Key symptoms and signs that may suggest bowel cancer include rectal bleeding, changes in bowel habit, weight loss and iron deficiency anaemia. Age and family history also influence the likelihood of cancer. Referral criteria for further investigations and urgency of referral are dependent on a combination of these factors. Asymptomatic patients with a family history of bowel cancer indicating moderate to high risk can also be offered direct access to surveillance colonoscopy.

The introduction of bowel cancer screening in New Zealand in 2017 has led to an increase in the number of people diagnosed with early stage bowel cancer, which is associated with a significant survival benefit. People aged 60 – 74 years (who are not already part of a high-risk surveillance bowel screening programme) are currently eligible for funded bowel cancer screening every two years using the faecal immunohistochemical test (FIT). The eligibility age is being lowered (as reported in Bulletin 118) within the next year from age 60 to 58 years for all people.

Supply issues affecting oxycodone immediate-release tablets have been ongoing for some time. Pharmac had announced that 5 mg oxycodone immediate-release tablets were out of stock and supply issues were still affecting 10 mg and 20 mg immediate-release tablets (as last reported in Bulletin 123). Re-supply of the 5 mg and 20 mg tablets has now arrived but may take some time to reach pharmacies; 10 mg tablets are still expected by the end of June. Supply of oxycodone 1 mg/mL oral liquid is also reportedly constrained. Clinicians are being asked to consider prescribing an alternative analgesic.

Alendronic acid + colecalciferol (Fosamax Plus) is now out of stock at the supplier. Re-supply has been delayed and is currently expected by the end of July. As reported in Bulletin 123, 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.

Stock of nicotine (Habitrol) 1 mg and 2 mg lozenges is limited. Re-supply is currently expected mid-July. Habitrol nicotine gum is available, however, patients will need a new prescription. Clinicians could also consider prescribing an alternative form of nicotine-replacement treatment, e.g. patches, or other smoking cessation options, e.g. varenicline. N.B. This supply issue only affects pharmacy dispensing stock.

For further information on nicotine-replacement treatment, see: bpac.org.nz/2024/smoking.aspx

Some cardiovascular medicines that are used in specific patient groups are currently affected by supply issues. These medicines are less commonly prescribed by primary care clinicians.

Labetalol 100 mg and 200 mg tablets (Trandate) are no longer being supplied to New Zealand. Existing stocks are expected to be exhausted by the end of June (100 mg tablets) and September (200 mg tablets). An alternative brand of 100 mg tablets (Biocon) is being temporarily listed on the Pharmaceutical Schedule from 1^st July, however, this brand is not Medsafe approved and so will need to be prescribed for supply under Section 29 of the Medicines Act 1981. A patient information sheet is available here.

Sotalol 80 mg tablets are out of stock due to manufacturing delays. Re-supply is currently expected by July. An alternative product was listed on the Pharmaceutical Schedule from 1^st June, 2025, however, it is not Medsafe approved and so will need to be prescribed for supply under Section 29 of the Medicines Act 1981.

The funded brand of clomipramine 25 mg tablets is changing from Teva to Apo-Clomipramine (previously funded from 2013 to 2022). Apo-Clomipramine has been listed on the Pharmaceutical Schedule since 1^st February, 2025, and will be the only funded brand available from July, 2025.

Advise patients taking clomipramine 25 mg tablets that their brand is changing and that the packaging will look different. The tablets will come in a larger pack size (50 rather than 30), will be pale yellow in colour and have “25” engraved on them. Reassure patients that there has been no change to the active ingredient.

Naltrexone + bupropion (Contrave; not funded), a medicine prescribed for weight management, is associated with a range of safety issues, including psychiatric symptoms (e.g. mania, panic attacks, suicidal events), seizures and cardiovascular effects (e.g. increased blood pressure and heart rate). Serious effects have also been observed with concurrent use of opioids, serotonergic medicines and medicines which inhibit or induce CYP2B6. Read more here.

Patients taking GLP-1 receptor agonists, e.g. dulaglutide, liraglutide, semaglutide (not funded; available from 1^st July), commonly experience vomiting and diarrhoea in the early stages of treatment. This can lead to dehydration and renal impairment. Inform patients of these potential effects; advise them to drink adequate fluids and to seek medical attention if symptoms are severe or persistent. Patients should follow their “sick day” plan, e.g. it may be appropriate to delay dose administration if acute symptoms are present.

Prescribers should consider delaying up-titration of the dose or lowering the dose if severe gastrointestinal symptoms occur. Read the full article here.

Hepatotoxicity is a known adverse effect of long-term use of nitrofurantoin, however, hepatic effects have now also been reported with short-term use. Severe hepatic reactions associated with nitrofurantoin include hepatitis, cholestatic jaundice (more common with short-term use), chronic active hepatitis (more common with long-term use), hepatic necrosis and autoimmune hepatitis. The nitrofurantoin data sheet will be updated to reflect this risk.

Advise patients taking nitrofurantoin about this potential risk and to seek medical attention if they experience symptoms or signs of potential hepatotoxicity, such as yellowing skin or eyes, upper right quadrant abdominal pain, dark urine, pale or grey coloured stools. Read the full article here.

A case of peripheral neuropathy associated with a vitamin B6-containing supplement was recently reported to the New Zealand Pharmacovigilance database. Several cases have also been reported in Australia, which has led to regulatory action.

Vitamin B6 is present in a range of supplements including multivitamin and mineral preparations, often in combination with magnesium or zinc. The risk of peripheral neuropathy is highest with long-term use of high doses, however, it has also been reported with long-term use of low doses. If a patient presents with symptoms or signs of peripheral neuropathy, e.g. paraesthesia, weakness, diminished reflexes, ask about any supplement use as the potential cause. Read more here.

The first case of BRASH syndrome (bradycardia, renal failure, atrioventricular nodal blockade, shock and hyperkalaemia) was recently reported to the New Zealand Pharmacovigilance database. It was associated with concurrent propranolol and diltiazem use. Medsafe is encouraging clinicians to report any additional cases.

Profound bradycardia occurs in BRASH syndrome due to the synergistic effects of medicines that block the AV node alongside hyperkalaemia. Decreased cardiac output then leads to reduced renal dysfunction which, in turn, exacerbates hyperkalaemia. This cycle can progress to multiorgan failure. Calcium channel blockers and beta blockers (in particular, those renally excreted, e.g. atenolol) are most often associated with BRASH syndrome as they slow AV node conduction. Other medicines that may be associated include ACE inhibitors, ARBs, spironolactone, digoxin and amiodarone, as these can cause acute kidney injury, hyperkalaemia and reduce cardiac output. Consider the possibility of BRASH syndrome in patients presenting with bradycardia and/or hyperkalaemia and who are taking medicines that block the AV node. Read more here.

An Australian-based study published in the New England Journal of Medicine (not open access), assessed whether treatment of BV-associated organisms in the male partner influenced the rate of BV recurrence in the female partner. A total of 164 heterosexual couples who were in a monogamous relationship where the female partner had BV participated in the study. There were two groups: partner-treatment (81 couples) and the control (83 couples). In the partner-treatment group, females were treated with oral metronidazole 400 mg tablets, twice daily for seven days (or if contraindicated, clindamycin 2% intravaginal cream for seven nights [not available in New Zealand] or metronidazole 0.75% intravaginal gel for five nights [not funded]), and the male partners were treated with oral metronidazole (400 mg tablets, twice daily for seven days) and 2% clindamycin cream (twice daily for seven days; applied to the penile skin; cream not available in New Zealand). In the control group, the females received first-line treatment (as above) and the male partner received no treatment (standard care).

The trial was stopped early (150 couples had completed the 12 week follow-up) as treating only the female partner was shown to be inferior at lowering recurrence of BV compared to treating both partners. Recurrence of BV within 12 weeks occurred in 35% of females in the partner-treated group (recurrence rate 1.6 per person-year; 95% CI: 1.1 – 2.4) and 63% of females in control group (recurrence rate 4.2 per person-year; 95% CI: 3.2 – 5.7); an absolute risk difference of -2.6 recurrences per person-year (95% CI: -4.0 – -1.2, P < 0.001). Adverse effects, e.g. nausea, headache, metallic taste, did not differ substantially between groups; no serious effects were reported.

While these results are promising, it is likely that further studies are needed before this practice becomes routine in New Zealand. In addition, the lack of availability of topical treatment would currently be a barrier, unless males were treated with oral antibiotics alone.

This month, the NZF team highlight the recommendations for vitamin D supplementation during pregnancy and for infants.

Pregnancy

• Offer vitamin D supplementation during pregnancy if the person has one or more of the following risk factors:
• Naturally darker skin tone
• Lives south of Nelson/Marlborough during winter or spring
• Spends limited time outdoors, or has minimal sun exposure due to religious, cultural, personal or medical reasons
• Prescribe 10 – 20 micrograms (400 – 800 IU; one to two drops) of colecalciferol oral liquid per day

Infants

• Offer to prescribe vitamin D to all exclusively or partly breast-fed babies. Supplementation should begin by age four weeks and continue until age one year.
• Prescribe 10 micrograms (400 IU; one drop) of colecalciferol oral liquid per day

For further information, see the NZF monograph on colecalciferol, the NZFC monograph on colecalciferol or section on vitamin D in pregnancy. Also see the bpac^nz article: “Vitamin D supplementation: an update”.

• This Canadian-based randomised controlled trial involved 776 older adults residing in assisted-living facilities with a median age of 88 years (72% female) who were taking at least one antihypertensive medicine, once daily (excluding loop diuretics)
• Rates of co-morbidities among the study population were high; dementia symptoms were reported in 86% of participants, while almost half had diabetes and 40% were diagnosed with coronary artery disease
• Participants were randomised to receive their once-daily antihypertensive medicine at the usual time (typically in the morning; n = 382) or before bed (n = 394)
• Participants in the intervention group could receive their dose at dinner time if bedtime dosing was problematic or not tolerated (rather than returning to morning dosing)
• Once-daily antihypertensive medicines accounted for 89% of total antihypertensive medicines given in the usual treatment group and 92% in the bedtime group
• Dosing times for antihypertensive medicines prescribed more than once-daily did not change
• Participants in the intervention group were taking: calcium channel blockers (43%), ACE inhibitors (37%), ARBs (29%), beta blockers (22%) and diuretics (19%); 60% were taking one of these medicines, 32% were taking two and the remainder were taking three or four
• The primary outcome was time to a composite of all-cause mortality or either hospitalisation or attending the emergency department for acute coronary syndrome, stroke or heart failure
• As well as individual aspects of the overall primary outcome, secondary outcomes included those relevant to an older population, e.g. falls and fractures, changes in cognition, need for hypnotic medicines
• Participants were followed up for a median of 415 days. All-cause mortality in this study population was high (29.7 per 100 patient-years).
• Of the 320 primary outcomes reported (160 in each group), 92% of these were deaths. Overall, there was no statistically significant difference between bedtime dosing or usual care for death or major adverse cardiovascular events, or any other single component of the primary outcome.
• A key limitation in this study was the low rate of adherence to the dosing protocol. Non-adherence was far higher in the bedtime group; two-thirds of participants were not taking their antihypertensive medicines at bedtime compared to 15% in the usual care group.
• According to the authors, the 67% non-adherence rates in the bedtime dosing group was mainly due the doctors and pharmacists who cared for the participants not approving the switch to bedtime dosing. A highlighted example was the reluctance to prescribe diuretics in the evening because of the increased risk of nocturia.
• When narrowing the study population to the assisted-living facilities in which at least 60% of antihypertensive medicines in the bedtime group were administered at night, however, there was still no difference in outcomes observed
• This study was conducted in a population residing in assisted-living facilities and may not be applicable to older adult populations in the community. Medicine administration was also managed by nurses, which limited any changes in adherence over the course of the study.