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Published: 5th September, 2025

Best Practice Bulletin: Issue 131

Contents

New from bpacnz: Recovery at Work podcast

Returning to work after an injury is a key component of the recovery process. However, evidence shows that people in New Zealand are spending increasing time away from the workplace. Early decisions regarding a patient’s capacity for work can influence their long-term outcomes. Clinicians have an important role within this model by performing injury consultations, evaluating work capacity, setting shared expectations and making decisions around medical certification. In fact, ACC statistics show that primary care clinicians complete approximately 45,000 medical certificates per month.

bpacnz is pleased to announce the release of a panel discussion podcast, which is the latest in the series of resources we have published to support clinicians in understanding and applying the ACC Recovery at Work initiative. To prepare for this discussion, we invited a group of primary care specialists (general practitioners, urgent care clinicians, nurse practitioners) to share with us their experiences with the Recovery at Work programme. The podcast is based on their feedback and questions, which we posed to the team from ACC.

“If you have signed your patient off as fit for selected work, it actually doesn't matter what duties are available. That is your medical and clinical opinion of how that person has presented with the injury that they have. That still stands true regardless of what is available out there. And again, they will still get paid regardless. I think that's really important when we're having these challenging conversations, that we really start to bust that myth because we don't want people unnecessarily presenting back to primary care providers just to have a med cert changed. I think we can all agree that that's not very a valuable use of a very busy primary care provider’s time.”

- Merian Graham, Portfolio Manager, ACC

“I can definitely relate to the frustration of not being able to find the right code when you're trying to complete a form. It's a really annoying thing to happen and it feels like it takes up a lot of time sometimes, but those accurate injury codes do help ACC assess claims efficiently and ensure that your patients receive the right support. So, it is really helpful for both your patient and for ACC if you can find the right code. If you can't find it though, I'd say don't panic, choose the best one and add a free text comment with a diagnosis that you can't find the code for, and that will be picked up when the certificate comes through.”

- Dr Maartje Lyons, Clinical Advice Manager, ACC

Listen to the podcast here

Read the comprehensive Recovery at Work guide, here. A B-QuiCK summary, case study quiz and peer group discussion are also available.

Access criteria for COVID-19 antivirals: determine priority by need

bpacnz has prepared a brief resource to support prescribers in determining which patients are suitable for COVID-19 antiviral treatment. Read the article here.

COVID-19 continues to circulate in the community, although at a much lower rate than during the pandemic. Most people with COVID-19 experience mild symptoms that can be managed with supportive care alone. However, some people are at high risk for severe outcomes (i.e. hospitalisation and death) and therefore may be suitable for antiviral treatment.

From 1st September, 2025, the access criteria for funded COVID-19 antivirals for people aged 50 – 64 years were amended to include all people aged 50 years and over with COVID-19 who are considered by their healthcare professional to be at high risk of hospitalisation or death from COVID-19 (as reported in Bulletin 130). Healthcare professionals can use their clinical judgement, including knowledge of COVID-19 epidemiology and risk factors, to prescribe COVID-19 antivirals to patients aged ≥ 50 years based on need. This may include consideration of the patient’s medical, personal and/or social factors and circumstances, such as ethnicity and access to healthcare, e.g. social or geographical isolation, lack of transport, unreliable phone or internet connection, housing issues.

People aged 65 years and over remain eligible for funded COVID-19 antiviral treatment based on age alone. People of any age can also access funded COVID-19 antivirals if they meet other criteria, e.g. if they are immunocompromised, have previously required care in the intensive care or high dependency unit for COVID-19, people with a disability or severe vulnerability due to medical conditions or a combination of risk factors.

To read more details about these groups, including independent factors that increase risk of severe outcomes from COVID-19, click here.

Coming soon: The appropriate use of COVID-19 antivirals in a primary care setting

A more comprehensive article about prescribing oral antivirals for patients with COVID-19 is currently in development by bpacnz and will include information about dosing, medicine interactions, adverse effects and effectiveness.

In case you missed it: Lead exposure and toxicity associated with Ayurvedic medicines

circle image Ayurveda is one of the earliest forms of traditional medicine and it is still practiced by many people today. At the end of 2023, New Zealand monitoring agencies became aware of a cluster of people with dangerously elevated blood lead levels, linked to the use of Ayurvedic medicines. Many of the people affected were symptomatic and some required chelation treatment. Ayurvedic medicines are unregulated in New Zealand, and the symptoms of lead toxicity are non-specific, therefore primary care clinicians need to be aware of the risk in patients who use these products, and investigate as appropriate.

Read the full article here

Medicine news: Liraglutide, Flixotide Accuhaler, Fosamax Plus, macrogol, labetalol

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.

COVID-19 vaccine ongoing supply secured and access to be widened

It has been confirmed that Comirnaty (Pfizer) will remain the funded brand of COVID-19 vaccines in New Zealand until at least 2027. Pharmac has awarded Principal Supply Status to Pfizer following consultation on this decision (as reported in Bulletin 124). Comirnaty will be the principal funded brand of COVID-19 vaccine from 1st February, 2026 – 30th September, 2027 (with the possibility of extension, up to 30th September, 2029). A pre-filled syringe presentation (30 micrograms) for adults will also be listed on the Pharmaceutical Schedule from 1st February, 2026 (alongside the vial presentations), to make administration more convenient for vaccinators.

Also from 1st February, 2026, eligibility criteria for the 3 microgram and 10 microgram COVID-19 vaccine will be widened, so that children aged under 12 years who are severely immunocompromised or at high risk of severe illness will be eligible to receive an additional dose every six or 12 months. Pharmac has also clarified that people aged 12 – 29 years who are severely immunocompromised or at high risk of serious illness will be eligible for an additional dose every six months with the most current variant-matched vaccine.

Proposal to widen access to ticagrelor

Pharmac has released a proposal to widen access to ticagrelor for patients with minor stroke or high-risk transient ischaemic attack (TIA) when clopidogrel is not clinically appropriate. This proposal comes following the discontinuation of dipyridamole long-acting 150 mg tablets (most recently reported in Bulletin 130) which are sometimes prescribed for patients following a stroke if other antiplatelets, e.g. clopidogrel, are unsuitable. Ticagrelor is currently funded with Special Authority approval for use in patients for thrombosis prevention following neurological stenting, percutaneous coronary intervention with stent deployment and post-ACS.

It is proposed that Special Authority for ticagrelor will be widened from 1st November, 2025, to include patients with a minor stroke or high-risk TIA (based on clinical scores) who have an allergy to, or are not expected to respond well to, clopidogrel; to be prescribed for a maximum of 21 days. For full proposed criteria, click here. Any relevant practitioner could apply for Special Authority and approvals would be valid for one month.

Consultation closes 5 pm, Wednesday, 17th September. Feedback can be emailed directly to: consult@pharmac.govt.nz.

NZF updates for September

Significant changes to the NZF in the September, 2025, release include:

  • Cautions have been updated for dulaglutide and liraglutide (minor wording changes and link added to Prescriber Update article on dehydration with GLP-1 receptor agonists). The contraindications for liraglutide have also been updated to align with other GLP-1 receptor agonists.
  • General revision of all sections in the therapeutic notes for gout
  • Warts have been added as an indication to the salicylic acid (topical) monograph. Contraindications, cautions, adverse effects and patient advice have also been updated for topical salicylic acid.
    • The therapeutic notes for warts and calluses, including anogenital warts, have also undergone a general revision
  • An alternative brand and strength of dipyridamole has been listed. This product is temporarily available prior to the discontinuation of dipyridamole; see Bulletin 130 for details.
  • Giant cell arteritis has been added as an indication for upadacitinib. Diabetes has also been added as a caution.
  • Concomitant administration with sodium fusidate (systemic) has been added as a contraindication to statins: atorvastatin, pravastatin sodium, simvastatin, ezetimibe + simvastatin, rosuvastatin

You can read about all the changes in the September release, here. Also read about any significant changes to the NZF for Children (NZFC), here.

Latest edition of Prescriber Update released: including safety of ADHD medicines

The September edition of Prescriber Update has been published. A particular item of interest for primary care is the safety of medicines used to treat ADHD in adults, e.g. lisdexamfetamine, methylphenidate, atomoxetine. Clinicians are asked to consider psychiatric effects (e.g. worsening of co-morbid psychiatric conditions), cardiovascular effects (e.g. increase in blood pressure or heart rate) and seizure risk when prescribing these medicines. There was an increase in the number of adverse reactions associated with ADHD medicines reported to CARM in 2024, and this is likely to continue to increase when prescriber restrictions for stimulant medicines change to allow initiation in primary care from February, 2026, resulting in more people taking these medicines. Read the full article here.

Other relevant items include a safety reminder on the use of systemic fluoroquinolone antibiotics, systemic retinoids and diffuse idiopathic skeletal hyperostosis (DISH) and medicine-induced Pisa syndrome.

View the full edition here

National STI surveillance report: Chlamydia most prevalent, syphilis on the rise

The New Zealand Institute for Public Health and Forensic Science (PHF Science; formerly known as ESR) has released the 2024 annual sexually transmitted infection (STI) surveillance report. Syphilis infections in 2024 increased by approximately 5% from the previous year to 774 cases. The highest number of cases were among men who have sex with men (MSM) and people aged 30 years and over. Chlamydia infections decreased by approximately 2% in 2024 compared to 2023, but it remains the most prevalent STI in New Zealand, with 27,691 reported cases (predominantly female). The number of reported gonorrhoea infections also decreased slightly from the previous year by around 3%, with a total of 7,582 cases, with the highest rates among MSM.

Prioritise opportunistic sexual health discussions and STI screening among at-risk patient groups. A sexual health audit may be an effective strategy to increase awareness in your practice about STI screening. The bpacnz sexual health checks in younger males audit provides a structured plan and can also be customised for different demographic groups.

Read the full report here. An online dashboard is also available.

Reminders in brief: Community Referred Radiology criteria, Bexsero access, breast screening age extension

From 1st September, 2025:

  • Mandatory national criteria for Community Referred Radiology apply; see Bulletin 129 and local HealthPathways for further information. Criteria are available here. A webinar on navigating the new radiology programme is being held by the Goodfellow Unit this month; see next item for details.
  • Access to the meningococcal B vaccine (Bexsero) has been widened to include all children aged under five years. This means they can complete the full meningococcal B vaccination course if it was not done within the first 12 months of life. See Bulletin 129 for further information. Eligibility criteria for funded meningococcal B vaccination for older children and adults at high risk remain the same.

Extension of breast screening age applies from next month. Females aged between 45 and 69 years are currently eligible for free mammogram screening every two years. This age range is being progressively extended to females aged 70 – 74 years, as reported in Bulletin 120. This change has already occurred in Nelson-Marlborough; the rest of the country is expected to transition over the next four years, starting from October, 2025.

From 1st October, 2025:

  • Females who turn age 70 years on or after 1st October, 2025, are eligible for free mammogram screening every two years from their last screen until they turn age 75 years
  • Females aged 70 – 74 years before 1st October, 2025, are eligible for one final mammogram screen at age 74 (if booked before turning age 75 years)

Upcoming webinars

The Goodfellow Unit, University of Auckland, is hosting several free access webinars in September. 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:

The Immunisation Advisory Centre (IMAC) is hosting an upcoming webinar on measles and MMR vaccinations. This free webinar is expected to cover the effect of measles on the immune system, MMR vaccine eligibility, including dose zero information, and a review of resources and practical information. The webinar will be held on Thursday, 18th September, from 12.30 pm. Click here to register.

Podcast of the Week: Shin splints

Increasing physical activity is a core component of lifestyle advice and likely features in multiple conversations during a day in a general practice clinic. However, what happens when the “cure” becomes the problem? An increase in exercise in a previously sedentary person, or sustained exercise in people who are highly active, can sometimes result in stress-related musculoskeletal injury.

A recent episode of GPnotebook, a clinical education platform in the United Kingdom for primary care clinicians, discusses the epidemiology, diagnosis and management of shin splints.

Shin splints, also known as medial tibial stress syndrome (MTSS), is a common type of leg tenderness and pain caused by repetitive stress on the bones and muscles around the tibia. It is often triggered by running, jumping, or high impact sports, but causes can be multifactorial and related to biomechanical abnormalities. The outlook for patients with shin splints is generally positive with early recognition and management, e.g. rest and modifying exposure to contributory factors.

Listen to the podcast here (15 minutes)

Paper of the Week: Aspirin for primary prevention in older adults – has the message changed?

The use of aspirin for primary prevention is contentious at the best of times. The Cardiovascular Disease Risk Assessment and Management for Primary Care consensus statement, published in 2018, remains the most recent guidance in New Zealand, and recommends against prescribing low-dose aspirin for the primary prevention of cardiovascular disease (CVD) events in patients aged over 70 years. This recommendation, which reflects international guidelines, is supported by the results of a secondary analysis of the 2018 ASPirin in Reducing Events in the Elderly (ASPREE) trial, that identified an increased risk of bleeding events in patients aged over 70 years prescribed aspirin for primary prevention, without any reduction in major adverse cardiovascular events (MACE) over 4.7 years. Use of aspirin for primary prevention in patients aged under 70 years is determined on a case-by-case basis, after considering potential benefits and bleeding risk.

The original ASPREE trial, which examined disability-free survival as a primary endpoint, was terminated early due to a lack of observed benefit with aspirin treatment. A subsequent extension study continued the follow-up of a large proportion of the initial ASPREE trial population to examine outcomes after intervention cessation; the results of which were recently published in the European Heart Journal. Over a median of 8.3 years of combined follow-up, no reduction in MACE incidence was observed in older adults randomised to receive aspirin relative to the placebo group. The rate of bleeding events was also 24% higher in participants who received aspirin, and an increase in MACE incidence following aspirin cessation was also observed.

So, to answer the title question: no, the message has not changed. These results further support the initial ASPREE trial finding that the risks of prescribing aspirin outweigh the potential benefits for older adults. We often discuss practicing-changing evidence, but it is just as important to report findings that reinforce established clinical practice.

Do you prescribe aspirin for primary prevention of cardiovascular events in any of your patients aged over 70 years? Do patients ever express any hesitancy when they are advised to stop taking aspirin? In patients aged under 70 years, what factors make you hesitant to prescribe aspirin for primary prevention?

Wolfe R, Broder JC, Zhou Z, et al. Aspirin, cardiovascular events, and major bleeding in older adults: extended follow-up of the ASPREE trial. Eur Heart J 2025: ehaf514. doi:10.1093/eurheartj/ehaf514.

For further information on the use of aspirin for the management of cardiovascular disease risk, see: https://bpac.org.nz/2018/aspirin.aspx

This Bulletin is supported by the South Link Education Trust

If you have any information you would like us to add to our next bulletin, please email: editor@bpac.org.nz

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