Want to receive Best Practice Bulletin directly to your inbox?
Sign up here.
Published: 14th August, 2026
Contents
New from bpacnz – Beyond breathlessness: Diagnosis and management of patients with COPD
Chronic obstructive pulmonary disease (COPD) is estimated to affect more than 60,000 adults in New Zealand, with Māori and Pacific peoples experiencing a higher burden of disease. Smoking remains a strong risk factor for developing COPD but the substantial proportion of people who develop obstructive lung disease without a history of smoking suggests clinicians must consider a diagnosis of COPD in any patient aged over 40 years with relevant symptoms. The progressive nature of COPD and significant impact on quality of life also necessitates early optimisation of management and regular follow-up to identify clinical deterioration.
The bpacnz COPD resources have undergone a full revision to align with the New Zealand COPD Guidelines: 2025 Update. Spirometry remains essential to confirm a COPD diagnosis and where appropriate, prompt escalation to bronchodilator combination inhalers is recommended for symptom control. Triple treatment with a long-acting muscarinic antagonist (LAMA), a long-acting beta2-agonist (LABA) and an inhaled corticosteroid (ICS), in a single inhaler, provides clinicians with an effective tool to manage patients (who meet Special Authority criteria) at risk of exacerbations, but may not be clinically appropriate for everyone.
Read the article here. A B-QuiCK summary is also available.
Coming soon: The bpacnz COPD prescribing tools are currently being re-developed to align with the New Zealand COPD Guidelines: 2025 Update.
Also new: CKD case study quiz
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. CKD is a growing issue in New Zealand that disproportionately affects Māori and Pacific peoples. Early detection of CKD through regular testing of at-risk patients enables timely interventions to slow the rate of progression and modify the associated increased risk of cardiovascular disease. The management of CKD has advanced in recent years and is achieved through lifestyle interventions and a combination of medicines targeting different aspects of the cardio-renal-metabolic system; the “four pillars” approach.
A case study quiz has now been developed to accompany this article. It follows the story of Kam Singh, a 56-year-old male with type 2 diabetes who has recently enrolled in your practice after shifting towns. Kam presents for a new metformin prescription, but it becomes apparent that he has not had a comprehensive review in a while. Laboratory tests reveal persistent renal impairment, suboptimal glycaemic control and dyslipidaemia. How will you assess Kam’s cardio-renal-metabolic risk? Do you feel confident that you can help Kam reduce his risk of CKD progression and long-term cardiovascular disease risk?
Can you help Kam? Also test your knowledge on our “extra for experts” question. Complete the case study quiz here.
N.B. You will need to log-in to “My bpac” or create a free account. Quizzes are endorsed as a professional development activity by the RNZCGP (two CPD credits) and InPractice; a certificate of completion is also provided for all participants.
A B-QuiCK summary, clinical audit and peer group discussion are also available to complement the main resource
Rewind: Wrap-up of recent key messages
Key dates and updates on news items from recent editions of Best Practice Bulletin:
- Reconsidering the risks and benefits of community iron infusions. Ferric carboxymaltose IV infusion for iron replacement treatment is associated with significant fracture risk and a higher incidence of hypophosphataemia than previously thought. Clinicians should be aware of the risks and routinely discuss these with patients before making a joint decision to prescribe/undergo this treatment. See Bulletin 153 for more on this developing story.
- The Coversyl brand of perindopril is being updated to a new formulation (from perindopril erbumine to perindopril arginine). Patients will require a new prescription in the coming months for an equivalent strength of the new formulation. See Bulletin 153 for further details, including dose equivalence.
- Keep measles front of mind. Several cases of measles have been detected in New Zealand this year (as last reported in Bulletin 148); the latest case was recently reported in Palmerston North. Healthcare professionals are reminded to remain vigilant for cases of measles in the community and to ensure patients are up to date with MMR vaccination.
Access to type 2 diabetes medicines widened
Pharmac has announced the decision to amend Special Authority criteria and widen access to empagliflozin (alone and in combination with metformin), dulaglutide and liraglutide for patients with type 2 diabetes, following consultation (as reported in Bulletin 148). Access has widened further than originally proposed, following feedback received during the consultation period.
From 1st September, 2026, Special Authority criteria related to cardiovascular disease, diabetic kidney disease and ethnicity will be removed, meaning that these medicines will be funded for all people with type 2 diabetes who are unable to achieve a HbA1c of ≤ 53 mmol/mol with other funded diabetes medicines. For empagliflozin (with or without metformin) to be funded, target HbA1c must not have been achieved despite regular use of metformin, vildagliptin or insulin for at least three months. For dulaglutide or liraglutide to be funded, empagliflozin, metformin and vildagliptin must have been trialled for at least six months, where clinically appropriate.
The restriction on concurrent use of empagliflozin with liraglutide or dulaglutide remains and will be moved from the notes section into Special Authority criteria.
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.
Dexcom G6 continuous glucose monitor to stop being supplied
The Dexcom G6 model of interoperable continuous glucose monitor (CGM) will no longer be funded from early 2027 as it is being discontinued by the manufacturer. Patients currently prescribed a Dexcom G6 CGM will need to be transitioned to either the Dexcom G7 or Freestyle Libre 3 Plus CGM before the end of the year. The Dexcom G7 has recently been upgraded so that it is now compatible with both funded insulin pumps (Tandem and YpsoPump), allowing use as part of an automated insulin delivery system; the Freestyle Libre 3 Plus was already compatible with these pumps.
A patient information sheet is available here
Three-month supply of Mylan oestradiol patches returns
Pharmac has announced that from 1st September, 2026, stat dispensing of the TDP Mylan brand of oestradiol patches will be reinstated and the patch limit will be removed. This means that people can be dispensed up to three months’ supply of this brand of oestradiol patches at once, with no weekly patch limit. This change does not apply to Estradot patches; the two patch per week limit will remain in place for each strength of this brand as well as monthly dispensing, due to ongoing supply issues (as last reported in Bulletin 153).
To manage supply of the Estradot brand, Pharmac is reminding clinicians to prescribe 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. Pharmacists are asked to stock both brands of oestradiol patches and to dispense Estradiol TDP Mylan, unless Estradot is specifically requested by the prescriber or patient. Other funded menopausal hormone therapy options are also available; click here for further information.
Sildenafil supply issue; reserve stock for funded indications
Stock of the 25 mg and 50 mg strengths of the Vedafil brand of sildenafil is limited due to manufacturing issues. A re-supply date is yet to be announced. The 100 mg strength is not currently affected. Sildenafil is funded with Special Authority approval for some people with pulmonary arterial hypertension (unapproved indication), Raynaud’s phenomenon (unapproved indication) and erectile dysfunction due to a spinal cord injury. Most people in New Zealand who use sildenafil for erectile dysfunction access it unfunded, either via prescription or direct supply from a pharmacist.
The supplier of the Vedafil brand, Viatris, is asking pharmacies to reserve stock of this brand for patients who have a valid Special Authority. An alternative brand of the 50 mg strength (Amarox) has been listed on the Pharmaceutical Schedule, however, it is not approved by Medsafe, therefore, will need to be prescribed for supply under Section 29A of the Medicines Act. Pharmac is working to list an alternative brand of the 25 mg strength (tentatively from October); stock of the 25 mg Vedafil brand is expected to last until then, if reserved for patients for whom this medicine is funded.
For patients who self-fund Vedafil, prescribers are recommended to discuss other brands of sildenafil or alternative management options where possible.
Supply issue affecting clotrimazole 1% vaginal cream
There is a supply issue affecting stock of clotrimazole 1% vaginal cream (Clomazole) due to manufacturing delays. This product is used to treat vulvovaginal candidiasis and is available via prescription or direct supply from a pharmacist, i.e. pharmacist-only. Funded alternatives are available for patients affected by this supply issue, e.g. Clomazole 2% vaginal cream which provides a shorter three-day treatment course (via prescription or pharmacist-only). Re-supply is expected at the end of August/early September.
Tetracycline 250 mg tablet brand change + now funded by endorsement
The funded brand of tetracycline 250 mg tablets, used as part of quadruple therapy for Helicobacter pylori eradication, has changed from Tetracycline Accord to Tetracycline AA. Tetracycline AA has been listed on the Pharmaceutical Schedule since 1st August, however, it is not approved by Medsafe (neither is the Accord brand), therefore, will need to be prescribed for supply under Section 29A of the Medicines Act.
Reassure patients that there has been no change to the active ingredient, but the medicine will now come in the form of a capsule rather than a tablet.
Change in access criteria type
Tetracycline was previously funded with Special Authority approval when prescribed as part of the H. pylori quadruple treatment regimen and first-line treatment was not successful. Since July, 2026, Special Authority has been removed from tetracycline and replaced with subsidy by endorsement. A prescription is considered endorsed if tetracycline is prescribed in conjunction with a proton pump inhibitor, bismuth and metronidazole for H. pylori eradication (i.e. quadruple treatment can be prescribed first-line if the clinician considers it appropriate).
Proposal to expand PSO list
Pharmac is seeking feedback on a proposal to widen the range of medicines and products available on Practitioner Supply Order (PSO), as well as amending rules of the Pharmaceutical Schedule to better define the intended use of PSO supplies. This consultation comes following a pilot study conducted in 2025, which allowed some non‑rural general practices to access PSO medicines under rural access settings (as reported in Bulletin 113).
Read more
From 1st November, 2026, a range of medicines are proposed to be added to the PSO list, including (see proposal for full list):
- Antibiotics, antivirals and anti-infectives:
- Cefalexin 250 mg and 500 mg capsules and 25 mg/mL and 50 mg/mL oral liquid
- Valaciclovir 500 mg and 1,000 mg tablets
- Chloramphenicol 0.5% eye drops and 1% eye ointment
- Dimethicone 4% lotion
- Permethrin 5% lotion
- Hydrogen peroxide 1% cream
- Triamcinolone acetonide + neomycin + gramicidin + nystatin ear drops (Kenacomb)
- Analgesics:
- Codeine 15 mg tablets
- Diclofenac 50 mg enteric-coated tablets
- Ibuprofen 200 mg tablets and 20 mg/mL oral liquid
- Antihistamines:
- Cetirizine 10 mg tablets and 1 mg/mL oral liquid
- Loratadine 10 mg tablets and 1 mg/mL oral liquid
“Treatment of single-episode presentations” and “Routine administration within a clinical setting” would also be added to the Schedule rules for when a medicine or product can be supplied to a patient on PSO. “Emergency use, teaching and demonstration purposes” and “For provision to certain patient groups where an individual prescription is not practicable” would remain as suitable uses.
Consultation closes on Monday, 31st August. Feedback can be submitted here.
NZF updates for August
Significant changes to the NZF in the August, 2026, release include:
- Updated indications and dosing regimens for trimethoprim + sulfamethoxazole and vancomycin to align with Te Whata Kura – National Antibiotic Guidelines. Cautions, monitoring and renal impairment advice has also been updated for vancomycin.
- Medicine-overuse headache added as a caution for medicines used for the treatment of headache and acute migraine: diclofenac potassium, diclofenac sodium (systemic), ibuprofen (systemic), ibuprofen + paracetamol, naproxen, naproxen sodium, paracetamol, paracetamol + codeine, rizatriptan, sumatriptan
- New caution added for metoclopramide and domperidone: “Avoid concurrent anticholinergics (e.g. cyclizine, hyoscine) – prokinetic effects will be reduced”
- Cautions, pre-treatment screening, monitoring, contraception and conception advice and adverse effects updated for leflunomide
- Cautions and monitoring information updated for hydroxychloroquine
- Dosing regimen for the HPV vaccine updated (see Bulletin 150 for further information)
- Full monograph revision for fluconazole
- Suicidality added as an adverse effect for finasteride and dutasteride (Section 29, unapproved medicine)
- Updated cautions for etanercept, calcipotriol and calcipotriol + betamethasone (topical). New pre-treatment screening and monitoring has also been added to these monographs.
- Updated therapeutic notes for:
You can read about all the changes in the August release, here. Also read about any significant changes to the NZF for Children (NZFC), here.
South GP CME conference this week
If you are attending the GP CME conference in Christchurch this weekend, come and see our colleagues on the South Link Education Trust stand (619 – 621). The South Link Education Trust is the Diamond Sponsor of the GP CME conferences, and is home to South Link Health, BPAC Clinical Solutions, InPractice, bpacnz Publications and the New Zealand Formulary.
Grab yourself a copy of the special conference edition B-QuiCK cardio-renal-metabolic themed booklet. We would love to hear your feedback on our resources.
Podcast of the Week: Atopic dermatitis, opioids, chronic pain – three brief topics, one listen
NB Medical Education is a clinical education platform in the United Kingdom for primary care clinicians. In a recent episode of their Hot Topics podcast, Dr Neal Tucker, discusses three new research papers relevant to general practice: antihistamines for atopic dermatitis, impact of treatment duration on the effectiveness of opioids and self-directed vs clinician-delivered CBT for chronic pain.
Listen to the podcast here (21 minutes; skip ahead to ‘3.17’ for the main content) to find out:
- If antihistamines cause more harm than good when managing atopic dermatitis, and whether the choice of antihistamine matters?
- Is it time to re-think what we know about opioid analgesia in the short and long term?
- If self-directed CBT could be an effective alternative for managing chronic musculoskeletal pain?
The results might just surprise you…
Paper of the Week: Contraceptive choices - providing “sport on” advice for athletes
Contraceptive counselling is a routine aspect of primary care practice. Clinicians are well-versed in discussing contraceptive options with patients and helping them decide on an appropriate method that suits their clinical needs and personal preferences. Many patient-specific factors influence this decision; common considerations include relationship status, future pregnancy plans and concerns about adverse effects. Contraceptive choices are also influenced by a person’s co-morbidities and health status. While we often focus on conversations about healthy lifestyle interventions, eating well, losing weight and exercising more, what about patients who are in optimal physical health and want to ensure that their medicine choices do not compromise this? People in competitive sports, or even recreational athletes, may have concerns about the effects of contraception on their menstrual patterns, body composition, athletic performance and training demands.
An article published in Canadian Family Physician provides practical advice for addressing physical activity-related concerns when delivering contraceptive counselling. Tailoring contraceptive counselling to a patient’s personal circumstances, including their athletic and performance goals, fosters trust and facilitates informed shared decision-making. There is limited evidence on how different contraceptive options affect physiological performance, but practical factors can be addressed such as iron status (due to blood loss), menstrual symptom and cycle management.
Do you routinely ask about a patient’s physical activity goals or athletic performance while discussing contraceptive options? Have you ever had a patient express concern about the impact(s) of contraception on their athletic performance? If so, how did you navigate this discussion?
Read more
Approaching contraceptive counselling
- A commonly reported frustration among female athletes is that clinicians do not consider their sporting performance when discussing contraceptive options; this inevitably leads to them seeking advice from alternative sources, which can negatively impact their health
- While elite-level athletes may be more likely to require a tailored approach to their contraceptive choices, do not underestimate the value that other people may place on their sporting performance, even at recreational level
- A suggested approach to contraceptive counselling is to follow the FIFE framework. For example:
- Feelings - “Are there any concerns you have about how contraception might affect your body, health or athletic performance?”
- Ideas - “What have you been told by others about different contraceptive options?” “What are your beliefs about how specific hormones might affect your body?”
- Function - “How important is athletic performance in your life?” “Are there any specific events we need to plan for when considering your choices?”
- Expectations - “What are you hoping contraception will help with, e.g. pregnancy prevention, symptom control, cycle timing?”
Performance considerations
- There is limited evidence on the impact of different contraceptive options on athletic performance
- A practical approach is to consider factors that are likely to impact performance, e.g.:
- Iron deficiency and anaemia caused by heavy menstrual bleeding can impair performance due to reduced oxygen transport. Copper IUDs can increase blood loss; hormonal methods can be used to reduce bleeding volume.
- Menstrual symptoms can disrupt training and competition, hormonal methods can reduce symptom burden
- Controlling cycles so menstruation is avoided during competition, can be achieved with continuous use of combined oral contraceptives or progesterone-only methods
- Body composition may be a concern for those in weight-class, endurance or aesthetic sports. DMPA injections and combined oral contraceptives are often avoided, IUDs may be a preferred choice.
- Injury risk may be increased due to hormone levels affecting joint laxity, strength and neuromuscular control. There is limited and inconclusive evidence to support this, but some may wish to avoid DMPA injections and combined oral contraceptives.
- Timing of treatment initiation to avoid initial adverse effects occurring during competition time
Consider the possibility of Relative Energy Deficiency in Sport (REDs)
- When delivering contraceptive counselling to athletic patients, consider the possibility of REDs, a syndrome characterised by impaired physiological or psychological functioning because of problematic low energy availability (either intentional or unintentional); for further information, click here
- Oligomenorrhoea or amenorrhoea are key indicators of REDs; hormonal contraceptive use can complicate diagnosis by masking menstrual irregularities, therefore, alternative monitoring strategies are required
- Monitor growth (in adolescents), BMI, indicators of potential bone fragility, fatigue, frequent illness, unexplained performance decline
- Use of a questionnaire-based screening tool is recommended to identify those at risk of REDs, over-exercise or disordered eating, e.g. Low Energy Availability in Females Questionnaire, Eating Disorder Examination Questionnaire, Sick, Control, One, Fat, Food (SCOFF) Questionnaire
- Further evaluation for indicators of REDs, e.g. bone stress injury, low bone mineral density, low T3, elevated total or LDL cholesterol, is recommended for patients at risk
- Treatment of amenorrhoea or low bone mineral density with oral contraceptives is not recommended
Guiding selection of a contraceptive
- Balance the individualised risks and benefits of each contraceptive option to find the “best” one for the patient; no single option optimises all performance-relevant factors
- Consider patient-specific factors, e.g. a hormonal contraceptive is likely to be preferrable to a copper IUD in a patient with low ferritin levels and dysmenorrhoea
- Schedule routine follow-up appointments and encourage patients to return earlier if they experience persistent or intolerable adverse effects
- DMPA injections should be considered a last-line option for athletes as it is associated with reversible bone mineral density loss and weight gain, and there is some observational evidence it may increase fracture risk
- Consider management of modifiable factors that may adversely affect athletic performance, e.g. recommend increased dietary iron intake or iron supplementation for patients with anaemia
Ryall S, Ohrling H, Thornton J. Approach to sport-savvy contraceptive counselling for athletes. Can Fam Physician 2026;72:377–82. doi:10.46747/cfp.7206377.
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
© This resource is the subject of copyright which is owned by bpacnz. You may access it, but you may not reproduce it or any part of it except in the limited situations described in the terms of use on our website.
