Published: 30th May, 2025
Contents
New from bpacnz – Overcoming gout: from acute resolution to long-term prevention
Gout is highly treatable with regular urate-lowering medicine use, but many people do not seek, or receive, the level of management they require. Often patients are not fully aware of the long-term consequences of untreated gout, and the association with cardiovascular and renal co-morbidities. Beyond the acute treatment of flares, primary healthcare professionals can help establish strategies for long-term prevention. Urate-lowering medicines should be considered and discussed with all patients with gout from the first presentation, even if not immediately prescribed. The key for urate-lowering treatment is to ensure that the dose is titrated to the level that achieves serum urate levels consistently below target, while balancing adverse effects. Allopurinol is first line, but other treatments can be added or used alternatively, if targets are not achieved.
This is a revision of a previously published article and includes a general update (plus addition of 2024 New Zealand pharmaceutical dispensing data), and consolidation of the previous two-part article series. Further discussion about the optimal timing of urate-lowering treatment initiation has also been added.
View the full article here. A B-QuiCK summary is also available here.
Information on barriers to successful care is now part of a peer group discussion resource. Numerous factors influence the long-term success of gout care, including patient-, clinician- and system-level barriers. Proactively identifying and addressing barriers within the control of primary care is essential to improving patient outcomes, as is a collaborative approach to care by all members of the primary care team. View the peer group discussion on improving gout care, here.
An updated clinical audit on lowering serum urate levels in patients with gout is also available.
Medicine news: Duolin inhaler, ethosuximide
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.
Duolin HFA inhaler to go out of stock again
Salbutamol with ipratropium bromide inhaler (Duolin HFA) is expected to go out of stock from June due to manufacturing delays. Duolin inhalers have previously been affected by ongoing supply issues, which were resolved most recently in March (as briefly reported in Bulletin 118). Re-supply is currently due in October. A salbutamol inhaler (SalAir) and ipratropium bromide inhaler (Atrovent) may be appropriate alternatives; however, two new prescriptions (and pharmacy co-payments) will be required. A patient information sheet is available here.
Ethosuximide brand name change
Pharmac has advised of an upcoming brand name change for ethosuximide 250 mg capsules (Essential Ethosuximide; Section 29), indicated for patients with absence seizures. The new brand, Zarontin (Medsafe approved), will be listed on the Pharmaceutical Schedule from 1st June, 2025, and is expected to be dispensed to patients from June/July. Essential Ethosuximide will be de-listed on 1st December, 2025.
The Zarontin brand was previously funded in New Zealand.* Pharmacists should advise patients taking this medicine that while the product packaging states “New formulation”, this specifically relates to the previously funded Zarontin formulation (orange capsules). The new Zarontin brand is identical to the Essential Ethosuximide brand medicine (clear capsules) and patients should be reassured that there has been no change to the formulation, supplier or manufacturing method. An information sheet is available to give to patients here.
* The previously funded Zarontin brand will be de-listed from the Pharmaceutical Schedule on 1st June, 2025
Proposal to continue supply of Comirnaty COVID-19 vaccines
Pharmac has released a proposal to award Principal Supply Status to the Pfizer brand of COVID-19 vaccine, Comirnaty, from 1st February, 2026, until 30th September, 2027 (with the possibility of extension, up to 30th September, 2029). This would maintain the status quo, i.e. continued supply and funding of the Comirnaty COVID-19 vaccine in New Zealand throughout this period for people who meet eligibility criteria (which are not proposed to change). If the proposal is accepted, a pre-filled syringe presentation (30 micrograms) for adults would also be listed on the Pharmaceutical Schedule (alongside the vial presentation), to make administration more convenient for vaccinators.
The proposal would allow access to a different brand of COVID-19 vaccine for people in whom the Comirnaty vaccine is not clinically suitable, e.g. hypersensitivity to a component within the vaccine, prior experience of myocarditis or pericarditis.
Consultation closes Thursday, 5th June, 2025. This link contains an online form to complete.
In a separate consultation, Pharmac is seeking feedback on a proposal to fully fund enteral nutrition (oral feed 1.5 kcal/mL bottles) for patients with Crohn’s disease in the community from 1st July, 2025. Read more here. Consultation closes Wednesday, 4th June, 2025.
LearnOnline courses are moving: download records before July
The LearnOnline website, provided by the Ministry of Health, Manatū Hauora, is closing down on 30th June, 2025. From 1st July, the free e-Learning modules offered through LearnOnline (e.g. cervical screening using HPV testing, End of Life Choice Act, cultural competency) will move to regional learning sites:
- Ko Awatea Learn (North Island and Nelson Marlborough, except Bay of Plenty)
- healthLearn (South of Nelson Marlborough + Bay of Plenty)
Records of completion of existing courses and any certificates on LearnOnline will not be transferred and so must be downloaded prior to 30th June if you wish to have a copy. To download your record of learning, log in and click on the tab “Verified Record of Learning” and export the record of completed courses. Any certificates can be downloaded using the “My certificates” tab.
Updated NICE guidelines on falls assessment and prevention
Falls are common in older people and can result in considerable morbidity. The National Institute for Health and Care Excellence (NICE) recently updated its guidance on falls: assessment and prevention in older people and in people aged 50 years and over at higher risk. Key points for falls reduction interventions are consistent with guidance followed in New Zealand:
Read more
- Medicines review
- Identify any medicines that may increase the patient’s falls risk, particularly psychotropic medicines; adjust medicines as needed to reduce falls risk
- Vitamin D supplementation
- There is insufficient evidence that vitamin D supplementation lowers falls risk; patients should be supplemented with vitamin D based on their risk of deficiency (see: “Vitamin D supplementation: an update” for further information)
- Home hazard assessment and modification
- Consider a home safety assessment and organise modifications if needed; this is best provided by an occupational therapist
- Vision assessment and correction, if needed
- Strength/balance training or referral to a community falls prevention exercise programme. Cognitive behavioural interventions can also be considered for patients who have concerns about falling despite trialling strength and balance exercises.
Do you know about Nymbl? Nymbl is a free app that is part of the ACC Live Stronger for Longer programme. Patients use a combination of exercise and cognitive behavioural training to improve balance and decrease falls risk. The app is intended for people aged over 50 years, to be used regularly for short durations, e.g. ten minutes/day for a few days per week. Consider whether there are any older patients in your practice who might benefit from using Nymbl.
Coeliac Awareness Week coming up
Coeliac Awareness Week runs from Monday, 9th June to Sunday, 15th June. The theme for this year is “Coeliac disease is different for every body”. Coeliac disease is still often underdiagnosed due the varied range of non-specific symptoms and signs that may occur. People can have “classic” gastrointestinal symptoms such as diarrhoea, constipation, nausea, vomiting, bloating and cramping, or other features such as faltering growth, short stature and delayed puberty in children, recurrent miscarriage, muscle and joint pain, headache or skin conditions, e.g. dermatitis herpetiformis. Some people are asymptomatic but may have underlying intestinal damage resulting in nutritional deficiencies as a result of malabsorption.
Coeliac Awareness Week provides an opportunity for clinicians to refresh their knowledge about the condition and to consider whether they are testing appropriately. In addition to investigating a patient with possible symptoms of coeliac disease, testing is also recommended in those at increased risk, e.g. strong family history or an associated condition such as type 1 diabetes, autoimmune thyroid disease or unexplained infertility.
For patients with known coeliac disease, this is a chance to check how they are managing with a gluten-free diet and whether they have any new or persistent symptoms that require further investigation.
For further information on the investigation and management of coeliac disease in primary care, click here. A checklist, developed by Coeliac New Zealand, for primary care clinicians on managing patients with coeliac disease is also available here.
Upcoming Goodfellow Unit webinars
The Goodfellow Unit, University of Auckland, is hosting several free access webinars in June. These webinars are intended to provide topical and relevant health information for primary care clinicians. Continuing professional development (CPD) points are also available. Webinars are often recorded and available to watch at a later date. Upcoming webinars include:
A webinar on pre-conception consultations and preventing pre-term birth was recently held on Tuesday, 27th May. If you missed it, view a recording of the webinar here.
Medical Factorium: Why is gout called gout?
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: Gout has been called the “disease of kings”, among other names, but where does the term “gout” actually come from?
Read more
Gout is an inflammatory response to the accumulation of monosodium urate crystals in the joints. It has been recognised in some form for thousands of years; evidence of uric acid crystals (renal calculi and tophi) has been identified in Egyptian mummies from 4,000 – 7,000 years ago.1, 2 Hippocrates described gout as “the unwalkable disease” resulting from overindulgence in rich foods and alcohol. He used the term “podagra” (meaning “foot trap”), to describe gout symptoms at the first metatarsophalangeal joint. Podagra was considered an “arthritis of the rich” as opposed to rheumatism, an “arthritis of the poor”.1–3 This association with wealth and aristocracy also led to the term “disease of kings”.3 Gout may have even been considered socially desirable at some stages in history, given its prevalence in the upper echelons of society.3
It is not clear when or why the term podagra fell out of favour but the term we use today, gout, can be traced back to the Latin word “gutta” (meaning drop).3 Gutta was first used at some point between the 11th and 13th centuries to describe how an excess of one of the four humors (bodily fluids, i.e. black bile, yellow bile, blood and phlegm) would flow or drop into the affected joint causing the characteristic symptoms.2–4 The connection between elevated urate levels in the blood and gout was not identified until the 1900’s.2 Nowadays, the association between gout and overconsumption of purine-rich food and alcohol is still prominent but diet is generally considered to be a trigger for gout flares, rather than the root cause. Genetic predisposition and renal impairment are thought to play a far greater role in gout development for most people.
References
- MacKenzie CR. Gout and hyperuricemia: an historical perspective. Curr Treat Options in Rheum 2015;1:119–30.doi:10.1007/s40674-015-0012-9.
- Bhattacharjee S. A brief history of gout. Int J of Rheum Dis 2009;12:61–3. doi:10.1111/j.1756-185X.2009.01381.x.
- Nuki G, Simkin PA. A concise history of gout and hyperuricemia and their treatment. Arthritis Res Ther 2006;8:S1. doi:10.1186/ar1906.
- Galassi FM, Ingaliso L, Papa V, et al. On the early uses of the word ‘gout’: novel evidence and a critical assessment of the published literature. Reumatismo 2024;76. doi:10.4081/reumatismo.2024.1704.
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
Paper of the Week: “Doc… I can’t sleep” – Could it be the medicines?
Sleep disturbances affect most people at some stage in their lives and this is a common reason for primary care consultations. As such, the discussions and investigations involved in this consultation are well established and factors that impact sleep are widely understood, e.g. sleep hygiene, proximity of exercise/meals to bedtime, alcohol consumption. However, perhaps less often considered is the association between medicines and disturbed sleep, e.g. beta blockers. When prescribing medicines to treat one condition, it can sometimes be difficult to weigh this up against the unintended consequences for another aspect of the patient’s wellbeing.
A study published in Mayo Clinic Proceedings reviewed the effects of medicines commonly prescribed in primary care on sleep. The authors evaluated antihypertensives, statins, antidepressants, levothyroxine, proton pump inhibitors, metformin and phosphodiesterase (PDE) type-5 inhibitors. Beta blockers and PDE-5 inhibitors were associated with sleep disturbances, with the latter effect relating specifically to individuals with obstructive sleep apnoea. Antidepressants are well known to affect sleep, however, there is variation in the adverse effect profiles of individual medicines which complicates prescribing, e.g. bupropion can cause insomnia whereas mirtazapine may cause sedation. In contrast, diuretics may improve sleep for patients with obstructive sleep apnoea (by reducing fluid retention), but this must be balanced against nocturia causing possible sleep disruption. Clinicians should review medicine use in patients presenting with sleep disturbance and use clinical judgement when determining whether the therapeutic need outweighs the potential for sleep disturbance.
What predisposing factors do you commonly identify in patients who present with disturbed sleep? Do you regularly consider prescription medicines as a cause of sleep disturbances? In your experience, are there any medicines commonly prescribed in primary care that patients report sleep disturbances with when taking?
Read more
- Beta blockers (no longer considered first-line for hypertension in New Zealand, but classified as antihypertensives in this study) are the antihypertensive most frequently associated with sleep disturbances and have been linked to increased fatigue and somnolence
- Beta blockers that cross the blood brain barrier (lipid soluble, e.g. metoprolol) are implicated in the development of nightmares – switching patients to atenolol (low lipid solubility) may be appropriate if these effects are not tolerable
- Diuretics reduce overall body fluid volume and may reduce the impact of airway resistance on ventilation in people with obstructive sleep apnoea. However, taking diuretics at night may negatively affect sleep due to nocturia.
- Statins have occasionally been associated with adverse sleep effects, e.g. nightmares, insomnia (< 2% of total adverse events)
- Antidepressants as a medicine class are associated with a range of sleep-related adverse effects (e.g. somnolence, sedation, insomnia), but the specific adverse effect profile varies between individual medicines. Given the association between sleep disturbance and anxiety and depression, an antidepressant’s adverse effect profile should be considered when deciding on the most appropriate treatment, e.g. choosing mirtazapine over fluoxetine for patients with insomnia.
- The extent of sleep-related adverse effects is dose dependent for some antidepressants, e.g. the risk of somnolence increases linearly with dose for fluoxetine and sertraline
- Some antidepressants may worsen restless leg syndrome, e.g. venlafaxine, mirtazapine
- Levothyroxine is not associated with sleep-related adverse events, even at higher doses (despite insomnia being an established symptom of hyperthyroidism)
- Taking levothyroxine in the evening may actually improve thyroid hormone management
- Proton pump inhibitors (e.g. omeprazole) reduce reflux symptoms and may improve sleep quality in people who experience reflux symptoms overnight
- Sleep disturbances directly relating to PDE-5 inhibitors are rare. However, erectile dysfunction is common in people with obstructive sleep apnoea, and PDE-5 inhibitors have been shown to worsen obstructive sleep apnoea, reducing sleep quality.
- Sleep disturbances such as poor sleep quality and insufficient sleep are risk factors for insulin resistance. The effect of metformin on metabolism may promote improved sleep in people with conditions relating to insulin resistance (e.g. type 2 diabetes, polycystic ovary syndrome), however, the evidence to support this is mixed.
Klugherz LJ, Mansukhani MP, Kolla BP. Effects of commonly prescribed medications on sleep: a review of the literature. Mayo Clin Proc 2025;100:856–67. doi:10.1016/j.mayocp.2025.02.005.
For further information on managing sleep disturbances in primary care, see: https://bpac.org.nz/2017/insomnia-1.aspx and https://bpac.org.nz/2017/insomnia-2.aspx
This Bulletin is supported by the South Link Education Trust
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