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Published: 3rd October, 2025
Contents
New from bpacnz – Treatment resistant atopic dermatitis in adults and adolescents: a topical issue
Atopic dermatitis typically begins in childhood and often resolves by adolescence, however, for some, it persists into adulthood (or may first develop then) and can significantly impact quality of life. Conventional management of atopic dermatitis with regular emollient use and topical corticosteroids is sufficient to control symptoms for most people. Phototherapy or oral systemic immunosuppressants, e.g. ciclosporin, methotrexate, are the usual next steps when escalation of treatment is required. But if a patient experiences an inadequate response with conventional systemic immunosuppressants, what can primary care prescribers do? What is the next “brick in the wall” of treatment?
Upadacitinib, an oral Janus-kinase inhibitor, is now funded for patients with moderate to severe atopic dermatitis who meet Special Authority criteria. It has a faster onset and a different mechanism of action than many other immunosuppressants used for atopic dermatitis and has demonstrated considerable efficacy in clinical trials. Special Authority applications can be made by any relevant practitioner, providing another option in the community for patients with treatment resistant atopic dermatitis.
This article aims to provide primary care with sufficient information so that upadacitinib can be confidently prescribed in the community. We acknowledge that medicines of this nature have traditionally been initiated by dermatologists and that absorbing additional work such as this creates resourcing pressure for primary care. However, where possible, being able to bridge barriers by facilitating access to dermatology treatments in the community will improve patient outcomes.
Click here to read the full article. A B-QuiCK summary is also available.
Also new this week: Clinical Audit – Reviewing asthma treatment in adolescents and adults
The popular bpacnz clinical audit for asthma has recently been updated. This revision focuses on optimising pharmacological control, ensuring that all adolescent (aged 12 – 17 years) and adult patients with asthma are taking AIR therapy (i.e. budesonide/formoterol) in place of a SABA reliever unless clinical justification exists supporting the continued use of a maintenance ICS with a SABA reliever instead.
Click here to view the audit.
Recovery at Work Certificate of Accreditation – Have you got yours yet?
We now offer a Certificate of Accreditation to eligible participants acknowledging completion of the bpacnz Recovery at Work education module, supported by ACC. This certificate is available to any clinician authorised to issue ACC45 or ACC18 medical certificates for time off work who demonstrates sufficient knowledge and understanding of the ACC medical certification process. This includes reading the Recovery at Work: reframing the conversation article, listening to the Recovery at Work panel discussion podcast and completing the Recovery at Work case study quiz. Ideally, every medical practice will have at least one clinician with a Recovery at Work Certificate of Accreditation. CPD credits are also available!
To check your eligibility and apply for a Recovery at Work Certificate of Accreditation, click here.
Rewind: Wrap-up of recent key messages
Key dates and news items from recent editions of Best Practice Bulletin:
- The eligibility age for bowel cancer screening was lowered from 60 to 58 years for people in the Northern and Te Waipounamu (South Island) regions from October. The remaining two regions will transition to the lower age from March, 2026. See Bulletin 118 for further information.
- The supply agreements for the COVID-19 antiviral nirmatrelvir/ritonavir (Paxlovid) changed on 1st October. Community pharmacies can now order supplier-owned Paxlovid stock and claim in the usual way. Remaining Pharmac-owned Paxlovid stock still can be sourced but will be delisted from the Pharmaceutical Schedule on 1st December, 2025. Pharmac-owned stock cannot be claimed for. Click here for more information.
- The HealthPathways webinar on abnormal uterine bleeding has been postponed. It will now be held on Tuesday, 31st March, 2026, from 7 pm. See Bulletin 132 for further information.
Authorised vaccinators require a standing order to administer adrenaline
Health New Zealand, Te Whatu Ora, has recently clarified that authorised vaccinators do require a prescription or a Standing Order when administering adrenaline for post-vaccination anaphylaxis. Medicines Regulations 1984 (44A) enables non-prescribing registered healthcare professionals to administer vaccines, i.e. vaccinator authorisation. It was previously believed that this regulation also enabled authorised vaccinators to administer adrenaline for post-vaccination anaphylaxis, if required. However, adrenaline is a restricted (pharmacist-only) medicine and a prescription or Standing Order must be issued before non-prescribing registered healthcare professionals (other than pharmacists) can administer it. Review of any previous administration of adrenaline without a prescription or standing order is not expected at this stage.
A standing order template and FAQ sheet explaining the requirements for specific vaccinator roles are available via Dropbox, here.
Alert Communication: New measures and advice to prevent topiramate exposure during pregnancy
Medsafe has issued an Alert Communication that topiramate should not be used during pregnancy unless “absolutely necessary”. This is because of an increased risk of congenital malformations and neurodevelopmental disorders that has been identified in the children of mothers who took topiramate during pregnancy. There is also an increased rate of infants born small for gestational age to mothers who took topiramate during pregnancy. Medsafe has previously issued an Alert Communication regarding the increased risk of neurodevelopmental disorders and birth defects in children exposed in utero to topiramate (as reported in Bulletin 72).
Read more
Children born to mothers who take topiramate during pregnancy are at higher risk of congenital malformations such as craniofacial defects, e.g. cleft lip/palate, hypospadias and other body system anomalies. Higher rates of neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and intellectual disability, were also identified in two observational studies involving children born to mothers who took topiramate for epilepsy during pregnancy. This translated to a two to three times higher risk of neurodevelopmental disorders in children exposed in utero to topiramate compared to children not exposed. However, a third observational study involving more than 1,000 children did not find an association with ASD in a similar population.
An increased number of children born small for gestational age following in utero exposure to topiramate has also been reported. This effect is seen at all doses of topiramate but is more likely with higher doses and when topiramate continues to be taken later in pregnancy.
Medsafe is advising healthcare professionals to take steps to limit patient exposure to topiramate during pregnancy. These include:
- Switching females who are planning pregnancy to an alternative treatment
- Offering a pregnancy test before initiating topiramate in females of child-bearing potential
- Informing patients starting topiramate of the increased risk of fetal harm from topiramate if they become pregnant
- Advising that patients use adequate contraception while taking topiramate and for four weeks after stopping treatment. Also remind patients currently prescribed topiramate of this when issuing repeat prescriptions.
- Re-evaluate the need to continue topiramate annually
- Refer patients who become pregnant while taking topiramate for specialist advice
Letters to healthcare professionals from the sponsors of topiramate in New Zealand, Janssen-Cilag and Teva Pharma, are available.
Medicine news: Capsaicin cream, mesalazine, ezetimibe + simvastatin, Soframycin, podophyllotoxin
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.
Capsaicin cream no longer Section 29
The Section 29 classification has been removed from Capsaicin cream 0.025% (Zo-Rub Osteo) and 0.075% (Zo-Rub HP) as of 1st October, 2025. Authorised prescribers (working within their scope of practice) will now be able to prescribe capsaicin cream to patients who meet funding criteria.
Mesalazine supply issue update and new brand listed
Supply issues affecting stock of mesalazine tablets (Asacol) have been ongoing since 2024. The 400 mg Asacol tablets are currently out of stock (as reported in Bulletin 130) while stock of the 800 mg tablets is low. The 1600 mg tablets (which were listed on the Pharmaceutical Schedule from July, 2025) are not approved by Medsafe so will need to be prescribed for supply under Section 29 of the Medicines Act 1981.
An alternative brand of 400 mg tablets (Octasa) has now been listed on the Pharmaceutical Schedule (from 1st October, 2025). This brand is also not approved by Medsafe so will need to be prescribed under Section 29. Pharmacists should advise patients taking Octasa that it has the same active ingredient as their previous brand but the appearance and packaging of their tablets has changed. N.B. Other oral mesalazine formulations, e.g. 500 mg modified-release tablets (Pentasa), are not generally considered directly interchangeable because of variations in delivery characteristics.
A patient information leaflet about the new brand of mesalazine is available, here.
Ezetimibe + simvastatin supply issue
There is a supply issue affecting ezetimibe 10 mg + simvastatin 10 mg combination tablets (Zimybe) due to manufacturing delays. Re-supply is expected by mid-October. Patients taking ezetimibe 10 mg + simvastatin 10 mg in combination will either need to change to a combination tablet with a different simvastatin strength or alternative medicines, i.e. ezetimibe and simvastatin separately; a new prescription will be required. Other strengths of ezetimibe + simvastatin are not currently affected by this supply issue.
Soframycin back in stock
Pharmac has announced that framycetin sulphate 0.5% ear/eye drops (Soframycin; partly funded) is back in stock with the supplier. The supply issue was the result of increased demand (as reported in Bulletin 128). However, it may take some time to distribute stock to all pharmacies. In the meantime, funded alternatives are available (click here for details), but a new prescription will be required.
Supply issue affecting podophyllotoxin (Condyline)
There is a supply issue affecting stock of podophyllotoxin (Condyline), indicated for the treatment of genital warts, as the recent shipment cannot be released due to a storage issue during shipping. Re-supply is expected in January, 2026.
An alternative product (Section 29) was listed on the Pharmaceutical Schedule from 1st October, 2025, and stock is expected to be available by late October. It is exactly the same product, but the product label is in French; pharmacists are being asked to use a pharmacy generated label to cover the French text. There may be a brief period this month when podophyllotoxin is out of stock. Imiquimod may be a suitable alternative, however, a new prescription will be required.
Proposal to increase access to HIV medicines
Pharmac is seeking feedback on a proposal to remove all funding restrictions and change supply arrangements for antiretroviral medicines used for the prophylaxis and treatment of HIV. From 1st December, 2025:
- All Special Authority and Hospital Indication restrictions which currently apply to antiretroviral medicines for the treatment of HIV would be removed
- The subsidy by endorsement rule that applies when emtricitabine + tenofovir disoproxil is used as part of a HIV treatment regimen would also be removed
- Special Authority restrictions would be removed from antiretroviral medicines for HIV pre- and post-exposure prophylaxis (PrEP and PEP)
As part of this proposal, patients would be able to collect up to three-months supply of antiretroviral medicines at one time* (i.e. stat dispensing would be permitted), and up to 30 tablets each of both emtricitabine + tenofovir disoproxil and dolutegravir, indicated for PEP, would be available on a Practitioner’s Supply Order (PSO), allowing immediate access to treatment.
* Stat dispensing already applies to emtricitabine + tenofovir disoproxil
Consultation closes at 4 pm, Monday, 20th October, 2025. 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.
Proposal to fund medicines for multiple sclerosis, eye conditions, breast and lung cancers
Pharmac is seeking feedback on a proposal to widen access to several medicines from 1st December, 2025. As part of this proposal, any relevant practitioner could apply for Special Authority approval for any of the medicines. The proposal includes funding:
- Ocrelizumab (Ocrevus SC), a new subcutaneous injection for relapsing remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS)
- Pertuzumab and trastuzumab (Phesgo) as a combination subcutaneous injection for HER2-positive metastatic breast cancer
- Faricimab (Vabysmo), an ocular injection, as a second-line treatment option for diabetic macular oedema and wet age-related macular degeneration
- Entrectinib (Rozlytrek), an oral capsule, for ROS1-positive, locally advanced or metastatic non-small cell lung cancer
- The Avastin brand of bevacizumab, an (ocular) injection for patients with ocular neovascularisation or exudative ocular angiopathy. N.B. Bevacizumab is already funded but this proposal would secure access to ongoing supply.
As part of this proposal, access to rituximab (Mabthera) for rheumatoid arthritis and obinutuzumab (Gazyva) for chronic lymphocytic leukaemia and follicular/marginal zone lymphoma would also be widened due to changes in contract arrangements.
Consultation closes 5 pm, Wednesday, 8th October, 2025. This link contains an online form to complete.
NZF updates for October + Bronchiectasis practice highlight
Significant changes to the NZF in the October, 2025, release include:
- General revision of all sections in the therapeutic notes for bronchiectasis (non-cystic fibrosis) – see below
- The isolated systolic hypertension section in the therapeutic notes for hypertension and heart failure has been updated to reflect changes in treatment approach
- The hypertension dosing regimen for immediate-release tablets has been updated in the metoprolol tartrate monograph (initiating treatment at a lower dose may reduce the incidence of adverse effects)
- New section added on deprescribing opioids in the opioid analgesics therapeutic notes
- Sections on pre-treatment screening and monitoring have been added to the azathioprine monograph. The patient advice section has also been updated (relating to hepatic adverse effects).
- The emtricitabine + rilpivirine + tenofovir alafenamide monograph has been reactivated as it is now available again (Odefsey; approved, but not funded for the treatment of HIV infection)
- Post-exposure prophylaxis of syphilis and chlamydia in cisgender males or people assigned male at birth at high risk has been added as an unapproved indication to the doxycycline monograph
- Dosing regimen for mesalazine has been updated to include the alternative brand, Octasa (Section 29), listed in response to ongoing supply issues (see above). Dosing information for the Asacol brand of tablets has also been updated.
- A standardised batch sheet for valaciclovir suspension 50 mg/mL has been added to the valaciclovir monograph
You can read about all the changes in the October release, here. Also read about any significant changes to the NZF for Children (NZFC), here.
NZF practice highlight – Bronchiectasis
This month, the NZF team highlight bronchiectasis, a chronic condition characterised by thick-walled and dilated bronchi that occurs following chronic airway inflammation. Bronchiectasis can be progressive, and may co-present with other respiratory conditions, e.g. asthma, COPD. Symptoms include a recurrent cough, often with sputum, recurrent lower respiratory tract infections requiring antibiotic treatment and unexplained haemoptysis.
- Assess symptom severity and their impact on quality of life for the patient and their family/whānau. The findings of this assessment should inform the development of an individualised management plan that includes multidisciplinary support
- Treatment aims to optimise patient quality of life and improve long-term outcomes by controlling symptoms, reducing exacerbations and preserving lung function. In children, optimising lung growth and reversing bronchiectasis are also priorities.
- Treat mild-to-moderate exacerbations with 10 – 14 days of oral antibiotics. Antibiotic choice is determined by lower airway cultures, local antibiotic susceptibility patterns and patient-specific factors.
- Initial empiric treatment with oral amoxicillin + clavulanic acid is recommended for patients of all ages. Doxycycline is an alternative option for adolescents and adults.
- Prescribe oral ciprofloxacin if Pseudomonas aeruginosa has been identified in recent cultures
- Patients with a severe exacerbation require treatment with IV antibiotics in the hospital setting. Ideally IV antibiotics will be administered for a minimum of five days, with a switch to oral antibiotics only considered with clear evidence of clinical improvement, with a total treatment duration of 10 – 14 days.
- Empiric antibiotic choices include IV amoxicillin, amoxicillin + clavulanic acid or cefuroxime
- If P. aeruginosa is identified in recent cultures, IV ceftazidime +/- tobramycin or piperacillin + tazobactam are preferred
- Six-monthly monitoring of patients with bronchiectasis is recommended to identify complications and manage comorbidities
For further information on managing bronchiectasis in children and antibiotic selection see: “Preventing and managing bronchiectasis in high-risk paediatric populations” and the bpacnz Primary Care Antibiotic Guide.
In brief: Measles cases in the Northland region and Queenstown
The number of measles cases in New Zealand has risen to ten; nine cases in the Northland region and one case in Queenstown at the time of publishing. The Northland and Queenstown cases are not thought to be related but both involve overseas travel. There is a possibility of measles transmission in both the Bay of Islands and Central Otago communities since early September, 2025. Multiple exposure events have been reported in both regions and are listed here in more detail. For further information on the symptoms and signs of measles, and MMR vaccination, click here.
Medical Council seeking feedback on the use of artificial intelligence in patient care
The Medical Council of New Zealand has developed a new statement on “Using artificial intelligence (AI) in patient care”, and is seeking feedback from doctors on this. The Medical Council acknowledges that AI is becoming widely used in almost all aspects of healthcare, e.g. to support a diagnosis, to guide treatment options and to assist with note-taking during consultations, but that it must be used in ways that ensure quality of care and patient safety.
It should be noted that the statement does not cover business or administrative AI tools designed to assist with processes such as inbox management, although the cautions in the statement are likely to apply to any application of AI in medicine.
Consultation closes Wednesday, 29th October, 2025. This link contains an online form to complete or your submission can be emailed to consultation@mcnz.org.nz.
Upcoming Goodfellow Unit webinars
The Goodfellow Unit, University of Auckland, is hosting several free access webinars in October. 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:
- Unlocking Options: Insulin Use in Type 2 Diabetes Management, presented by Dr Ryan Paul. This webinar will be held on Tuesday, 14th October, from 7.30 pm. Click here to register.
- Breast health in midlife: Risk assessment & cancer detection, presented by Dr Magdalena Biggar, Dr Carla Pajak and Dr Sugania Reddy. This webinar will be held on Tuesday, 21st October, from 7.30 pm. Click here to register.
- Back to basics: Sun, sunscreen, skin cancer prevention, presented by Dr Sam Mayhew. This webinar will be held on Tuesday, 28th October, from 7.30 pm. Click here to register.
Did you know bpacnz podcasts are now available on Apple Podcasts and Spotify?
Both our Recovery at Work podcast and Last Days of Life podcast can now be streamed on Apple Podcasts and Spotify. We plan to add more resources to these platforms in the future. Watch this space!
Paper of the Week: Catch me if you can(‘t): delusional infestation
Many of us have experienced an itch that we just can’t scratch. However, for some people, an overwhelming feeling of something ‘under their skin’ without an identifiable cause extends beyond a minor irritation and represents a psychopathological condition. These presentations to primary care, while rare, can be challenging for clinicians because of the intensity of the interactions, level of patient distress, and often, the demand for investigations and consultations.
Delusional infestation is characterised by the persistent and false belief that one is infested, either with a biological organism, e.g. parasites, bacteria, or an inanimate agent, e.g. fibres. It is estimated to affect 20 – 80 people per million annually and can occur in isolation or secondary to an underlying psychological, neurological, infectious, endocrine or pharmacological cause. As delusional infestation causes significant distress in the people who experience it, awareness of the clinical presentation and management of the condition is essential for promoting empathetic and timely care and improving patient outcomes.
A recent article in the British Journal of General Practice outlines the identification and assessment of patients with delusional infestation and presents an evidence-informed approach to the management of the condition in general practice. The bottom line? Validate the person’s distress without reinforcing their delusional thinking.
Have you ever had a patient present with a delusional infestation? If so, what was your management approach? What strategies would you implement to help support a patient with dermatological symptoms with no obvious external cause, e.g. persistent itch or sensations of crawling under the skin?
Read more
Delusional infestation is characterised by sensations of crawling, stinging or biting on the scalp, eyes, mouth and/or body in the absence of infestation. Symptoms may start following resolution of a genuine infestation, or the patient may attribute their onset to a seemingly strange but clearly remembered event. In general:
- Patients with delusional infestation often present with an intense and unrelenting focus on their symptoms, which are a significant source of distress. They are usually insistent that they require treatment for their infestation.
- Eradication attempts have usually occurred, e.g. over-the-counter pharmaceutical treatments, chemicals and/or ‘extreme’ behaviours, e.g. employing pest removal services, obsessive cleaning, selling or discarding ‘contaminated’ items, removing body hair
- Benign skin lesions or debris may be misinterpreted as signs of infestation. They may provide ‘evidence’ of their infestation, e.g. photos, videos, skin samples collected with Sellotape or scraped into a container.
- Physical examination may reveal non-specific excoriations or contact dermatitis, resulting from scratching, picking, or eradication attempts, e.g. irritant exposure, repeated washing
The priority at initial presentation is to rule out a genuine infestation, establish trust and rapport and validate the patient’s experience. Acknowledge that their symptoms are distressing, independent of the cause, and conduct an empathetic and respectful assessment.
- Undertake a physical examination, consider differential diagnoses and arrange relevant tests, as appropriate
- This may require managing expectations about a reasonable level of investigation, as patients often remain adamant that they are infested even after being presented with evidence to the contrary
- Identify potential underlying causes or contributors, including:
- Psychological, e.g. schizophrenia, anxiety, depression
- Neurological, e.g. Parkinson’s disease, dementia
- Endocrine, e.g. diabetes, thyroid dysfunction
- Infectious, e.g. tuberculosis, leprosy
- Pharmacological, e.g. levodopa, methylphenidate, erythromycin, NSAIDs
- Substance misuse, e.g. illicit drugs, alcohol
- Assess and manage mental health co-morbidities, e.g. anxiety, depression, self-harm, suicidal ideation
- Provide dermatological supportive care, e.g. emollients, soap substitutes
Management is individualised depending on the patient’s level of insight and willingness to engage with interventions. For some patients, early and repeated assurance may be sufficient, while others may need more intensive multidisciplinary support, including referral to psychiatric services:
- Validate the person’s distress but avoid reinforcing their delusional thinking
- State your position calmly and rationally and do not prescribe antibiotics or ivermectin without clinical justification
- Provide advice on limiting maladaptive coping strategies such as avoidance of social interaction, excessive internet searching
- Manage mental health co-morbidities, e.g. self-help, counselling, pharmacological management, if indicated
- Consider acute psychiatric referral in severe cases, e.g. additional signs of psychosis, severe anxiety or depression, high risk of self-harm
- Consider referral to addiction services if substance abuse is suspected
- Some patients may require treatment with low-dose antipsychotics, e.g. risperidone, olanzapine; discuss with a psychiatrist
Patients with delusional infestation often reject psychological or psychiatric explanations for their symptoms. If a patient declines mental health referral, maintaining a positive clinical relationship is critical:
- Help them to recognise the potential for harm associated with elimination attempts
- Provide repeated but gentle offers for referral, in conjunction with continued follow-up and safety netting
Gonçalves RB, Goulding JM, Mughal F. Delusional infestation: an evidence-informed approach for general practice. Br J Gen Pract 2025;75:485–7. doi:10.3399/BJGP.2025.0288.
This Bulletin is supported by the South Link Education Trust
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