currently out of stock; resupply is expected sometime in May
Latest edition of Prescriber Update released
The March edition of Prescriber Update has been published. Particular items of interest for primary care include:
Safety profile of weekly methotrexate
Methotrexate, prescribed as a once weekly dose, is indicated for some patients with rheumatoid arthritis and severe psoriasis when other treatments have been ineffective. It can, however, cause significant adverse effects and toxicity which in some cases, can be fatal. This is more likely in patients taking high doses; however, any dosing regimen may induce toxicity.
Methotrexate is often initiated in secondary care. Prior to the initial prescription, a relevant patient history (in particular, personal or family history of liver disease, alcohol use and gastrointestinal ulcerative conditions) is taken, and laboratory tests (full blood count, liver and renal function tests) and a chest X-ray will be requested. To reduce the risk of gastrointestinal adverse effects, folic acid or folinic acid is normally prescribed alongside methotrexate.
Ensure patients (and their families/carers) understand that the medicine is to be taken once weekly, on the same day each week. Educate patients on the symptoms and signs of methotrexate toxicity, e.g. sore throat, mouth ulcers, fever, cough, vomiting or diarrhoea, and to report if any of these occur. Read the full article here.
Factors contributing to colchicine toxicity
Medsafe is reminding clinicians of the factors to consider when prescribing patients colchicine. Factors that contribute to colchicine toxicity include renal and hepatic impairment, older age and certain medicines, e.g. azole antifungals, calcium channel blockers, macrolide antibiotics. Educate patients on the possible symptoms of colchicine toxicity, e.g. burning sensation of the mouth, throat, stomach or skin, gastrointestinal symptoms, and advise them to stop taking the medicine and to seek medical advice. Read the full article here.
For further reading, see the bpacnz focus on colchicine: https://bpac.org.nz/Bulletin/bestpractice/114.aspx#7
Meningiomas: a very rare adverse effect of medroxyprogesterone acetate
Depo-Provera and Provera tablet data sheets have been updated to include a warning about the rare association between long term medroxyprogesterone acetate use and meningiomas, a primary intracranial tumour. A dose- and time-dependent association was identified in a 2024 French case-control study; however, the result was based on a small number of cases and should be interpreted with caution - the absolute risk remained low.
Medroxyprogesterone should be prescribed with caution in patients with a history of meningioma, and if meningioma occurs, the medicine should not be continued. Read the full article here.
Meningiomas have also been associated with other types of progesterone, e.g. cyproterone acetate; read more about this risk here.
View the full edition of Prescriber Update here.
Monitoring Communication update: Pericarditis following mpox vaccination
In March, 2023, Medsafe asked clinicians to report any possible cases of pericarditis following mpox vaccination (as reported in Bulletin 69). The reporting period has now ended, and the Centre for Adverse Reactions Monitoring (CARM) has received a total of five reports of patients with suspected pericarditis associated with mpox vaccination (Jynneos). Myocarditis has been added as an adverse effect of Jynneos vaccination in the United States.
The New Zealand data sheet will be updated with advice reminding healthcare professionals to advise patients to seek medical attention post-vaccination if they experience chest pain, shortness of breath or abnormal heartbeats, and to urgently refer patients presenting with these symptoms for diagnosis and treatment.
Mpox cases continue to be reported internationally. Most recently, there has been a clade IIb mpox outbreak across some states of Australia, e.g. New South Wales, that has been linked to the Sydney Gay and Lesbian Mardi Gras festival which took place on 14th February – 2nd March. Many people from New Zealand are expected to have attended. The New Zealand Public Health Advisory is asking healthcare professionals to be alert for potential cases. Mpox may be suspected in patients presenting with flu-like symptoms and acute, unexplained skin and/or mucosal lesions or proctitis (e.g. anorectal pain, bleeding). Notify the local public health service on suspicion of mpox. Check local HealthPathways for further details.
In brief: Bowel cancer screening age to be lowered
The Government has announced that the eligibility age for bowel cancer screening will be lowered from 60 to 58 years for all people. This is part of a strategy to align with Australia where eligibility begins at age 45 years. Population bowel cancer screening using faecal immunohistochemistry (the FIT test) is currently recommended every two years for people aged 60 – 74 years who are not already part of a high-risk surveillance bowel screening programme. It is reported that the eligibility age will be lowered to 58 years in two Health New Zealand, Te Whatu Ora, regions from October, 2025, and the remaining two regions will transition to the lower age from March, 2026.
Flu season starts next month
The 2025 Influenza Immunisation Programme is right around the corner, beginning Tuesday 1st April. Access to funded influenza vaccination remains the same as last year; click here for eligibility criteria.
Influvac Tetra remains the funded brand of influenza vaccine this year. Non-funded vaccines that are available for purchase also remain the same: Flucelvax Quad, Fluad Quad, Fluquadri, Alfuria Quad. A new strain is included in 2025: A/Croatia/10136RV/2023 (H3N2)-like virus for Influvac Tetra, Fluad Quad, Fluquadri, Alfuria Quad, and A/District of Columbia/27/2023 (H3N2)-like virus for Flucelvax. Other included strains are the same as last year.
A summary of the influenza vaccines available in 2025 can be found here. The 2025 “Flu kit” for healthcare professionals is also available, here.
As reported in Bulletin 117, IMAC and Health New Zealand, Te Whatu Ora, recently hosted a webinar on the 2025 winter immunisation programme for influenza, COVID-19 and RSV. If you missed it, you can view a recording of the webinar here.
New skin cancer prevention and early detection strategy released
Skin Cancer Prevention and Early Detection Strategy 2024 – 2028 is now available, following consultation by the Melanoma Network of New Zealand (MelNet) on proposed changes in 2024 (as reported in Bulletin 104). The strategy is aimed at those involved in the prevention and early detection of skin cancer, including primary care clinicians, and outlines 12 recommendations to reduce the incidence of skin cancer in New Zealand.
Of these recommendations, those most relevant to affect the daily work of primary healthcare professionals include:
- Establish a comprehensive, multi-sectoral, nationally co-ordinated skin cancer prevention and early detection programme
- Provide all healthcare professionals working in New Zealand with structured training in the prevention and early detection of skin cancer
- Develop a nationally consistent triage and audit service for the early detection and management of skin cancer that involves both primary and secondary care
Healthcare professionals are encouraged to raise awareness with patients about skin cancer prevention and the importance of early detection, to support and reinforce sun-smart behaviours, encourage regular skin checks and, if time allows, to opportunistically ask about any skin concerns.
The remainder of the 12 recommendations include public health measures and education campaigns on sun safety and early detection, the introduction of sun protection policies across a range of settings, including education, sports, outdoor occupations, and implementation of a ban on sunbeds.
Read the strategy document here (view a summary of the recommendations here). Further information, including a toolkit for healthcare professionals is available from MelNet.
Further information on melanoma is available from bpacnz:
Toxic algal blooms: Identifying and managing suspected cyanotoxin poisoning in primary care
Health New Zealand, Te Whatu Ora, has been warning of toxic algal blooms across freshwaters of many regions in New Zealand over the past few months. This occurs most commonly during summer and early autumn when warmth and low rainfall facilitate growth. People are advised to avoid recreational water activity in affected areas due to significant rises in the cyanobacteria concentrations. Cyanobacteria, also referred to as blue-green algae, are micro-organisms that live in freshwater and marine environments. Under certain conditions (i.e. warmth and low rainfall), cyanobacteria can multiply and form blooms. Some blooms produce toxins (cyanotoxins) that have adverse health effects, targeting a diverse range of organs.
Clinicians should consider cyanotoxin poisoning in patients who present with gastrointestinal (e.g. nausea, vomiting, diarrhoea), respiratory (e.g. cough, sore throat) or dermatological symptoms (e.g. rash) with onset during or after contact with lake or river water, particularly during the warmer months.
What can primary care do if cyanotoxin poisoning is suspected in a patient?
- There is no test available to confirm cyanotoxin poisoning; diagnosis is based on clinical symptoms and signs in association with a history of exposure (e.g. swimming or boating on a river or lake with a current toxic cyanobacterial bloom) and exclusion of other causes
- Non-specific laboratory tests or investigations may be considered based on the patient’s symptoms and signs, e.g. electrolytes and renal function to assess dehydration and potassium
- There are no antidotes to cyanotoxins; treatment is supportive and guided by the type and severity of symptoms, for example:
- Skin irritation – rinse with cool water, apply cold compress, prescribe mild topical corticosteroid if inflammation
- Eye irritation – bathe eyes with cool clean water, apply warm compress, prescribe lubricating eye drops
- Ear irritation – consider prescribing a topical mild corticosteroid, analgesics for earache
- Respiratory tract – prescribe medicines for bronchospasm (e.g. salbutamol inhaler), analgesics for sore throat
- Gastrointestinal – fluid replacement, consider prescribing antiemetic or antidiarrhoeal medicine
- All cases of suspected cyanotoxin poisoning must be notified to the local Medical Officer of Health, which can be done using the Hazardous Substances Disease and Injury Reporting Tool available via some patient management systems or the local Public Health Unit can be contacted directly
For further information, see: “Consider blue-green algal blooms this summer: Identifying and managing suspected cyanotoxin poisoning in primary care”, bpacnz, 2020.
NZF updates for March
Significant changes to the NZF in the March, 2025, release include:
You can read about all the changes in the March release, here. Also read about any significant changes to the NZF for Children (NZFC), here.
Paper of the Week: Non-pharmacological management of IBS
Irritable bowel syndrome (IBS) is a frequently seen chronic condition in primary care. Patients typically present with acute abdominal discomfort and persistent changes in bowel habit. However, many also experience non-gastrointestinal symptoms, e.g. anxiety, fatigue. IBS is classified as IBS with diarrhoea (IBS-D), IBS with constipation (IBS-C) or mixed (IBS-M). The uncertain and heterogeneous nature of IBS pathology, as well as variation in presenting symptoms (and severity), can make management challenging. Treatment strategies that are beneficial for one person may be ineffective for others. As the understanding of IBS evolves and new treatments are developed, primary care clinicians should familiarise themselves with the spectrum of management options currently available and on the horizon.
Pharmacological treatment options are limited, secondary to lifestyle interventions, and will not be appropriate for all patients, but may include low dose tricyclic antidepressants (see POTW, Issue 107), antispasmodics, laxatives or antidiarrhoeals. A clinical review published in the British Medical Journal evaluated the evidence for non-pharmacological management options for IBS. Optimising diet is the first-line treatment. This may involve eliminating specific foods (e.g. low FODMAP diet), increasing soluble fibre intake or changing eating behaviours. Psychological and behaviour-based interventions are also now considered as part of standard care for IBS, e.g. cognitive behavioural therapy. Peppermint oil, probiotics and glutamine may be beneficial for some patients, but there is less evidence supporting these. Access to interventions, particularly psychological therapies and tailored dietary advice, remain a challenge.
What non-pharmacological strategies do you recommend to patients with IBS? What interventions do patients generally report as being most successful? Have you had any experience with patients using psychological therapies for IBS?
Read more
Many patients with IBS struggle to manage their condition and seek frequent advice from their primary care clinician on “what to try next”. Optimal management remains uncertain, as does the understanding of IBS causes and triggers. A literature search over a ten-year period has revealed where we are at with the evidence on non-pharmacological interventions for IBS.
Optimising diet is a standard treatment option for most patients with IBS as many report symptoms in relation to the consumption of certain foods.
- Identifying and then eliminating trigger foods (e.g. lactose, caffeine, spicy foods) is a key step in IBS management, however, this can be challenging if multiple foods groups are not tolerated
- FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) are short-chain carbohydrates that are incompletely absorbed in the gut, resulting in excessive production of gas causing bloating and discomfort, which can be particularly problematic for people with IBS. Following a low FODMAP diet can often be beneficial and relieve symptoms. The challenge is that FODMAPs are found in a wide variety of foods and often dietitian guidance is required to successfully eliminate FODMAP foods and ensure a balanced diet. Online resources are available, e.g. from Monash University.
- NICE guidance for IBS highlights the importance of eating behaviours in conjunction with any dietary changes. This includes regular mealtimes, eating slowly and not skipping meals.
- Soluble dietary fibre (psyllium husk is most recommended, but also in corn fibre, methylcellulose, oat bran, fruit and vegetable flesh) absorbs water in the gastrointestinal tract softening the stool and improving colonic transit (beneficial for IBS-C). The increased stool bulk may also reduce urgency and improve IBS-D symptoms. A total fibre intake of 25-35 g/day is recommended but may need to be slowly built up to. Insoluble fibre (e.g. fruit and vegetable peel/skin, seeds, whole grains, wheat bran) should be avoided by people with IBS (particularly IBS-D) as it may worsen abdominal discomfort and bloating.
- Kiwifruit is associated with improving bowel health, although there is a lack of large-scale randomised controlled trials (RCTs) to support its use specifically for IBS. Except for kiwifruit allergy, there is limited harm to increasing consumption and it is accessible to most people (frozen kiwifruit pulp is also available when kiwifruit is out of season).
Supplements
- Glutamine is an amino acid thought to help maintain gastrointestinal integrity. It has shown promising results in small RCTs in terms of improved symptoms and bowel habits in people with IBS (used in conjunction with a low FODMAP diet).
- Vitamin D has shown benefit in some patients with IBS but the evidence is less clear. There is also a risk of toxicity with inappropriate vitamin D supplementation.
- Evidence to support probiotics is mixed and generally of low quality as there is inconsistency in study designs and the strains used. It is not possible to recommend a specific type of probiotic, but a short trial could be considered, e.g. three months, and continued only if beneficial. There is currently no evidence of benefit for prebiotics.
Complementary and alternative medicines
- A systematic review and meta-analysis of 10 RCTs involving over 1,000 patients found peppermint oil to be superior to placebo for abdominal pain and global IBS symptoms, however, an increased risk of gastrointestinal adverse effects was also observed, e.g. dyspepsia, flatulence
- Studies on the use of specific cannabinoids (e.g. CBD, synthetic THC derivatives) in people with IBS have not shown any benefit compared to placebo. Whole cannabis plant has so far not been investigated as a treatment option for IBS. The risk of harm outweighs any potential benefit of cannabis-based treatments for IBS.
Psychological strategies
- Cognitive behavioural therapy (CBT) skills can improve how people process and respond to symptom triggers, maladaptive thoughts and life stressors that may worsen IBS symptoms. An improvement in coping ability may also be beneficial for those who experience anxiety associated with their IBS. This is therefore a recommended treatment for IBS in many guidelines.
- Gut-directed hypnotherapy is also an evidence-based treatment for people with IBS
- Access to psychological strategies is likely to be limited by availability and cost. Online CBT may improve accessibility, however, there are currently no free New Zealand-based IBS-specific resources available. Generic online CBT resources can be found here.
- General strategies such as mindfulness and relaxation techniques are also likely to be beneficial
Mind-body interventions
- Exercise is strongly recommended as a first-line management option for IBS symptoms in the 2021 British Society of Gastroenterology IBS guidelines. However, there is low quality evidence that exercise may improve IBS symptoms, alongside its established health benefits.
- The postures and meditative movements found in yoga, tai-chi or qi-gong, increase physical activity while also reducing nervous system arousal and may be beneficial for people with IBS, especially their quality of life. Evidence of benefit for IBS symptoms is mixed, however, and further investigations are required.
Acupuncture
- Evidence supporting the use of acupuncture for IBS symptoms is limited; while the benefit remains unclear, there is a low risk of adverse effects
Emerging therapies that require further study
- Polymethylsiloxane polyhydrate (Enterosgel) is an oral intestinal adsorbent that has been shown in RCTs to be beneficial in reducing symptoms in patients with IBS-D with no increase in adverse effects
- Vagal nerve stimulation trials on patients with IBS have been shown to improve quality of life, pain and bowel habits
- Virtual reality as a therapeutic tool is an emerging area of research. It acts via distraction, decreased sensitisation and improving mood. Study is currently underway on a specific programme for people with IBS.
The bottom line: Further investigation is required for many of these treatment strategies, however, they can be trialled if the patient has not experienced symptom improvement with standard lifestyle interventions and pharmacological options. Access to some interventions is likely to be limited by availability and cost.
Wang XJ, Thakur E, Shapiro J. Non-pharmaceutical treatments for irritable bowel syndrome. BMJ 2024;:e075777. doi:10.1136/bmj-2023-075777
For further information on the management of irritable bowel syndrome in primary care, see: https://bpac.org.nz/BPJ/2014/February/ibs.aspx (published in 2014; some content may no longer be current)
A peer group discussion is also available.
GPnotebook, a clinical education platform in the United Kingdom for primary care clinicians, recently released a podcast on IBS. Listen to the podcast here (17 minutes).
This Bulletin is supported by the South Link Education Trust
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