Published: 16th May, 2025
Contents
New from bpacnz: Urinary tract infections (UTIs) – an overview of lower UTI management in adults
Urinary tract infections (UTIs) are a common reason for primary care consultations and antibiotic prescribing in New Zealand, with almost half of all females experiencing at least one episode during their lifetime. In the absence of complicating factors, empiric antibiotic treatment is usually sufficient for most patients with a lower UTI, without the need for additional investigations, e.g. urine microscopy, culture and sensitivity analysis.
This is a revision of our previously published article and includes a general update, and information on fosfomycin which is now funded with Special Authority approval for some patients with an uncomplicated UTI. We have also reviewed the most recent evidence on recurrent UTI prophylactic strategies and included information on vaccines, e.g. MV140 (Uromune), for the prevention of recurrent UTIs.
Read the full article here. A B-QuiCK summary is also available here.
Spotlight on: Getting prepared for winter
With the cooler temperatures and shorter days, we are under no illusion winter is almost here. That also means the avalanche of winter ills and chills in primary care is on its way. bpacnz has many winter illness resources available for primary care clinicians on our website, including an overview of managing community-acquired pneumonia, identifying the risk of serious illness in young children with fever, cough medicines: do they make a difference?, and CPD activities such as a peer group discussion on managing winter illnesses in primary care, and a clinical audit on managing winter illnesses without antibiotics, which is also endorsed by the Royal New Zealand College of Urgent Care.
View all of our resources, here, or you can browse by category, e.g. infections, respiratory conditions.
Patient information sheets are also available. The following information sheets have been designed to support primary care clinicians during patient consultations, and can be downloaded and printed, or the link sent to patients:
Message to our subscribers
For over twenty years, the bpacnz Publications website has provided educational resources to primary care health professionals; Best Practice Bulletin is currently delivered to over 12,000 subscribers. bpacnz has been, and continues to be, funded by the South Link Education Trust. However, with competing requests for Trust funding, as well as exciting new developments we wish to bring to our subscribers, we are considering seeking sponsorship/funding from other reputable sources.
We will keep you informed of our activities and seek your input as we develop appropriate policies and processes to ensure we meet all the ethical standards as we move forward.
We would appreciate hearing from you at any time and please email contact@bpac.org.nz with any comments, suggestions or concerns that you may have.
Emeritus Professor Murray Tilyard
Editor-in-Chief, bpacnz Publications and Chair of South Link Education Trust
murray@southlink.co.nz
Measles case in Auckland
A new case of measles, related to overseas travel, has been confirmed in New Zealand. Exposure events are listed here. Healthcare professionals should be alert for symptoms and signs of measles in patients, particularly those who are not vaccinated or are immunocompromised, and have a history of recent overseas travel.
Consider the possibility of measles in a patient with the following:
- Generalised maculopapular rash, that starts on the head and neck and spreads down and out and fades
- Fever > 38℃ (usually begins around two days before the rash appears)
- Cough, coryza, conjunctivitis or Koplik spots
All suspected cases of measles must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before notifying.
Is your patient population up to date with MMR vaccinations?
This is another timely reminder to opportunistically check whether patients have received both doses of the MMR vaccine and to offer vaccination where appropriate (see IMAC for clarification on MMR vaccination advice for older adults). 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 acute rheumatic fever guideline update
Health New Zealand, Te Whatu Ora, has released updated national guidelines for acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This is an update and amalgamation of previous editions of the New Zealand guidelines to create a comprehensive resource for clinicians.
Key changes from previous guidelines include simplification of criteria for patients at higher risk of ARF who should receive empiric antibiotics if they have a sore throat, and the removal of roxithromycin as an alternative antibiotic option for patients with Group A Streptococcus (GAS) pharyngitis and penicillin allergy. If an individual is diagnosed with ARF, it is no longer recommended to routinely swab for GAS in asymptomatic household members (only those with a sore throat).
Read more about the updates on ARF
- Criteria for determining patients with a sore throat who are at higher risk of ARF (and therefore require empiric antibiotics) has been simplified to include those with either a personal or family history of ARF/RHD or Māori or Pacific peoples aged 3 – 35 years (with emphasis on children and adolescents aged 4 – 19 years)
- A throat swab for GAS remains appropriate for people with sore throat at higher risk of ARF (as per criteria above), but if follow up is not possible or likely, this does not need to be done. A swab may also be considered for people with sore throat who are at high risk of spreading infection or if they are immunocompromised.
- Antibiotic treatment for GAS pharyngitis:
- Phenoxymethylpenicillin (Penicillin V) dosing has changed to twice daily (instead of two to three times daily)
- Benzathine benzylpenicillin tetrahydrate (benzathine penicillin) dosing for ARF is now categorised by weight under and over 20 kg (instead of 30 kg)
- Erythromycin dosing is now twice daily (instead of two to three times daily)
- Roxithromycin is no longer recommended as an alternative antibiotic option for patients with documented penicillin allergy (erythromycin can be used)
- Transient advanced atrioventricular (AV) block is now considered to be a major manifestation of ARF and has been included in the diagnostic criteria
- Diagnosis of Definite ARF can be made with either a GAS throat culture, polymerase chain reaction (PCR), or serology in patients with carditis
- Positive serology is needed to confirm a diagnosis of Definite ARF in patients without carditis
- It is not necessary to routinely swab for GAS in asymptomatic household members of a new ARF case, only those who also have a sore throat
Click here to read the full guideline. A summary guide for clinicians is available here.
Medicine news: Alendronic acid + colecalciferol, oxycodone, dipyridamole, insulin isophane, macrogol
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.
Alendronic acid + colecalciferol (Fosamax Plus) supply issue
Pharmac has advised that stock of alendronic acid + colecalciferol (Fosamax Plus) will be limited or exhausted this month, due to unexpected demand. Re-supply is expected by the end of May. Patients with osteoporosis who are being treated with a bisphosphonate and require vitamin D supplementation will need to be prescribed alternative medicines if Fosamax Plus is out of stock, e.g. alendronic acid (Fosamax) and colecalciferol separately. Stock of Fosamax is not affected by this supply issue. N.B. The dose of colecalciferol in Fosamax Plus is 140 micrograms per week compared to 1.25 milligrams per month for the colecalciferol capsule.
Re-supply of oxycodone immediate-release tablets delayed
There is an ongoing supply issue affecting stock of 10 mg and 20 mg oxycodone immediate-release tablets (as reported in Bulletin 121). Re-supply is now expected by early June. Pharmac advises oxycodone 5 mg immediate-release tablets (also previously affected by a supply issue but now resolved; as reported in Bulletin 118) are a suitable alternative*, however, a new prescription will be required. Otherwise, clinicians could consider prescribing an alternative analgesic.
* Oxycodone 1 mg/mL oral liquid may also be an alternative but stock of this is now reported to be low
Clinical advice for dipyridamole tablet discontinuation
The supplier of dipyridamole tablets (Pytazen SR) is discontinuing this medicine due to problems with accessing the active ingredient (as reported in Bulletin 117). Pharmac expects stock to run out in May/June (any remaining stock will expire at the end of July). Dipyridamole is used in the secondary prevention of ischaemic stroke and TIA (unapproved indication), usually in combination with aspirin.
Clinical advice is to consider switching patients still taking dipyridamole to either clopidogrel or aspirin monotherapy, as there is no alternative brand of dipyridamole available. Long-term dual antiplatelet treatment should only be used for secondary prevention of stroke or TIA under specialist supervision.
Reminder: insulin isophane discontinuation
Pharmac has previously announced the discontinuation of several Novo Nordisk brands of biphasic insulin (most recently reported in Bulletin 119). Stock of PenMix 30, Mixtard 30 and PenMix 50 has been exhausted. Both Mixtard 30 and PenMix 50 will be delisted from the Pharmaceutical Schedule on 1st June, 2025; a delisting date for PenMix 30 is yet to be announced.
NovoMix 30 FlexPen (insulin aspart with insulin aspart protamine) is also being discontinued with supply expected to run out in mid-2026 (as reported in Bulletin 119). Patients still taking NovoMix 30 FlexPen will need to be prescribed a funded alternative. The combination medicine insulin degludec and insulin aspart (Ryzodeg) was recently funded for patients with diabetes (as reported in Bulletin 121) and may be an appropriate alternative for these patients.
The New Zealand Society for the Study of Diabetes (NZSSD) has provided guidance when switching patients to an alternative insulin preparation (as reported in Bulletin 105).
For further information on prescribing insulin, see:
Prioritise macrogol for patients taking clozapine
The supply issue affecting stock of macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride powder (Molaxole) remains ongoing (as reported in Bulletins 119 and 122). Re-supply is expected at the end of May (as reported in Bulletin 122). Stock of the alternative brand (APO Health Macrogol; Section 29) has now arrived, but prescribers are being asked to consider reserving macrogol for patients taking clozapine (in whom constipation is a significant adverse effect). Other funded alternatives for treating constipation are available (click here for details), however, a new prescription will be required.
Consultation on widening access to COVID-19 antivirals
Pharmac is seeking feedback on a proposal to widen access criteria for COVID-19 antivirals. From 1st September, 2025, nirmatrelvir with ritonavir (Paxlovid) and remdesivir (Veklury) would be funded for all people aged 50 years or over with an active COVID-19 infection who are considered by their healthcare professional to be at high risk of hospitalisation or death. Currently, people aged 50 years or over who are of Māori or Pacific ethnicity or who have not completed a primary course of COVID-19 vaccination are eligible for funded antiviral treatment. There are no proposed changes to other access criteria. Click here to view the full access criteria.
Changes to the way COVID-19 antivirals are ordered, supplied and claimed for would also occur as part of this proposal to align with other funded medicines. These changes would take effect from 1st September, 2025, for remdesivir and 1st October, 2025, for nirmatrelvir with ritonavir. Read more about these proposed changes, here.
Consultation closes 5 pm Friday, 30th May. This link contains an online form to complete, or feedback can be emailed directly to: consult@Pharmac.govt.nz. An associated news release is available here.
In brief: Decision to fund and widen access to treatments for advanced melanoma and immune checkpoint inhibitor-related toxicity
Pharmac has announced that from 1st June, 2025, dabrafenib (Tafinlar) and trametinib (Mekinist) will be funded for patients with resectable stage IIIB to IV BRAF mutated melanoma after surgery and unresectable or metastatic BRAF mutated melanoma. Access to pembrolizumab (Keytruda) will also be widened to include patients with resectable stage IIIB to IV melanoma, and more patients will be able to access infliximab (Remicade) and tocilizumab (Actemra) for the management of immune checkpoint inhibitor-related toxicity (occurring during cancer treatment).
Upcoming webinar on chronic kidney disease
HealthPathways is hosting a national webinar on the diagnosis and management of chronic kidney disease (CKD). This free webinar is expected to cover topics including the identification of high-risk patients, understanding CKD in the context of the individual patient and considering it as part of the wider cardiac-kidney-metabolic syndrome as well as optimising outcomes through medicines, education and lifestyle changes. The webinar will be held on Tuesday, 17th June, 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.
GP CME Conference Rotorua is back for 2025
The GP CME conference has come around once again. It is being held at the Rotorua Energy Events Centre from the 5th – 8th June. The South Link Education Trust returns as the Diamond Sponsor of the GP CME conferences in 2025. The Trust is home to South Link Health Services, BPAC Clinical Solutions, InPractice, bpacnz Publications and the New Zealand Formulary. Representatives from across the organisation will be at stands 75 – 77 so be sure to pop in and hear about the latest offerings.
It’s not too late to get involved; click here to register.
Podcast of the Week: Temporal arteritis in primary care
A recent episode of GPnotebook, a clinical education platform in the United Kingdom for primary care clinicians, discusses temporal arteritis, also referred to as giant cell arteritis. This is an inflammatory condition that affects large and medium sized arteries, predominantly in the head. It usually occurs in people aged over 50 years and is more common in females. It must be treated urgently, as it is associated with a significant risk of permanent visual loss and other complications, e.g. aortic aneurysm. Symptoms include headache, scalp tenderness, jaw claudication, visual disturbances and systemic symptoms, such as sweats, fever and anorexia.
If temporal arteritis is suspected, immediately initiate the patient on high-dose corticosteroids, seek rheumatology or ophthalmology advice and organise appropriate investigations, e.g. laboratory testing (ESR, CRP), temporal artery ultrasound or biopsy (ultrasound is now usually favoured over biopsy for diagnosis).
Listen to the podcast here (18 minutes).
For further information on temporal arteritis, see: https://bpac.org.nz/bpj/2013/june/arteritis.aspx (published in 2013; some information may no longer be current)
Temporal arteritis has a strong association with polymyalgia rheumatica (PMR). For further information on PMR, see: https://bpac.org.nz/2023/pmr.aspx. This article also includes a section on temporal arteritis: https://bpac.org.nz/2023/pmr.aspx#cranial.
Paper of the Week: Teeing up a diagnosis - Parkinson's disease and chemical exposure at the golf course
The development of Parkinson’s disease is dependent on both genetic and environmental components. Many risk factors are associated with Parkinson’s disease including chemical exposure, e.g. organophosphates, chlorpyrifos and paraquat. Asking about occupational factors when patients present with possible Parkinson’s disease symptoms is sensible as chemical exposure is common in many industries, e.g. agriculture, landscaping and pest control. However, chemical exposure does not only occur in the workplace and clinicians should think more widely when it comes to possible exposure modalities, e.g. pesticides encountered during outdoor recreational activities or contaminated drinking water sources.
A study published in JAMA Network Open investigated whether Parkinson’s disease diagnosis is more common in people who live near golf courses, due to pesticide contamination of water sources. The results suggest that living near a golf course may increase the chance of developing Parkinson’s disease; the odds of participants being diagnosed with Parkinson’s disease reduced by 9% for every mile (1.6 km) further they resided from a golf course. Furthermore, participants whose residential water source was in the vicinity of a golf course were twice as likely to be diagnosed with Parkinson’s disease compared to those whose water came from areas without a golf course. While correlation does not equal causation, these results warrant a wider discussion about the importance of thinking outside the box when it comes to Parkinson’s disease and asking about the potential for any chronic chemical exposures from any source.
Do you consider a history of chemical exposures when a patient presents with symptoms and signs suggestive of Parkinson’s disease to strengthen the potential diagnosis? Are there any particular jobs, activities or chemical exposures that stand out to you as clear risk factors for Parkinson’s disease?
Read more
- This United States-based case-control study identified 419 participants with Parkinson’s disease (median age 73 years; 61% male) and more than 5,000 controls, using the Rochester Epidemiology Project database (median age 72 years; 69% male)
- Controls were matched to Parkinson’s disease cases by age and sex at the date of symptom onset
- The risk of Parkinson’s disease was greatest for people who lived within three miles (4.8 km) of a golf course, and decreased with every mile (1.6 km) further away thereafter
- After three miles, the odds of Parkinson’s disease diagnosis reduced by 13% (odds ratio [OR] = 0.87; 95% confidence interval [CI] = 0.77 – 0.98)
- Overall, linear modelling demonstrated an odds reduction of 9% (OR = 0.91; 95% CI = 0.85 – 0.98) for every one mile away from a golf course up to 18 miles (29 km)
- As a comparison, the authors calculated that living within one mile of a golf course was associated with 126% increased odds of Parkinson’s disease compared to living more than six miles (9.7 km) away
- The odds of being diagnosed with Parkinson’s disease were twice as high for participants with a tap water source from an area that included a golf course near their groundwater service areas, compared to areas without golf courses (OR = 1.96; 95% CI = 1.20 – 3.23), and 49% higher than participants with private wells (OR = 1.49; 95% CI = 1.05 – 2.13)
- The association between proximity to a golf course and diagnosis of Parkinson’s disease was still observed when the results were adjusted for water-source vulnerability, suggesting there may also be a risk of airborne pesticide exposure
- Participant occupational history and data on other confounders (e.g. traumatic brain injury, family history) was not available and may have influenced the results
- The types of chemicals used, and the quantity of pesticides sprayed in this study may not be applicable to New Zealand
Krzyzanowski B, Mullan AF, Dorsey ER, et al. Proximity to golf courses and risk of Parkinson Disease. JAMA Netw Open 2025;8:e259198. doi:10.1001/jamanetworkopen.2025.9198.
For further information on the management of Parkinson’s disease in primary care, see: https://bpac.org.nz/BPJ/2014/February/parkinsons.aspx (published in 2014; some content may be no longer be current)
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