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Published: 12th December, 2025
Contents
In case you missed it: Latest publications from bpacnz
Clinical Audit - Reviewing type 2 diabetes management in patients at high risk of cardiovascular and renal complications
Some people with type 2 diabetes are at increased risk of cardiovascular or renal complications and therefore may be eligible for funded treatment with either empagliflozin or a GLP-1 receptor agonist (dulaglutide or liraglutide). This audit helps healthcare professionals identify these patients to ensure that their diabetes management regimen is optimised to include one of these medicines.
Read the audit here.
COVID-19 antivirals: Eligibility and prescribing guidance
COVID-19 continues to circulate in the community, although at much lower levels than during the peak of the pandemic. Most people with COVID-19 now experience mild symptoms that can be managed with supportive care alone. However, some people remain at high risk for severe outcomes (i.e. hospitalisation and death) and are therefore likely to benefit from COVID-19 antiviral treatment.
This article details the access criteria for funded COVID-19 antiviral treatment, including factors that increase the risk of severe outcomes from COVID-19. It also includes guidance on nirmatrelvir/ritonavir (Paxlovid) dosing, medicine interactions, adverse effects and effectiveness of treatment.
Read the full article here. A B-QuiCK summary is also available. N.B. Full PDFs of the article and B-QuiCK are now available.
Treatment resistant atopic dermatitis: a topical issue
Most people with atopic dermatitis achieve adequate symptom control with regular emollient and topical corticosteroid use. However, some people do not respond to conventional management and require additional treatments. Upadacitinib, an oral Janus-kinase inhibitor, is now funded for patients with moderate to severe atopic dermatitis who meet Special Authority criteria. Special Authority applications can be made by any relevant practitioner, providing another option in the community for patients with treatment resistant atopic dermatitis.
Read the full article here. A B-QuiCK summary is also available. N.B. Full PDFs of the article and B-QuiCK are now available.
Rewind: Wrap-up of recent key messages
Key dates and news items from recent editions of Best Practice Bulletin:
- The number of measles cases in New Zealand has risen to 30, with an additional nine cases across the country since last reported in Bulletin 137. View the update from Health NZ here.
- The specified prescription medicines lists for designated registered nurse prescribers in primary health and specialty teams and pharmacists prescribers have been amended, following consultation (as reported in Bulletin 132). Further information is available from the Ministry of Health here.
- IMAC recently hosted a webinar on immunisation catch-ups (as reported in Bulletin 137). If you missed it, a recording of the webinar is available here. The latest guidance from IMAC on MMR vaccination is available here.
The bpacnz Publications Team will be taking a break from December 22nd – January 9th. The final edition of Best Practice Bulletin for this year will be on December 19th.
New feature added to resources for InPractice members
bpacnz resources are approved CPD activities for the InPractice recertification programme, as well as other progressional organisations such as the RNZCGP, PSNZ and RNZCUC (selected topics).
We have now introduced a new feature for InPractice members to make recording CPD credits in your e-portfolio easier. Look out for the InPractice button at the top of new articles (available since October); click and you will be prompted to log into your InPractice account, where you will find the title of the resource you were reading along with a handy summary. Select a goal and click “Record CME to my portfolio”. The summary will then be saved to your e-portfolio.
Did you know that we publish a range of professional practice articles that are relevant for all medical doctors (and other health professionals), not just general practitioners, such as Recommended vaccinations for healthcare workers; a range of new topics are planned for next year.
Click here to see our latest articles and start logging your CPD credits now!
Medicine news
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.
Supply issue affecting zinc capsules
Supply issues affecting zinc 50 mg capsules have been ongoing since October due to factory delays. An alternative product (Section 29) is available, but stock is reportedly low. This product is supplied for general sale in Australia therefore does not contain the words “prescription only medicine” on the packaging, but it is still a prescription-only medicine in New Zealand and must be kept in the dispensary. Re-supply of the New Zealand-packaged product is now expected to arrive in February, 2026.
Mometasone furoate (Elocon) 50 g ointment out of stock
Amiloride + furosemide (Frumil) to be discontinued
Amiloride 5 mg with furosemide 40 mg (Frumil) tablets are being discontinued globally by the supplier (Sanofi) due to low sales; approximately 450 people were dispensed this medicine in New Zealand in 2024. Stock is expected to run out by the end of February, 2026. A delisting date is yet to be announced. There are no other brands of this combination medicine available. Prescribers should identify any patients still taking this medicine and switch them to another option prior to February. See NZF for information on available diuretics. N.B. Amiloride 5 mg tablets are funded but not approved by Medsafe and would need to be prescribed for supply under Section 29.
A patient information sheet about the discontinuation is available here.
Latest edition of Prescriber Update released
The December edition of Prescriber Update has been published. Particular items of interest for primary care include:
Intestinal angioedema with ACE inhibitors/ARBs
Angioedema of any mucosal surface can occur with the use of ACE inhibitors/ARBs. The tongue, face and upper respiratory tract are most commonly affected, but it can also occur in the intestines. Consider the possibility of intestinal angioedema if a patient taking an ACE inhibitor/ARB presents with non-specific gastrointestinal symptoms, e.g. abdominal pain, diarrhoea, nausea, vomiting. The medicine should be discontinued if intestinal angioedema is suspected. Read the full article here.
Paracetamol and the risk of high anion gap metabolic acidosis
Information about the risk of high anion gap metabolic acidosis (HAGMA) was recently added to paracetamol data sheets. Metabolic acidosis occurs when there is a reduction of sodium bicarbonate and accumulation of acid in the body that is unable to be excreted. It can be categorised depending on the anion gap, which is calculated based on the balance of cations and anions in the blood; a high anion gap means that unmeasured anions are present. When paracetamol is metabolised, it can cause pyroglutamate (a metabolite that can contribute to a high anion gap) to accumulate, particularly in people with low glutathione levels. This is known as pyroglutamic acidosis, a type of HAGMA.
HAGMA has been reported in people taking long-term paracetamol at therapeutic doses. Other risk factors include severe illness (renal impairment, sepsis), malnutrition, alcoholism and flucloxacillin use. Management of HAGMA will usually occur in secondary care. Read the full article here.
Myocarditis, myositis and myasthenia gravis (Triple M overlap syndrome) with immune checkpoint inhibitors
Immune checkpoint inhibitors (e.g. ipilimumab [Yervoy], pembrolizumab [Keytruda]), used for the treatment of some cancers, have been associated with the development of myocarditis, myositis and myasthenia gravis, also known as Triple M overlap syndrome. The syndrome is related to the immune-mediated adverse reactions on various organs that can occur with immune checkpoint inhibitors targeting healthy cells. Management will usually occur in secondary care. Three cases have been reported in New Zealand; one related to the use of both ipilimumab and nivolumab and two with pembrolizumab. Read the full article here.
View the full edition of Prescriber Update here.
New immunisation management guidelines for primary care published
Health New Zealand, Te Whatu Ora, has published national guidelines for immunisation management in primary care, developed by the National Public Health Service, General Practice New Zealand and Primary Health Organisation nursing leads. The guidelines are intended to standardise the recording and management of immunisations across New Zealand, and cover:
- Declined immunisations
- Delayed and missed immunisations
- Pre-calls and recalls for childhood vaccinations
- Referrals to outreach immunisation services or other community-based providers
Our five key takeaways
- A declined vaccination is a “moment in time” and can be revisited again
- Only record a decline for vaccinations that are due or overdue
- Practices must contact the local Aotearoa Immunisation Register team to communicate that a family/whānau has decided to delay vaccination
- Completion of the six-week vaccinations are a strong predictor of future immunisation
- Referral to outreach immunisation services is a priority for children whose family/whānau are unlikely to engage with primary care for immunisations. At least three contact attempts should be made, and children should not be referred if logistical access barriers, e.g. transport, are identified as preventing their immunisation in primary care; there are other ways this can be addressed.
Consultation on the regulation of physician associates/assistants
The Medical Council of New Zealand (MCNZ) is seeking feedback on a proposal about regulating physician associates/assistants (PAs). This comes after it was announced by the Minister of Health earlier this year that PAs would be regulated by the MCNZ under the Health Practitioners Competence Assurance Act 2003.
The consultation is made up of five sections:
- Scope of practice
- Qualifications
- Supervision framework
- Cultural safety
- Determining the appropriate title for PAs in New Zealand
The MCNZ is also working to address other aspects of PA regulation, including standards of clinical and cultural competence and ethical conduct, recertification requirements, accreditation standards for training programmes that deliver education for PAs and the establishment of fees for registration and annual practice certificates; consultation on these topics are expected in the future.
Read the full proposal here. A six-minute video summarising the key points of the consultation is also available.
Consultation closes 12 pm, Monday, 16th February, 2026. This link contains an online form to complete.
Paramedic Council consultation on prescribing
Te Kaunihera Manapou | Paramedic Council is seeking feedback on a proposal to introduce a designated prescribing authority for paramedics in New Zealand. This proposal was preceded by a survey earlier this year to assess support for a paramedic prescribing authority; 87% of respondents were in support of this. It is proposed that registered paramedics who complete an approved post-graduate prescribing qualification (yet to be determined), in addition to other requirements, would be able to prescribe certain medicines (list also to be determined; a separate consultation will be undertaken at a later date) within their scope of practice.
Extended Care Paramedics are increasingly becoming involved in general practice clinics as part of the multidisciplinary team supporting patients with urgent unscheduled community care needs. Benefits of introducing paramedic prescribers include patients being able to access medicines and treatments in a timelier manner, the potential to reduce health inequities for certain groups, e.g. those who live rurally, Māori and Pacific peoples, and reducing the burden of work on other health care providers.
Consultation closes Tuesday, 20th January, 2026. This link contains the online survey to complete, or your submission can be emailed directly to: registrar@paramediccouncil.org.nz.
In brief: NZF updates for December
Significant changes to the NZF for December, 2025, have been released. There are no major updates for primary care prescribing. Read about all the changes in the December release, here. Also read about any significant changes to the NZF for Children (NZFC), here.
Helping patients keep their cool this summer
At the time of writing, New Zealand was in the grip of a heatwave – a glorious few days of temperatures in the 30s. By the time this is read, the country will no doubt have returned to the inevitable pre-Christmas cool down.* Disappointing for those planning a BBQ on Christmas day, but a welcome relief for many people who do not do well in the heat.
* Right on cue, it did: https://www.odt.co.nz/news/dunedin/thunderstruck-region-left-shakin-knees-or-wet-anyway
So, what can we do for vulnerable patients to keep them safe when the mercury climbs? Ensure they have a “heat plan” in place and know what to do to keep cool, and prevent dehydration and heat stroke, which can be life threatening especially in frail, elderly people.
Read more
There are a range of resources available from Health New Zealand, Te Whatu Ora, on health effects from heat, including posters for the clinic and patient handouts on tips for staying cool and advice about dehydration.
Key points to discuss with patients include:
- Watch the weather forecasts and prepare for the heat: have a supply of necessary items on hand (see below), manage the inside temperature (close curtains, open windows for ventilation) and have arrangements for where to go if it gets too hot
- Find a cool place to be during the day – this may be at home, or at a public place with air conditioning such as a library, community centre or Marae
- Drink water or other cold drinks regularly throughout the day; avoid hot drinks, caffeine and alcohol
- If mild dehydration occurs (e.g. dry mouth, headache, concentrated urine), recommend oral rehydration with regular fluids, e.g. diluted juice, “sports” drink or homemade solution (six teaspoons sugar, ½ teaspoon salt, 1 L water)
- If a freezer is available, have a supply of frozen food items such as ice blocks, bananas or other fruit/vegetables. Also have some ice packs on hand or put a damp washcloth or tea towel in to freeze: these can be used to help cool down.
- If going outside, wear a hat and loose, light clothing, and keep activity level to a minimum
- If the heat is beginning to cause an effect (e.g. hot, flushed skin, fatigue, increased heart or respiratory rate), ways to cool down include a spray/mist bottle of cold water (for extra cooling a fan can be used to evaporate the water from the face/body after it is sprayed), ice packs/damp or frozen towels under the armpits, back and on the neck or a cool shower
- Give instructions on checking in with the medical centre or another health provider if they feel unwell; discuss red flag symptoms that require more urgent action. N.B. Heat exhaustion/heat stroke can occur when the internal body temperature exceeds approximately 40 °C.
Don’t forget the pets: Would you go for a walk in bare feet on burning hot asphalt, while wearing a fur coat and hat? No? Don’t expect your dog to then! Bring them inside and make sure they have a long, cool drink too.
Paper of the Week: Unsafe paracetamol use common among the general public
Paracetamol is the most frequently dispensed medicine in New Zealand. It is also readily available over the counter from most supermarkets, petrol stations and corner dairies. This ease of access reflects its wide use, often without seeking clinical advice. Paracetamol is generally well tolerated and safe when taken at recommended doses, i.e. 15 mg/kg (in people weighing under 50 kg) or 500 mg to 1 g, every four to six hours and not exceeding four doses in 24 hours. However, when taken outside these recommended doses, paracetamol can cause significant morbidity and potentially life-threatening hepatotoxicity. Given that it is the most common therapeutic enquiry to the National Poisons Centre, is the general understanding of paracetamol safety lacking?
A study published in the Journal of Primary Health Care investigated knowledge among the general public in New Zealand about paracetamol and its use. The online survey of adults found that while most people thought they were taking paracetamol safely, nearly one-third were intentionally taking more than the recommended two 500 mg tablets in a single dose. Other examples of intentional misuse included exceeding the four doses per day maximum and taking their next dose within four hours of the previous dose. Worryingly, some participants were intentionally misusing paracetamol despite claiming to have read the packaging instructions. These findings highlight the importance of not assuming patients know the dose they are supposed to be taking (or follow the instructions they are given). While paracetamol is not always procured in the presence of a healthcare professional, when it is, take any opportunity to have a discussion about the correct dose, the daily maximum dose and potential harms. Also remind about the potential for other products to contain paracetamol, e.g. cough and cold preparations, and what to do if you take too much.
Do you know what the toxic dose of paracetamol is? Do you regularly check that patients are taking the correct dose of paracetamol when prescribing or dispensing it? Do you remind parents and caregivers that the paediatric dose of paracetamol will increase as the child’s weight increases, i.e. the previous dose written on an old label may no longer be the correct dose for the child’s current weight (and is likely not correct for other children in the family)? Do patients generally know to contact the National Poisons Centre if they exceed the recommended dose of paracetamol?
Read more
- Approximately 1,700 participants aged 18 years and over (47% female) were invited to complete an online survey about paracetamol and paracetamol-related behaviours and attitudes in November, 2022
- There was a relatively even age distribution amongst the study population and the proportion of Māori study participants reflected the overall New Zealand population, however, Pacific peoples were underrepresented
- Paracetamol use was common among the study population; more than half reported taking paracetamol “a few times per month”
- Three-quarters of participants thought paracetamol was easy to access in New Zealand and two-thirds felt that paracetamol could be purchased from the supermarket because it was a safe medicine
- More than half of participants were aware that a standard paracetamol tablet is 500 mg, and the general understanding of what conditions paracetamol is indicated for was good – fever (74%), headache (91%) and pain (93%)
- Most participants (72%) knew not to exceed more than four doses (eight tablets) in a 24-hour period and at least half understood to contact the National Poisons Centre if they exceeded the recommended dose
- Notably, less than half of participants (49%) thought it was safe to take paracetamol and ibuprofen together
- One-quarter of participants were unaware that many over-the-counter cold and flu preparations contain paracetamol and contribute towards the total daily paracetamol dose, and approximately half could not identify paracetamol-containing products based on the packaging
- Many participants felt their doctor or pharmacist had not directly discussed the potential harms of paracetamol or asked if they had any questions about the medicine
- Nine out of ten people thought they took paracetamol safely, however, 29% of participants reported taking more than two tablets in a single dose, 13% reported not waiting at least four hours between doses and 11% reported exceeding the recommended daily dose
- Participants who said that they knew how to take paracetamol safely were less likely to report intentionally misusing paracetamol, compared to those who said they did not know or were unsure of the recommended dosing
- The number of participants who reported not waiting at least four hours between doses was smaller among those who read the instructions for taking paracetamol on the box or leaflet, compared to those who did not
- However, reading the instructions did not affect the number of participants taking more than two tablets in a single dose or exceeding the recommended daily dose
- Study limitations:
- The survey was conducted through a national online market research group, and the study population may not be an accurate representation of the general population, e.g. higher computer literacy
- Some of the wording and response options for survey questions may have been confusing for participants and affected answers
For information on the management of paracetamol overdose, see: https://onlinelibrary.wiley.com/doi/full/10.5694/mja2.50428.
Marsh S, Kumpula E-K, Hetrick S, Fortune S. Paracetamol-associated knowledge, attitudes and practices of the New Zealand public: an online survey. J Prim Health Care 2025. doi:10.1071/HC25060.
This Bulletin is supported by the South Link Education Trust
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