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Published: 17th July, 2026
Contents
New from bpacnz – Medicines safety: Methotrexate
Oral methotrexate is prescribed in the community setting for the treatment of people with autoimmune conditions, such as rheumatoid arthritis. In most cases, treatment is safe and effective, but serious adverse effects can occur even at low doses, and incorrect use is associated with a significant risk of toxicity, which can be fatal. This article discusses the practical steps needed to ensure safe and effective prescribing of methotrexate, including appropriate pre-treatment screening, ongoing monitoring and clear communication between prescribers, pharmacists and patients. Methotrexate is often initiated in a specialist care setting; however, specialist involvement is not a requirement for funded treatment. Clinicians who are confident about prescribing methotrexate can initiate it in primary care if it is safe and appropriate to do so.
Read the article here. A B-QuiCK summary and patient information sheet are also available.
In case you missed it - Upfront: Making sense of medicines access criteria
Access criteria, e.g. Special Authorities, are applied to medicines to target funding to groups likely to gain the most benefit. They are generally not intended to guide clinical practice. In recent years, Pharmac has been making changes to access criteria for some medicines, e.g. removing prescriber restrictions and Special Authority renewal requirements. In some cases, access criteria have been removed entirely. The intention behind these changes is to “cut the red tape” and make accessing funded medicines easier, while still balancing the budget. Prescribers ultimately decide whether a medicine is appropriate for a patient; access criteria only define who is eligible to receive that medicine funded.
In this Upfront article, we take a closer look at what access criteria are, why they exist and how they should (and should not) be used to influence prescribing in primary care.
Read the article here
Have your say: Contribute to an upcoming CKD panel discussion
Earlier this year, we published Chronic kidney disease: the canary in the coal mine, the first in a series of resources about CKD in primary care. The comprehensive main article covers identification, classification and management of patients with CKD; a B-QuiCK summary, clinical audit and peer group discussion are also available to complement this resource. A case study quiz is due to be published soon.
The final component of this CKD resource series is a podcast panel discussion. This podcast will involve a conversation with several experts who are at the forefront of improving the standard of care for people with CKD in New Zealand. It will expand on many of the key points that arise during peer discussion of the realities of managing CKD in practice, adding another layer of perspective when considering how improvements could be made.
Have your say: We would like to hear from our readers about your experiences with managing patients with CKD, challenges you face in practice, areas where further clarification is needed or specific aspects of CKD care you would like the panel to discuss. Email your questions or comments to: editor@bpac.org.nz.
Rewind: Wrap-up of recent key messages
Key dates and updates on news items from recent editions of Best Practice Bulletin:
- The supply issue affecting valaciclovir 1,000 mg tablets (Vaclovir) remains ongoing (as reported in Bulletin 150); stock of the 500 mg strength is now low. An alternative brand of the 500 mg strength (Valaciclovir Viatris; not approved by Medsafe) has been listed on the Pharmaceutical Schedule since 1st July.
- All strengths of the Tryzan brand of ramipril are now out of stock, following an anticipated supply issue due to manufacturing issues (as reported in Bulletin 147). Alternative brands have been listed on the Pharmaceutical Schedule for all strengths of ramipril, however, none are Medsafe approved.
- There is a global supply issue affecting all TruSteel insulin pump infusion sets, due to difficulties with the manufacturer sourcing a component (as reported in Bulletin 149). Guidance has now been published on the New Zealand Society for the Study of Diabetes (NZSSD) website to identify those who should be prioritised to receive remaining TruSteel stock.
- Selected insulin products from Eli Lilly and Novo Nordisk are being discontinued in 2026 (as reported in Bulletin 141). Pharmac has now advised that some products will remain available for longer than originally anticipated. For the latest information on supply and funding of affected insulin products, click here.
- A case of H5N1 bird flu has now been detected in New Zealand; the overall public health risk remains low. Health New Zealand, Te Whatu Ora, has published information for clinicians about bird flu; see Bulletin 151 and local HealthPathways for details.
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.
Betamethasone dipropionate (Diprosone): 15 g cream, 50 g ointment out of stock
The supplier is out of stock of betamethasone dipropionate (Diprosone) 15 g cream and 50 g ointment, a potent topical corticosteroid, due to manufacturing delays. Other funded presentations of Diprosone, i.e. 50 g cream, 15 g ointment, are not currently affected. Re-supply is expected mid to late July.
For further information on currently funded topical corticosteroids, click here (also see below for Key points when prescribing topical corticosteroids)
Supply issue affecting Estradot 100 microgram patches
There is a supply issue affecting the Estradot brand of oestradiol 100 microgram patches. Stock is reported to be very low, and an out-of-stock period may be possible. Other strengths of this brand are not currently affected, and all strengths of TDP Mylan, the other funded brand of oestradiol patches, are available. Supply issues affecting oestradiol patches have been ongoing since 2022.
Patients using 100 microgram patches who wish to continue with the Estradot brand are advised to talk to their pharmacist, who may be able to dispense a combination of different patch strengths, e.g. 75 + 25 microgram, to meet the prescribed dose; an additional charge is likely to apply, and a new prescription (and fee) may be required. Re-supply of Estradot oestradiol patches is expected in mid-August.
bpacnz focus: Getting topical corticosteroid prescribing right
Topical corticosteroids are an effective and generally safe treatment option when they are prescribed and used appropriately. However, serious adverse effects, such as skin atrophy, striae and adrenal suppression, can occur when use is not optimal. The risk of adverse effects is increased when higher potency topical corticosteroids are used, or with prolonged or frequent application, use on areas with thin skin, when applied under occlusion or with concomitant use of oral or high-dose inhaled corticosteroids. Topical steroid withdrawal syndrome can also occur after discontinuation of treatment, particularly following prolonged, frequent or inappropriate use of higher potency topical corticosteroids. The adverse effects from inappropriate use of topical corticosteroids were recently highlighted in a Medsafe Prescriber Update article (as reported in Bulletin 149).
Key points when prescribing topical corticosteroids
To reduce the risk of adverse effects with topical corticosteroids:
- Choose an appropriate formulation:
- Creams – useful for large areas of skin. Generally, more moisturising than lotions and less greasy than ointments. Creams may be preferred over ointments for daytime use.
- Ointments - useful for dry skin and skin with a thick scale. Greasier, stickier and more noticeable on the skin. Ointments may be preferred for use at night.
- Lotions - useful for large areas of skin, as well as the scalp or other areas with hair
- Prescribe the lowest potency topical corticosteroid that will adequately control the patient’s symptoms; see NZF for topical corticosteroid preparation potencies
- Treatment may need to be stepped up to a more potent product if a milder product is not adequate, particularly for eczema on the trunk and limbs
- Potent and very potent topical corticosteroids are not suitable for areas of thin skin
- Frequency of application should be limited to twice daily or less. Initially, topical corticosteroids should be applied generously once or twice daily to gain rapid control, then reduce to a thin layer once daily until the flare has settled.
- Prescribe an adequate quantity for an appropriate duration of treatment; the fingertip unit measurement can help to determine the “dose” and amount to prescribe. Ensure that enough product is prescribed for the intended treatment area(s), so that patients do not over- or under-apply.
- Provide patients with clear application instructions, including the quantity (fingertip unit measurements can be helpful), frequency, site and the duration of use. Explain the risks associated with inappropriate use.
- If prescribing more than one topical corticosteroid, explain the different potencies and where each product should be applied to reduce the risk of inappropriate use
- Consider short “bursts” with higher potency topical corticosteroids for patients with persistent eczema:
- Often preferable to longer courses of treatment with less potent products
- Patients can be treated with a higher potency topical corticosteroid initially to gain control of symptoms and then stepped down to a less potent formulation
- Consider seeking specialist advice for patients needing daily use of potent or very potent topical corticosteroids for longer than four weeks
- Diluting topical corticosteroids with emollients does not result in a less potent formulation or fewer adverse effects. Potency is related to the affinity of the particular corticosteroid molecule to the receptor. If a less potent product is needed, prescribe a milder topical corticosteroid rather than diluting a more potent formulation.
- Reinforce the importance of applying emollients liberally and regularly alongside topical corticosteroid treatment (including during flares). Topical corticosteroids can be applied before or after emollients. Regular use of emollients can reduce the risk of eczema flares and the need for topical corticosteroids. See NZF for information on emollient and barrier preparations.
- Review the patient's current and previous medicines when prescribing a new topical corticosteroid or adjusting an existing topical corticosteroid regimen
- Concomitant use of oral or inhaled corticosteroids can increase the risk of adverse effects; caution is advised
Pharmacists are encouraged to include topical corticosteroid potency on medicine labels. Labelling a topical corticosteroid as mild, moderate, potent (or strong) or very potent (or very strong) avoids confusion and the risk of inappropriate use. From mid-March, 2028, products containing a topical corticosteroid for treating inflammatory skin conditions must have information about potency on the container/packaging (as reported in Bulletin 143).
For further information on topical corticosteroids, see: https://bpac.org.nz/2021/topical-corticosteroids.aspx
Upcoming HealthPathways webinar on type 2 diabetes
HealthPathways is hosting an upcoming webinar on type 2 diabetes – essentials for general practice. This free webinar is expected to cover the new HbA1c thresholds, including what this means for diagnosis, follow-up and how to communicate the changes to patients. The webinar will be held on Tuesday, 11th August, from 7 – 8 pm. Click here to register (a certificate of attendance and CPD points are available). A recording will be available at a later date.
Free online course on anti-seizure medicines and pregnancy
The Health Quality and Safety Commission and New Zealand College of Midwives have developed a new free e-learning course on the safe use of anti-seizure medicines in people who may become pregnant. While developed for midwives, the course is also relevant for other primary healthcare professionals, including general practitioners, nurse practitioners and practice nurses. The course aims to improve awareness of the risks and benefits associated with anti-seizure medicines during pregnancy, and contributes to ongoing efforts to reduce medicine-related harm.
View the course, here. N.B. Registration with the New Zealand College of Midwives Online Portal (free) is required to access the course.
New online Women’s Health Hub for patients
Health New Zealand, Te Whatu Ora, has announced the launch of a new section on its website aimed at collating health information, resources and support options for females in New Zealand: Women’s Health Hub. The Hub provides New Zealand-based information on a range of topics relevant to different life stages, including menstruation, contraception, pregnancy, menopause, cervical and breast screening as well as long-term health conditions.
The Women’s Health Hub may be a useful resource to direct patients to if they would benefit from additional information following a consultation, or to support discussions about prevention, screening, treatment and self-management.
In brief: Wound Awareness Week 2026, 20th – 26th July
National Wound Awareness Week starts next Monday (20th July) and the theme for this year is Wound Hygiene. The New Zealand Wound Care Society is hosting a number of free webinars throughout the week (CPD points may be available); click the link above for further information.
The week provides an opportunity for clinicians to reflect on their approach to wound assessment and management, and to keep up to date with the latest evidence in wound care.
Paper of the Week: Why age and sex could impact which veggies to put on your plate
Diet is one of the strongest determinants of cardiometabolic health. Food choices made in young adulthood can have a significant impact on the risk of disease later in life. Therefore, developing good food habits and making smarter choices about what we eat at this stage are crucial, but also challenging, especially in the context of social changes, e.g. moving away from the support and comfort of home.
Smarter food choices bring us to the topic of vegetables. A higher intake of vegetables has been associated with antioxidant and anti-inflammatory effects, improvements in lipid profiles and a reduced risk of developing chronic diseases in adulthood. Many younger people could benefit from increasing their vegetable intake, but do all vegetables have the same health benefits? Should we focus on consumption of specific types of vegetables at different times of our lives to get the best bang for our buck? Can primary care clinicians provide more tailored guidance than just “make sure you eat 5+ a day”?
A study published in Nutrition, Metabolism and Cardiovascular Disease investigated the impact of different vegetable types on cardiometabolic risk in more than 600 young adults in Australia. Males with lower cardiometabolic risk were found to consume more legumes, such as peas and green beans, whereas females with lower cardiometabolic risk consumed more green leafy and cruciferous vegetables, e.g. cauliflower and broccoli. While sex differences in cardiometabolic risk factors are well established, these findings suggest that sex-specific factors may influence how our bodies metabolise the vegetables we consume. This could relate to micronutrients in specific vegetables modulating sex hormones or altering the gut microbiome influencing cardiometabolic risk. In addition, the discordance of some of these findings with those previously reported in older adults suggest that age may also play a role in mediating the beneficial effects of vegetables. Further research is still required to confirm a causal link, but the overall focus for young adults should be to build healthy food habits around vegetable intake – something that primary care clinicians are well placed to be involved in.
What would prompt you to discuss dietary choices with young adult patients? What are some of the key points you emphasise when discussing dietary choices? What’s your favourite vegetable?
Read more
- This cross-sectional study involved 638 participants (53% female, mean age 22 years), who were already enrolled in the multi-generational Raine Study, based in Western Australia
- Participants’ blood pressure, waist circumference, high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and glucose were measured
- 120 participants (19%) were classified as having high cardiometabolic risk (≥ 2 risk factors above diagnostic criteria for metabolic syndrome, e.g. elevated blood pressure, raised TG and blood glucose, reduced HDL-C)
- A 121-item food frequency questionnaire (Dietary Questionnaire for Epidemiological Studies version 2; DQES v2) was used to determine participant’s vegetable intake in the previous 12 months. Saturated fat and total daily energy intake were calculated based on food frequency questionnaire responses and alcohol consumption was self-reported.
- Vegetables were classified as:
- Allium – onion, leeks and garlic
- Cruciferous – cabbage, brussels sprouts, cauliflower and broccoli
- Green leafy – spinach, lettuce and other green salad leaves
- Legumes – peas, green beans, baked beans, bean sprouts, soybeans and other beans
- Yellow-orange-red – tomato, peppers, carrot and pumpkin
Cucumber, zucchini, celery, beetroot and mushrooms are recorded in the DQES (as part of total vegetable intake) but were not included in the above groups for this study. Other vegetable intake was calculated for analysis by subtracting an investigated group, e.g. legume intake, from total vegetable intake.
- Males with lower cardiometabolic risk were found to consume significantly more legumes, such as peas and green beans, compared to males with higher cardiometabolic risk
- Females with lower cardiometabolic risk consumed significantly higher quantities of green leafy and cruciferous vegetables, such as cauliflower and broccoli, compared to females with higher cardiometabolic risk
- Only legume consumption in males and cruciferous vegetable consumption in females remained significant predictors of lower cardiometabolic risk following adjustment for potential confounding factors, e.g. income, physical activity, education, smoking status, total energy intake, alcohol intake, saturated fat and other vegetable intake
- Possible explanations for these sex-specific differences in cardiometabolic risk:
- Micronutrient composition in some vegetables modulate the effects of sex hormones, e.g. flavonoids and saponins in legumes may influence testosterone, or glucosinolates and S-methyl cysteine sulfoxide found in cruciferous vegetables may influence oestrogens and progestogens
- Increased dietary fibre intake is associated with improved glycaemic control, blood lipid regulation and increased satiety and may have a role in the reduced cardiometabolic risk for males. In some cases, one serving of legumes may contain up to one-third of an adult’s recommended daily fibre intake.
- Legumes and cruciferous vegetables have been associated with gut microbiome effects. Gut microbiome changes from diets that focus on a high vegetable intake, e.g. Mediterranean diet, are linked with improvements in cardiometabolic biomarkers.
- Replacement of red meat with legumes as a possible cause of lower cardiometabolic risk in males was considered unlikely by the authors because saturated fat intake was adjusted for
- This study was conducted in a cohort of younger and generally healthier participants than those typically included in cardiometabolic health research. Allium and yellow-orange-red vegetable groups have previously been associated with anti-hyperglycaemic, anti-hypercholesterolaemic and antioxidant effects in older adults, however, no association was found in this study suggesting that the cardiometabolic benefits of some vegetables become more apparent later in life.
- One potential study limitation is the use of the food frequency questionnaire to assess dietary intake. Despite the DQES v2 having been validated in young adult populations, it excludes some commonly consumed vegetables, e.g. corn, eggplant, and may therefore underestimate overall vegetable intake. An updated version, DQES v3.2, is now available and includes new food items to reflect changes in food availability.
- The authors also did not adjust for confounding from all food groups to avoid overcomplicating the models
- Up to one-fifth of participant data were missing for some variability, resulting in the removal of family history of cardiometabolic disease in the confounding analysis
McNamara N, Blekkenhorst LC, Mori TA, et al. Higher legume and cruciferous vegetable intakes are associated with lower cardiometabolic risk in young adults: a cross-sectional study. Nutrition, Metabolism and Cardiovascular Diseases 2026;36:104709. doi:10.1016/j.numecd.2026.104709.
This Bulletin is supported by the South Link Education Trust
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