Published: 21st March, 2025
Contents
New from bpacnz - Vitamin D supplementation: an update
Vitamin D dispensing is increasing over time; in 2024, colecalciferol was the fourth most dispensed medicine in New Zealand, up from 12th in 2016. Its use is well established for some groups, e.g. older frail people with limited sun exposure, and in most cases it can be prescribed based on the patient’s risk of deficiency without testing. However, newer recommendations for vitamin D prescribing and testing may be less familiar for some clinicians, e.g. supplementation is recommended in all exclusively and partly breast-fed infants up to age one year.
Groups considered to be at high risk of vitamin D deficiency who may benefit from supplementation include people: with naturally very dark skin, with minimal sun exposure due to religious, cultural, personal or medical reasons, living in aged residential care facilities, with certain medical conditions or who take certain medicines that affect the metabolism or absorption of vitamin D.
In 2024, Health New Zealand, Te Whatu Ora, published an updated statement for healthcare professionals on vitamin D and sun exposure in pregnancy and infancy. A new practice changing recommendation is to supplement all exclusively or partly breast-fed infants up to age one year. Another new recommendation is to consider vitamin D testing for pregnant people with multiple risk factors for deficiency as this group is more likely to have vitamin D deficiency, and therefore, need higher supplement doses. Vitamin D supplementation continues to be recommended for pregnant people at risk of deficiency, e.g. those living south of Nelson/Marlborough in winter or spring, those with naturally very dark skin or with minimal sun exposure.
Read the full article here. A B-QuiCK summary is also available.
Also new: Atrial fibrillation case study quiz
Last year, bpacnz published an article on atrial fibrillation (AF), emphasising that a progressive approach to management should be taken for most patients newly diagnosed in primary care. Unless the onset of AF occurred within the past 12 hours, referral for electrical cardioversion is not appropriate in haemodynamically stable patients without prior anticoagulation due to the risk of thromboembolic complications. Treatment using direct oral anticoagulants (DOACs) and rate control medicines, alongside relevant lifestyle changes, is sufficient for most patients managed in primary care. AF will often spontaneously resolve without the need for intensifying management.
We have now developed a case study quiz to accompany this article, following the story of Ken Henderson, a 67-year-old male who presents with concerns about a “racing heart”. Are there any aspects of Ken’s presentation and history that give you an increased cause for concern? Do you feel confident you can set Ken on a positive path towards long-term control?
Can you help Ken? Complete the case study quiz here.
N.B. You will need to log-in to “My bpac” or create a free account. Quizzes are endorsed as a professional development activity by the RNZCGP (two CPD credits) and InPractice; a certificate of completion is also provided for all participants.
Recovery at Work peer group discussion
In 2024, bpacnz published a comprehensive guide for supporting primary care clinicians to help patients navigate the ACC Recovery at Work process. We have also developed several CPD activities to complement this resource. The topic of ACC medical certification often generates much discussion. To that end, we have created a summary of key points, accompanied by a series of questions that can be used as discussion points for peer groups or self-reflection of practice.
View the peer group discussion here.
Read the full article here. A B-QuiCK summary and case study quiz are also available.
What key learning points did you take away from reading these resources? Is there anything you are still unsure about? What else would you like to know about?
We are currently compiling questions to inform a discussion with an expert panel. We would like to hear from our readers about what you would like us to explore in more detail. This may include aspects of this process that require further explanation or challenges you have encountered that you would like us to address on your behalf. Send your questions and feedback to: editor@bpac.org.nz
In case you missed it: Fungal nail infections, coeliac disease checklist
We regularly add new content to our website – browse resources under the “articles" tab or search for a topic you are interested in. Here are some of our most recently published resources:
Management of fungal nail infections
Fungal infection of the nail, or onychomycosis, is not typically a life threatening condition but it can significantly impact a person’s quality of life. The wide differential diagnosis and strong commitment to treatment required from patients (often for several months, or even years) means laboratory confirmation of fungal infection is recommended before initiating treatment, even when clinical suspicion is high. Oral antifungal treatment is preferred, however, depending on patient factors such as severity of infection, co-morbidities and potential for medicines interactions, topical antifungals may be more appropriate.
Read the full article here. A B-QuiCK summary is also available for this topic.
Coeliac New Zealand primary care checklist
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.
Are your “My bpac” details up to date?
Most bpacnz readers have a “My bpac” account. This gives full access to all the features on our website, including the ability to make comments on articles, earn certificates for completing CPD quizzes, personalise the content you see, store favourite articles and manage electronic mailing list details.
Through “My bpac”, primary care prescribers also have access to personalised data when we release prescribing reports, allowing comparison against national averages, comparator prescribers and your practice colleagues; click here for an example.
If you already have a “My bpac” account, log-in to check that your details are up to date: click on “Amend account details” and ensure your occupation is selected to show you are a primary care prescriber (if applicable) and that your practice details are correct.
If you do not have a “My bpac” account, sign-up for free, here.
Medicine news: Cilazapril, insulin, macrogol
The following news relating to medicine supply, of particular interest to primary care, 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.
Reminder: Cilazpril being discontinued next month
Cilazapril is being discontinued from the Pharmaceutical Schedule from 1st April, 2025. Any remaining stock expired in October, 2024. Ensure that if you have any patients still taking cilazapril they are switched to an alternative antihypertensive now.
For further information on selecting an ACE inhibitor or ARB, see: https://bpac.org.nz/2021/ace.aspx
Reminder: Some brands of Novo Nordisk biphasic insulin (Penmix 30, NovoMix 30 FlexPen) being discontinued
Pharmac has announced that supply of PenMix 30 (insulin isophane with insulin neutral) is expected to run out in April, 2025. NovoMix 30 FlexPen (insulin aspart with insulin aspart protamine) is now also being discontinued with supply expected to be exhausted in mid-2026. These changes are part of the discontinuation of several Novo Nordisk brands of biphasic insulin (as reported in Bulletins 103, 105 and 112). Supply of Mixtard 30 and PenMix 50 was exhausted in November, 2024, however, these brands will continue to be listed on the Pharmaceutical Schedule until 1st June, 2025. Patients still taking PenMix 30 or NovoMix 30 FlexPen* will need to be prescribed a funded alternative; see the NZF for alternative treatment options.
The New Zealand Society for the Study of Diabetes (NZSSD) has published guidance for switching patients to an alternative insulin preparation (as reported in Bulletin 105).
* See Pharmac consultation below
For further information on prescribing insulin, see:
Supply issue affecting macrogol 3350 powder (Molaxole)
There is a supply issue affecting stock of macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride powder (Molaxole). Re-supply is expected at the end of April. An alternative brand (APO Health Macrogol) is being listed on the Pharmaceutical Schedule from 1st April; the active ingredients and flavour remain the same, but this brand is not approved by Medsafe and so will need to be prescribed for supply under Section 29 of the Medicines Act 1981.
Desogestrel (Cerazette) to be funded
The progestogen-only pill desogestrel (Cerazette) will be funded without restriction from 1st April, 2025. This decision follows consultation on a proposal by Pharmac (as reported in Bulletin 116). Progestogen-only pills require regular adherence for maximum efficacy, e.g. norethisterone and levonorgestrel-only pills (Noriday 28 and Microlut) must be taken within three hours of the regular dosing time each day. Desogestrel has a wider treatment window; it can be taken anytime within 12 hours of the regular dosing time and maintain efficacy. It is also more effective at inhibiting ovulation than other progestogen-only pills. Funding desogestrel provides patients affected by recent supply issues of other contraceptives, with another option.
For further information on selecting an oral contraceptive, see: “Oral contraceptives: selecting a pill”, bpacnz, 2021
Proposal to fund new insulin co-formulation
Pharmac is seeking feedback on a proposal to fund insulin degludec and insulin aspart (Ryzodeg) for patients with type 1 and type 2 diabetes without restriction from 1st May, 2025. Ryzodeg is an insulin co-formulation which combines the ultralong-acting insulin degludec (70%) with the rapid-acting insulin aspart (30%). It is expected to reduce the number of insulin injections required for some patients and may also improve blood glucose stability. Pharmac advises that insulin degludec and insulin aspart may be an appropriate alternative medicine for patients prescribed NovoMix 30 FlexPen, which is being discontinued (see above).
Consultation closes 5 pm Monday, 24th March.
Cryptosporidiosis outbreak in the Wellington region
The National Public Health Service (Health New Zealand, Te Whatu Ora) has announced an increase in cryptosporidiosis cases in the Wellington region. Eight cases were initially reported, but it is believed that number has now increased substantially. In the past three years, only 0 – 2 cases were reported per year for the same period. Many of the recent cryptosporidiosis cases have been linked to use of public swimming pools.
Healthcare professionals are being asked to consider cryptosporidiosis in patients reporting diarrhoea and abdominal pain, especially in children who recently attended a public swimming pool or other recreational water facility in the Wellington region. Patients should be advised to stay home from childcare/school or work until at least 48 hours after symptoms resolve and to avoid using public swimming pools/water facilities for at least 14 days after symptoms have resolved. Discuss good hygiene practices to prevent further spread. Symptoms generally last between 2-14 days; supportive care with adequate hydration and electrolytes is recommended. Antibiotic treatment is not indicated (Cryptosporidium species are protozoan parasites).
Immediately notify any suspected cases of cryptosporidiosis to the local Medical Officer of Health. Do not wait for laboratory confirmation before notifying.
Patient information about cryptosporidiosis is available here.
Immunisation reminders: Influenza, COVID-19 and pertussis
Influenza season
The 2025 Influenza Immunisation Programme launches on Tuesday, 1st April (as reported in Bulletin 118). Available vaccines and eligibility criteria to access funded vaccination remain the same as last year (one funded brand, four other brands available to purchase, all quadrivalent). For further information and associated resources including a summary of available vaccines and eligibility criteria, click here.
Pertussis update
A nationwide pertussis epidemic was declared in New Zealand in November, 2024 (as reported in Bulletin 113). Case numbers appear to be trending down since a peak in December. According to the latest data from ESR (week ending 7th March), there have been 1,969 cases of pertussis reported (confirmed, probable and suspected) since the beginning of this outbreak (19th October, 2024); infants aged under one year account for 7.5% of these cases. More than half (55.8%) of those aged under one year were hospitalised, compared to 9% of cases overall.
Healthcare professionals are advised to remain vigilant for possible cases of pertussis and to ensure eligible people are up to date with their pertussis vaccinations, particularly during pregnancy and infancy. For further information on pertussis vaccination, see Bulletin 113.
COVID-19 vaccination
The Comirnaty JN.1 COVID-19 vaccines have been available since January, 2025 (as reported in Bulletin 115). These replace the XBB.1.5 vaccines for both primary and additional doses. Funded COVID-19 vaccine eligibility has not changed: see full eligibility criteria here (Pharmac) and here (Immunisation Handbook).
Advise patients that additional doses continue to be available every six months for previously vaccinated people aged ≥ 30 years. Also, encourage eligible adults and children who have not yet received a primary COVID-19 vaccination, or are not up to date with additional doses, to do so. For additional resources from IMAC, click here.
Paper of the Week: The “four pillars” of CKD management
Wait, haven’t I heard this phrase before? You might recall hearing about the “four pillars” approach in our recent series on heart failure , where the combined use of four key medicine classes helps to enhance patient outcomes. In what might appear to be the new trend in chronic disease management, a similar “four pillars” approach has now been proposed for chronic kidney disease (CKD), emphasising the importance of comprehensive, guideline-directed treatment to slow CKD progression and reduce cardiovascular risk.
An article published in Nature Reviews Nephrology discusses the risk-based use of the “four pillars” in patients with CKD, including:
- ACE inhibitors or ARBs
- Mineralocorticoid receptor antagonists (MRAs)
- Sodium-glucose co-transporter 2 (SGLT-2) inhibitors
- Glucagon-like peptide-1 (GLP-1) receptor agonists
Unlike in heart failure, where introduction of all “four pillars” are recommended promptly for most patients irrespective of disease severity, this review notes that the absolute benefits of such combination treatment in patients with CKD are greatest in those at high risk of progression, e.g. those with significantly reduced eGFR or albuminuria. As such, it is suggested that clinicians adopt a risk-based approach to CKD-care and prescribing decisions. However, evidence suggests that these “four pillars” are underutilised among those who need them the most. In New Zealand, access to funded treatment will also be influenced by Special Authority criteria. For example, SGLT-2 inhibitors and GLP-1 receptor agonists are not funded for patients with CKD unless they meet other conditions, e.g. co-morbid diabetes or heart failure.
While use of eGFR (G1 – G5) and albuminuria (A1 – A3) categorisation can provide broad predictive information around CKD prognosis, treatment selection/timing and the need for secondary care referral, this review discusses four other validated prognostic tools. Options include the kidney failure risk equation (KFRE), risk for 40% GFR decline, predicting risk for CVD EVENTs (PREVENT) and the advanced CKD risk tool.
What is your approach to assessing risk of progression in patients with newly diagnosed CKD? Do you feel confident in prescribing treatments for CKD, both initially and as the patient’s condition advances?
Read more
- CKD affects approximately one in ten people globally. Even in the early stages, CKD is a significant risk factor for CVD events and death, and this risk increases further as kidney function declines.
- The four key medicine classes for reducing CKD progression, CVD events and mortality include:
- ACE inhibitors or ARBs – delay CKD progression in patients with or without diabetes, particularly when albuminuria is present. Both considered to be similarly effective, and once initiated, should be titrated to their maximum (approved) tolerated dose.
- MRAs – guidelines primarily recommend using non-steroidal MRAs such as finerenone, which have been validated in trials of patients with diabetes, CKD and severe albuminuria despite maximally tolerated ACE inhibitor/ARB dose
Non-steroidal MRAs are not routinely available in New Zealand; the only funded options available are steroidal MRAs (e.g. spironolactone, eplerenone) which have not been investigated in CKD-specific clinical trials (i.e. the benefit is unclear). Current practice is usually to prescribe calcium channel blockers (or diuretics) as a next step after ACE inhibitor/ARB treatment in many patients with CKD. Steroidal MRAs may still be used in patients with CKD for the treatment of co-morbid heart failure, hyperaldosteronism or refractory hypertension.
- SGLT-2 inhibitors – should be used in all patients with CKD if they have co-morbid diabetes or heart failure. In patients with CKD and diabetes, empagliflozin should be prescribed in combination with metformin (which also helps to reduce CVD and renal risk). International guidelines increasingly recommend SGLT-2 inhibitors in all patients with CKD, regardless of diabetes status.
- GLP-1 receptor agonists – while understanding around the role of GLP-1 receptor agonists in CKD management is still evolving, they offer cardiovascular benefits and may further reduce kidney disease progression. For example, the 2024 FLOW trial (N = 3,533) demonstrated that GLP-1 receptor agonist use (semaglutide) decreases the risk of major kidney disease events (kidney failure, ≥ 50% eGFR reduction or kidney-/cardiovascular-related death) by 24% in patients with CKD and type 2 diabetes compared with placebo. Benefits are also expected in patients with CKD and obesity without diabetes (further research is needed).
Under current Special Authority criteria, GLP-1 receptor agonists are only funded for patients with diabetes. In addition, prescribing a GLP-1 receptor agonist for the treatment of CKD would be considered “off label” use as this is not currently an approved indication in New Zealand. The FDA recently expanded the indications for semaglutide (Ozempic; a GLP-1 receptor agonist not readily available nor funded in New Zealand) to include CKD.
- Despite efficacy demonstrated in clinical trials, evidence suggests the “four pillars” are underutilised in patients with CKD, particularly among those at high risk. The absolute benefits of the above treatments (and lowest associated number needed to treat) are most significant in patients with a poor prognostic outlook.
- Risk estimates should therefore be incorporated into decision-making when making CKD-prescribing decisions (i.e. selection and timing) to balance benefits against potential harms, e.g. medicine-associated adverse effects
Given that Special Authority restrictions may require some patients with CKD to self-fund treatment (e.g. SGLT-2 inhibitors, GLP-1 receptor agonists), cost is also factor in risk-based decision-making in New Zealand.
- CKD “heat mapping” based on eGFR (G1 – G5) and albuminuria (A1 – A3) categorisation is one approach for assessing broad CKD prognostic risk in primary care. However, while eGFR is frequently assessed, many patients do not undergo an albuminuria assessment. Without this information, CKD risk estimates and treatment decisions may be suboptimal.
Urine ACR testing is routinely undertaken in patients with diabetes, but evidence suggests it is underutilised in patients without diabetes in New Zealand primary care, even in the setting of known CKD risk (e.g. hypertension, Māori or Pacific peoples). One primary care study from 2018 demonstrated that among 200,629 adults without diabetes in the Southern region, 148,529 (74%) had been tested for CKD but only 17,161 (8.6%) had been tested for albuminuria. Since that time there has been increased emphasis on evaluating urine ACR ratio as part of a comprehensive clinical risk assessment, therefore it is anticipated that these testing statistics will have improved.
- Additional prognostic tools for absolute risk prediction are discussed in this review that provide enhanced risk discrimination among patients with CKD, even within individual eGFR (G1 – G5)/albuminuria (A1 – A3) categories. These include:
- Kidney Failure Risk Equation (KFRE) – estimates the risk of kidney failure within two to five years and can guide the need for nephrology referral, transplant evaluation and vascular access placement. Intended for use in patients with an eGFR < 60 ml/min/1.73 m2. Incorporates either four (age, sex, eGFR and urine ACR) or eight (serum calcium, phosphate, bicarbonate and albumin; more accurate) parameters. KFRE is recommended in both KDIGO and NICE CKD guidelines.
- Risk for 40% GFR decline – identifies patients at high risk of significant disease progression. Developed for use in patients for whom KFRE might not adequately represent short-term risk, e.g. those with a high eGFR or other milder forms of CKD.
- Predicting Risk for CVD Events (PREVENT) – assesses 10- and 30-year cardiovascular risk in patients aged 30 – 79 years without known CVD. Incorporates eGFR and urine ACR, among other markers of CVD risk.
- Advanced CKD Risk Tool – integrates nine risk factors to guide late-stage CKD management; intended for use in patients with an eGFR < 30 ml/min/1.73 m2 to estimate the 2- and 4-year risks of kidney failure, CVD and death
The above tools have been validated in international cohorts, primarily from North America and Europe. Despite their strong predictive value, the applicability to New Zealand’s population (including Māori and Pacific peoples, who have a higher burden of CKD) is not fully understood. New Zealand CVD risk equations are available that incorporate renal function and give an estimate of end stage renal disease risk, but these only apply to patients with co-morbid diabetes (see: https://www.nzssd.org.nz/cvd_renal/).
- Further research is required to determine the optimal timing and intensity of “four pillars” treatment across all patient groups. However, given the strong evidence for these medicines in the setting of CKD, their use should be prioritised wherever possible, unless contraindicated.
Blum MF, Neuen BL, Grams ME. Risk-directed management of chronic kidney disease. Nat Rev Nephrol 2025; [Epub ahead of print]. doi:10.1038/s41581-025-00931-8
For further reading, see: Chronic kidney disease: the canary in the coal mine (2022) – bpacnz
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