Published: 27th June, 2025
Contents
New from bpacnz: The immediate management of patients with acute coronary syndrome
Most patients who present to primary care with chest pain are unlikely to be experiencing acute coronary syndrome (ACS). However, the consequences of missing ACS are significant, therefore, chest pain should always be considered as if it is an emergency, until another cause can be established. If symptoms and signs consistent with ACS are identified, urgently refer the patient for acute cardiology assessment and initiate management in primary care, where possible, while awaiting ambulance transfer. This includes pain relief (usually with sublingual GTN initially), aspirin (even if taking regular low dose aspirin) and oxygen if the patient is hypoxic or has signs of heart failure or cardiogenic shock.
If there will be a significant delay in reaching hospital, it may be appropriate to initiate additional treatment in primary care for some patients depending on the type of ACS and medicines available, e.g. dual antiplatelet treatment, fibrinolysis.
Read the full article here. A B-QuiCK summary is also available.
New search feature for B-QuiCKs
“When you’re in the middle of a consultation and need an answer fast – think B-QuiCK!”
B-QuiCK, which stands for bpacnz Quick Clinical Knowledge, provides short clinical summaries for some of the full articles available on our website. Relevant sections from these resources have been condensed into “notepad pages” or algorithms designed to offer rapid access to practical clinical information, e.g. what to ask, examine, investigate, prescribe and monitor. We regularly add new topics, with the aim of developing a comprehensive quick reference library for primary care clinicians.
You can find all the B-QuiCK topics in one place: save the page on your browser or click the B-QuiCK tile on the bpacnz home page. All topics are initially displayed and arranged by order of publishing. Topics can be filtered by category by clicking on the menu bar at the top. We have now also introduced the ability to search by title: start typing the first few letters of a topic and the list of matches will appear.
N.B. A link to the full article is included at the end of each summary; it is strongly recommended to review the original resource at your convenience for full details of recommendations and evidence.
Pharmac consultation on changes to support increased prescription lengths
Pharmac is seeking feedback on proposed changes to medicines funding rules to support increased prescription lengths. This follows the Government’s recent decision to allow medicines to be prescribed for up to 12 months on a single prescription (the original proposal was reported in Bulletin 110). The proposed changes would be applied from 1st February, 2026, when the amendments to the Medicines Regulations 1984 come into effect, to allow longer prescription lengths. Key changes to the Pharmaceutical Schedule would include aligning funding with the length of the prescription (up to 12 months where appropriate) and that repeats remaining on medicines funded with Special Authority approval would no longer be valid once the approval has expired. Click here to read the full proposal.
Read more
It is proposed that from 1st February, 2026:
- Pharmaceutical Schedule rules would be amended to allow prescribing of up to 12 months’ supply of medicines and other products on a single prescription, however, the decision to prescribe a quantity of medicine for supply longer than three months is at the discretion of the prescriber
- These prescriptions would still be dispensed as monthly, or three monthly repeats (or six-monthly for oral contraceptives)
- Prescriptions for a quantity of medicine of more than three months’ supply can only be dispensed if presented to a pharmacy within three months of the date it was issued
- All repeats must be dispensed within the number of months stated in the amended Medicines Regulations
- The description of the limit on quantities supplied on a single prescription for certain medicines or products would change from an amount per prescription to an amount per period (or similar), however, people would still receive the same quantity of a medicine or other product they currently do
- These limits allow fair allocation of resources, e.g. liraglutide, colecalciferol, insulin pump cartridges
- Limits for specific medicines or other products are not being reviewed as part of this consultation
- Repeats on medicines funded with Special Authority approval would no longer be valid after the Special Authority approval has expired. Currently, these repeats can still be dispensed after the Special Authority approval expiry date.
- A new prescription and Special Authority application would be required
- Some Special Authority approval periods would be extended to allow for the patient to finish treatment before the approval expires
- The need for Special Authority approval periods is not being reviewed as part of this consultation
Consultation closes Friday, 25th July, 2025. This link contains an online form to complete. N.B. Feedback regarding changes to prescription lengths should not be submitted as this decision has already been made by the Government.
ADHD medicines can be initiated in primary care from next year
Pharmac and Medsafe have announced the decision to change the prescriber restrictions for initiating stimulant medicines for ADHD, following consultation (as reported in Bulletin 115). This means that both the initiation and ongoing prescribing of stimulant medicines could be managed in primary care for adult patients, with clinicians seeking specialist advice if required.
From 1st February, 2026, methylphenidate, dexamfetamine and lisdexamfetamine will be able to be prescribed to:
- Patients aged 18 years and over by medical practitioners with a vocational scope of practice of paediatrics, psychiatry or general practice. Nurse practitioners working within their scope of practice could also initiate prescribing.
- Patients aged 17 years and under by medical practitioners with a vocational scope of practice of paediatrics or psychiatry, or nurse practitioners working within paediatric services or child and adolescent mental health services
The Special Authority criteria for methylphenidate, dexamfetamine and lisdexamfetamine will also be amended to allow application from any relevant practitioner.
These changes were originally proposed to take place from 1st July, 2025, however, the date has been delayed to ensure there is sufficient stock of these medicines available and to allow for training and educational resources to be developed.
Decision to fund Estradot oestradiol patches
Pharmac has announced a decision to fund Estradot as an alternative brand of oestradiol patches, following consultation (as reported in Bulletin 120). From 1st December, 2025, both Estradiol TDP Mylan and Estradot brands of oestradiol patches will be funded without restriction. However, stock may continue to be affected by ongoing global supply issues and people may not always have access to their preferred brand.
Pharmac is asking clinicians to consider prescribing Estradiol TDP Mylan to patients starting treatment or who are already using it without problems, and reserving the Estradot brand for those who need it.
Pharmac is asking pharmacists to consider dispensing Estradiol TDP Mylan, unless Estradot is specifically requested by the patient or prescriber. The dispensing limit of two patches of each strength per week will remain for at least the next 12 months as supply is evaluated. A brand switch fee for Estradiol TDP Mylan will be available from 1st December, 2025, until 28th February, 2026.
For further information on menopausal hormone therapy, see: bpac.org.nz/2019/mht.aspx
Mirena now approved for up to eight years for contraception
The Mirena levonorgestrel intrauterine system is now approved for up to eight years for contraception. The Mirena data sheet has been updated to reflect this. No changes have been made to the licensed duration of use for other indications (heavy menstrual bleeding, endometrial protection in patients taking oestrogen replacement treatment); this remains at up to five years.
N.B. The manufacturer states that for heavy menstrual bleeding, if symptoms have not returned after five years of use, continued use of Mirena may be considered but it should be removed or replaced after eight years at the latest. For endometrial protection during oestrogen replacement treatment, Mirena should be removed or replaced after five years.
For further information on long-acting contraceptives, see: bpac.org.nz/2021/contraception/long-acting.aspx
Melatonin products to be available over the counter
The Government has announced in a Beehive media release that melatonin will be available for purchase from pharmacies for jet lag for people aged 18 years and over and for primary insomnia in people aged 55 years and over. The Gazette notice (official medicine classification notification) for melatonin now includes a Pharmacy Only classification.
Read more
- When supplied in medicines for oral use in immediate release preparations containing 5 mg or less per dose unit for the treatment of jet lag in adults aged 18 or over, containing not more than 10 days’ supply, in the manufacturers original pack that has received consent from the Minister or Director-General for sale as a pharmacy only medicine;
- When supplied in medicines for oral use containing 3 mg or less per immediate release dose unit, or 2 mg or less per modified release dose unit, for the treatment of primary insomnia for adults aged 55 years or older, containing not more than 30 days’ supply, in the manufacturers original pack that has received consent from the Minister or Director-General
Pharmacy sale of melatonin is subject to specific packaging and medicines strength rules, as detailed in the Gazette notice above. There are currently no products that meet these requirements available in New Zealand; it is not known when melatonin will be available to purchase over the counter (as a Pharmacy Only medicine). It is also unclear how correct use and indication for melatonin treatment will be ascertained and monitored.
Currently, melatonin can be supplied by a registered pharmacist (who has completed additional training) without a prescription when used for primary insomnia in adults aged 55 years and over, for up to 13 weeks’ supply, or on prescription from a clinician for any indication.
For further information on melatonin, including evidence of effectiveness, see: bpac.org.nz/2024/melatonin.aspx
For information on the management of insomnia, including the place of melatonin in treatment after trialling non-pharmacological strategies, see: bpac.org.nz/2017/insomnia-1.aspx and bpac.org.nz/2017/insomnia-2.aspx
Psychiatrist granted approval to prescribe psilocybin
It has been announced that one psychiatrist has been granted approval to prescribe medicinal psilocybin (unapproved medicine; not funded) for patients with treatment-resistant depression in New Zealand. This was also announced in a recent Beehive media release. Psilocybin is a psychoactive chemical found in certain species of mushrooms and is classified as a Class A controlled drug. It has previously been used in clinical trials in New Zealand, but this will be the first time that it will be prescribed therapeutically in this country. This change aligns with Australia, where psilocybin can be prescribed by authorised clinicians for treatment-resistant depression.
The psychiatrist, who has experience with this medicine in the context of clinical trials, can prescribe, supply and administer medicinal psilocybin to any patient they have assessed and diagnosed with treatment-resistant depression, and there will be safeguard processes and procedures in place.
There will be a process for other healthcare professionals who wish to prescribe medicinal psilocybin to apply for approval from Medsafe; guidance is being developed to assist with the application process.
An overview on the use of psilocybin for treatment-resistant depression, published in BJPsych Bulletin, is available here.
Consultation on topical corticosteroid labelling
Medsafe is seeking feedback on a proposal to include warning statements about potency on the medicine packaging for topical corticosteroids. This would mean that topical corticosteroid products would be labelled as containing a:
- Mild (hydrocortisone); or
- Moderate (clobetasone butyrate and triamcinolone acetonide); or
- Potent (betamethasone valerate and dipropionate, hydrocortisone butyrate, mometasone furoate, methylprednisolone aceponate); or
- Very potent (clobetasol propionate and betamethasone dipropionate) corticosteroid
Consultation closes Monday, 28th July, 2025. This link contains an online form to complete.
Read more
In March, 2025, the Medicines Adverse Reactions Committee (MARC) noted following a review of the risk of topical corticosteroid withdrawal reactions, that “inappropriate overuse” of topical corticosteroids was common, and that having potency information on packaging labels would be beneficial for patients. Potency labelling on topical corticosteroid packaging was recently introduced in the United Kingdom.
Patients may be prescribed multiple topical corticosteroid products depending on the indication, and these may have different potencies and application instructions. Labelling of potency might help to prevent inappropriate overuse when multiple products are prescribed, e.g. accidental use of more potent products on delicate areas of skin such as the face. It may also make it easier for patients to identify that the product is a topical corticosteroid in the first place, if they are prescribed multiple different skin products.
Acute respiratory infection return-to-work guidance for healthcare professionals
Health New Zealand, Te Whatu Ora, has published guidance for clinical leaders and managers on healthcare professionals’ return to work following acute respiratory infection. The guidance defines acute respiratory infection and associated symptoms, outlines key points for reducing transmission and return to work pathways for healthcare workers post-infection. In general, healthcare professionals are recommended to stay at home when sick, and only return to work once symptoms have resolved, or are mild and improving.
To reduce acute respiratory infection transmission risk, healthcare workers are encouraged to:
- Stay at home when sick, and only return to work once symptoms have resolved or are mild and improving
- Mild symptoms are defined as: no fever in the past 24 hours without antipyretic medicine use, minimal cough/sneeze or runny nose
- Test for COVID-19, influenza A/B and RSV depending on current circulating viruses, the availability of suitable RATs (i.e. that test for these viruses) and local policies
- Testing may be prioritised in high-risk settings, e.g. working with immunocompromised patients
- Wear appropriate PPE (e.g. mask), adhere to infection prevention and control protocols and remain up to date with scheduled and occupational-related vaccinations, e.g. COVID-19, influenza and pertussis
Returning to work after testing positive for COVID-19, influenza or other respiratory infections
The guideline acknowledges that the ability to test is limited by the availability of RAT and PCR testing. The return-to-work pathway for healthcare professionals who test positive for COVID-19, influenza or another respiratory infection is summarised below:
- COVID-19
- Return to work five days after symptom onset or once acute symptoms have resolved. If RATs are available, test daily from day three, and return to work following two consecutive negative results after day four. If the RAT remains positive, return to work from day eight.
- Influenza
- Return to work five days after symptom onset or once acute symptoms have resolved, or 72 hours after commencing antivirals.
- Other respiratory infections
- Follow disease-specific advice
N.B. Healthcare professionals with acute respiratory symptoms but whom do not test should return to work once their symptoms have resolved. An earlier return to work may be considered if there are critical staff shortages, however, this should be done in accordance with local workplace policies and additional precautions taken, where appropriate.
Following their return to work, healthcare workers should wear a well-fitting medical mask until ten days after symptoms first began. If working with high-risk patients, e.g. older, with a disability, use of a P2 or N95 mask should be considered.
Paper of the Week: Raising awareness – antidepressants and postural hypotension in older people
Antidepressants are generally reserved for the treatment of patients with moderate to severe depression. They may also be prescribed off-label for pain or difficulty sleeping. Initiating an antidepressant, such as a selective serotonin reuptake inhibitor (SSRI) or tricyclic antidepressant (TCA) in older patients can be challenging as they may be more likely to experience adverse effects, e.g. hyponatraemia with SSRIs, reduced cardiac conduction with TCAs, constipation with mirtazapine, and require closer monitoring. Postural hypotension is an uncommon but established adverse effect of some antidepressants and older adults are at higher risk due to several factors, e.g. frailty, concomitant antihypertensive medicine use. Postural hypotension can have significant consequences in older adults (e.g. falls, injury, loss of independence) and clinicians must consider this when deciding which treatment option is most appropriate for the patient in front of them.
A study published in the British Journal of General Practice investigated the association between antidepressant medicines and postural hypotension in older adults. The medical records of approximately 2.5 million eligible participants were analysed. Of those who developed postural hypotension during the 18-year study period, approximately half had been prescribed an antidepressant before this diagnosis. An effect was identified for all classes of antidepressants in the first 28 days after initiation, with the largest risk associated with SSRIs. Given the potential consequences of postural hypotension in this population, consider close monitoring when initiating antidepressants in older patients, particularly those who have other risk factors for falls, e.g. frailty, diabetes, Parkinson’s disease.
Do you discuss the risk of postural hypotension when initiating antidepressants in older patients? Are there any specific antidepressants you prefer to prescribe to older patients and if so, why? Do you modify your initial monitoring and follow-up depending on the patient’s age or presence of risk factors?
Read more
- This self-controlled case series was carried out using the IQVIA Medical Research Database (IMRD) which contains health information from more than 18 million people registered to 750 general practices in the United Kingdom (UK)
- Eligible participants were aged 60 years and over and had been registered in the IMRD for at least one year between January, 2000, and December, 2018; approximately 2.5 million people were eligible
- The study outcome was a diagnosis of primary hypotension during the observation period and an exposure was defined as a first prescription for either a SSRI, TCA or other antidepressant (e.g. mirtazapine, venlafaxine) before the diagnosis
- Medicine exposure was examined during the pre-exposure period (90 days before the initial antidepressant prescription), the initiation risk period (1 – 28 days and 29 – 56 days after the initial prescription) and the continuation risk period (57 days after the initial prescription until 30 days after the final prescription), and compared to the reference period, i.e. any time not included in the medicine exposure risk periods
- A total of 41,005 people (51% female) were diagnosed with postural hypotension during the study period, of which 53% (21,868) were prescribed an antidepressant beforehand
- There were 8,899 (22%) people prescribed SSRIs, 8,313 (20%) prescribed TCAs, and 4,656 (11%) prescribed other antidepressants
- The most common SSRI was citalopram (35%), followed by fluoxetine (20%) and sertraline (17%)
- Amitriptyline accounted for 81% of TCAs prescribed
- Other antidepressants prescribed included mirtazapine (64%), venlafaxine (12%) and duloxetine (12%; not available in New Zealand)
- The likelihood of being diagnosed with postural hypotension in the first 28 days after being prescribed an antidepressant increased across all antidepressant classes, however, the risk for SSRIs (incidence risk ratio [IRR] = 4.2; 95% confidence interval [CI] = 3.8 – 4.7) was approximately double that of TCAs (IRR = 2.1; 95% CI = 1.8 – 2.5) and other antidepressants (IRR = 2.2; 95% CI = 1.8 – 2.7)
- The risk of being diagnosed with postural hypotension reduced after 28 days for all classes of antidepressants
- Notably, an increased risk of being diagnosed with postural hypotension was also found in the 90 days prior to being prescribed an antidepressant for both SSRIs and other antidepressants, but not TCAs
- The authors speculated this effect was related to a background risk of underlying depression and was not observed in the TCA group because these medicines are more commonly prescribed for neuropathic pain, migraine and insomnia than depression in the UK
- This was one of the first studies to evaluate postural hypotension as an adverse effect of antidepressants in an older population. It was not, however, powered to analyse differences between specific antidepressants or doses.
- A self-controlled case series assumes the outcome (i.e. the diagnosis of postural hypotension) is reported immediately when it first occurs, however, this process may be delayed in primary care (e.g. wait time for appointments, delayed recognition of symptoms, other conditions masking symptoms) and may influence these results
Bhanu C, Walters K, Orlu M, et al. Antidepressants and risk of postural hypotension: a self-controlled case series study in UK primary care. Br J Gen Pract 2025;:BJGP.2024.0429. doi:10.3399/BJGP.2024.0429.
For further information on the pharmacological management of depression in primary care, see: bpac.org.nz/2021/depression.aspx
This Bulletin is supported by the South Link Education Trust
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