Pharmac and several medical professional organisations (Pharmaceutical Society of New Zealand, Royal New Zealand College of General Practitioners and the College of Nurses Aotearoa) have issued an alert about omeprazole 40 mg capsules and flecainide 100 mg long-acting capsules looking the same. Both capsules have a grey body with a white cap.

Recently, the supplier of omeprazole changed the colour of omeprazole capsules and the packaging (as reported in Bulletin 109). New look omeprazole 40 mg (grey and white) and 20 mg (blue and white) capsules have been supplied since October, 2024; the 10 mg capsules (green and white) have been supplied since March/April, 2025.

Dispensing advice: Consider dispensing 2 × 20 mg omeprazole capsules instead of a single 40 mg capsule to help avoid dispensing errors when removing omeprazole from its original packaging. An information sheet for healthcare professionals is available here.

The funded brand of pregabalin is changing from Pregabalin Pfizer to Lyrica from 1^st July, 2025. Some patients may already be familiar with this brand as it was previously funded.

Pharmacists can dispense the newly funded brand if pregabalin is prescribed generically. Patients taking pregabalin should be advised that their brand is changing, and that the packaging will look different. The capsules will look the same, but will no longer have the word Pfizer printed on them. Patients should be reassured that there has been no change to the active ingredient. A brand switch fee is available is until 1^st January, 2026. A patient information leaflet about the brand change is available, here.

For information on prescribing pregabalin in primary care, see: https://bpac.org.nz/2021/gabapentinoids.aspx

There is an ongoing supply issue affecting stock of macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride powder (Molaxole); as reported in Bulletin 119. Re-supply has been delayed and is now expected by the end of May. Stock of the alternative brand that was listed on the Pharmaceutical Schedule on 1st April (APO Health Macrogol; Section 29), is anticipated to arrive mid-May; there may be a brief out of stock period between the time when supply of the original brand is exhausted, and the new brand becomes available. Other funded alternatives are available (click here for details), however, a new prescription will be required.

• If a patient is prescribed a Section 5 medicine that could impair driving, it is best practice to inform them of this and the LTAA legislation
• Advise patients that their medical defence may be invalidated if they consume alcohol and drive while also taking prescribed Schedule 5 medicines
• Consider whether referral for an occupational therapist driving assessment is appropriate if there is particular concern about a patient driving while taking their prescribed Schedule 5 medicine. Clinicians do not have to carry out driving suitability tests for patients during a consultation, e.g. reaction time testing.
• There is no clinical value in measuring blood concentration levels of Schedule 5 prescription medicines to assess a patient’s suitability to drive
• It is good prescribing practice to document driving instructions in the patient’s clinical notes and also on the prescription so the pharmacist can remind patients of the advice
• Patients should be advised not to drive if they feel sedated or feel like their driving is affected
  • Sedation is a subjective feeling. Advise patients that their driving ability may still be affected even if the sedative feeling has worn off.
• Patients taking stable doses of one Schedule 5 prescription medicine and no other psychoactive substances should be informed of the LTAA legislation, but in most circumstances a clinician would not tell these patients that they could not drive
• Patients with complex prescribing (e.g. taking multiple Schedule 5 medicines or taking other psychoactive substances) should have their suitability to drive discussed with a colleague, e.g. peer group, mental health pharmacist. In some circumstances, patients may need to be advised not to drive, or referral for an occupational therapist driving assessment may be appropriate.
• A practical rule for patients taking Schedule 5 prescription medicines short-term or as needed is to wait until at least two half-lives have passed before driving, i.e. ~75% of the medicine has been cleared
  • For example, codeine has a half-life of 3 – 4 hours, therefore, as part of good prescribing practices, patients may be advised to wait at least eight hours after taking the medicine before driving
  • For approximate half-lives of commonly prescribed Schedule 5 medicines, see Appendix Table 1 in the NZMJ article
• A longer stand-down period before driving (i.e. four half-lives) is appropriate in certain situations, such as patients with renal or hepatic impairment, who are older, who are taking higher than standard doses or multiple psychoactive medicines, patients who take ”as needed” medicines more than two to three times weekly (driving may be more impaired because they do not develop tolerance as much as someone who takes the medicine daily) or any other situation identified by the prescriber

The Influenza Immunisation Programme for 2025 started in April (as reported in Bulletins 118 and 119). The national target is for at least 75% of adults aged 65 years and over to be vaccinated this influenza season. As of 27^th April, the overall vaccination rate in this group is 38%, so progress is being made towards this target. Health New Zealand, Te Whatu Ora, publishes data on influenza vaccination uptake by districts, updated weekly; see how your area is doing, here. Ensure patients who meet eligibility criteria for funded vaccination are aware that they can receive a flu vaccine for free; view eligibility criteria here. See the Immunisation Handbook for further information.

Patient information sheets on managing at home with Cold & Flu and COVID-19

A reminder that you can download and print, send a link or direct patients to bpac^nz information sheets on managing at home with seasonal viral illness or COVID-19.

A nationwide pertussis epidemic was declared in New Zealand in November, 2024 (as reported in Bulletin 113). Cases continue to be reported, but at a lower rate than previously. According to the latest data from ESR (week ending 18^th April), there have been 2,282 cases of pertussis reported (confirmed, probable and suspected) since the beginning of this outbreak (19^th October, 2024); an increase of 313 cases from when we last reported on this in Bulletin 119. Infants aged under one year account for 8% of these cases; around one half of infants with pertussis require hospitalisation.

Healthcare professionals are advised to remain vigilant for possible cases of pertussis and to ensure eligible patients are up to date with their pertussis vaccinations, particularly during pregnancy and infancy. View eligibility criteria for funded pertussis vaccination, here; see the Immunisation Handbook for further information.

The number of measles cases being reported internationally is rising, which means the risk of travellers bringing measles into New Zealand is high. Healthcare professionals should opportunistically check whether patients have received both doses of the MMR vaccine and offer vaccination where appropriate. Also ensure that patients with upcoming international travel are fully vaccinated with MMR if needed. View eligibility criteria for funded MMR vaccination, here; see the Immunisation Handbook for further information.

For further information on MMR, see: https://bpac.org.nz/2021/mmr.aspx

New Zealand hand hygiene guidance from 2012/13 notes that when hands are not visibly dirty or greasy, an alcohol-based hand rub (hand sanitiser) is more effective against most microbes in a healthcare setting, compared to washing with soap and water. Hand sanitiser is also faster and more convenient to apply at the point of care, which can lead to more frequent use. Some hand sanitising products contain emollients and have less of a drying effect on the hands, which can make them better tolerated than repeated washing with soap and water. A systematic review and meta-analysis (2021) found that while hand hygiene with either soap and water or sanitiser reduced transmission of acute respiratory infections, in practice, sanitiser may be more effective. If hands are visibly dirty or greasy, washing with soap and water is usually more effective than hand sanitiser.

This month, the NZF team highlight the importance of considering renal function when prescribing and dispensing aciclovir and valaciclovir:

• There is a risk of renal accumulation and neurotoxicity when prescribing aciclovir (and its pro-drug, valaciclovir) in patients with renal impairment due to the medicine’s high renal clearance (approximately 80% of aciclovir is excreted unchanged in urine)
• Identify patients at higher risk of developing neurotoxicity while taking aciclovir and valaciclovir, e.g. older age, concomitant nephrotoxic drugs, dehydration and those taking high doses
• Consider the patient’s baseline renal function before prescribing or dispensing these medicines, i.e. acute kidney injury, history of chronic kidney disease
• Close monitoring of high risk patients is recommended. Potential symptoms and signs of neurotoxicity include dizziness, confusion, agitation, hallucinations, convulsions, ataxia, dysarthria and drowsiness.
• Advise patients to maintain adequate fluid intake

Further guidance, including dosing recommendations in different clinical situations, is available in the renal impairment section of the NZF aciclovir and valaciclovir monographs. A Prescriber Update article is also available: https://medsafe.govt.nz/profs/PUArticles/December2024/Aciclovir-and-valaciclovir-toxic-in-renal-impairment.html.

• This open-label randomised clinical trial involved 504 participants (67% male; mean age 69 years) from seven clinics across the Netherlands and ran from 2021 to 2024
• Patients with New York Heart Association (NYHA) functional class II or III heart failure symptoms for at least six months were included regardless of left ventricular ejection fraction. Most participants were also receiving guideline-directed medical therapy (GDMT) for heart failure.
  • Those with significant renal impairment (eGFR < 30 ml/min/1.73 m²), or previous hospitalisation with heart failure were excluded
• Participants were randomised to consume either < 1,500 mL of fluid per day (n = 250) or an unrestricted fluid intake regimen (n = 254) for at least three months
  • A shared decision on continuing fluid intake restriction was made between the participant and clinician after the three month assessment
  • Follow-up continued until six months post-randomisation to assess for adverse effects
  • Fluid intake values were based on a period of seven consecutive days in the participant’s fluid intake diary and reported at week six of the study
  • Approximately half of the study cohort had previously followed fluid restrictions
• Participants completed the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Thirst Distress Scale for patients with Heart Failure (TDS-HF) at baseline, following randomisation, after three months and at six months to evaluate heart failure symptoms, quality of life and perceived thirst distress
• The primary and secondary outcomes were the results of the KCCQ at three months (a five point change is considered clinically important) and TDS-HF respectively (higher scores indicate higher thirst distress)
• Participants fluid intake in the restricted group (median = 1,480 mL; interquartile range^* [IQR] = 1,357 – 1,561 mL) was lower than participants in the unrestricted intake group (median = 1,764 mL; IQR = 1,488 – 2,156 mL)
  • Approximately three-quarters of participants in the unrestricted intake group consumed > 1,500 mL of fluid per day, whereas only one-third consumed > 2,000 mL of fluid per day on average. In comparison, 43% of participants in the restricted intake group consumed more than 1,500 mL and 5% consumed > 2,000 mL of fluid per day.
• After three months, the KCCQ overall summary score was 72.2 (95% confidence interval [CI] = 69.6 – 74.7) in the fluid restricted group compared to 74.0 (95% CI = 71.5 – 76.6) in the unrestricted intake group. The mean difference between the two groups at three months was 2.2 (after baseline score adjustment), therefore the primary outcome was not met as this difference in health status was not clinically significant.
• Participants with no fluid restriction reported a lower perceived thirst distress score on the TDS-HF (mild; 16.9; 95% CI = 15.8 – 18.0) compared to participants in the restricted fluid intake group (moderate; 18.6; 95% CI = 17.5 – 19.6)
  • The median baseline perceived thirst distress across all participants was 15.5 (IQR = 10.0 - 21.0)
• No statically significant differences were found in safety outcomes (e.g. mortality, heart failure hospitalisation, acute kidney injury) between the two fluid intake groups, however, this study was not appropriately powered for this. There was also no difference in the number of treatment protocol changes required between the two groups (i.e. due to differences in fluid intake status).
• There was inconsistency in relation to intervention adherence; 88% of participants in the restricted fluid intake group reported adherence to the intervention (i.e. fluid intake < 1,500 mL per day at least five days per week), but this appears to be closer to 56% after analysing fluid intake diaries
• The unrestricted fluid intake intervention did not have a maximum daily intake, however, only one-third of the participants in the intervention group consumed more than 2,000 mL per day on average. Therefore, discussion about consumption of “adequate but not excessive” fluid intake (e.g. 1,500 – 2,000 mL/day) with patients is appropriate but the risk of overzealous fluid consumption is likely low.
• The authors also note that these results relate to a specific patient subgroup and should not be used to inform treatment decisions for patients with other stages of heart failure or those with co-morbidities

* The range between the 25^th and 75^th percentiles of the data