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Published: 24th November, 2023


New article: Oral anticoagulant selection in primary care

Direct oral anticoagulants (DOACs) such as dabigatran and rivaroxaban are now established as the “go to” choice in primary care for prevention of thromboembolic events in patients at increased risk. In addition to their superior clinical efficacy, DOACs also have a number of practical advantages compared with the conventional option, warfarin, including more predictable pharmacokinetic and pharmacodynamic properties, no INR monitoring requirements, significantly fewer medicine and food interactions and more rapid onset of action.

Oral anticoagulant selection should, however, always be individualised, and warfarin is still sometimes required on a case-by-case basis in patients with specific co-morbidities or characteristics that make DOACs unsuitable. For example, warfarin should be used in patients with mechanical heart valves, moderate-to-severe mitral stenosis or severe liver disease. Regardless of the option selected, ongoing management involves consideration of modifiable risk factors for bleeding, treatment adherence and monitoring for adverse effects.

The full article can be accessed here. A B-QuiCK summary is also available here.

World Antimicrobial Awareness Week: 18th – 24th November

Antimicrobial Awareness Week ends today, but our collective dedication to antimicrobial stewardship does not. As reported in Bulletin 87, the international theme this year is “Preventing antimicrobial resistance together”.

Make it meaningful: A New Zealand initiative encourages prescribers to include a specific indication on their antibiotic prescriptions, e.g. flucloxacillin, 500 mg, four times daily, for five days, for cellulitis. This allows reflection on medicine choice, to help promote a consistent and safe approach to the use of antibiotics.

The bpacnz antibiotic guide has been used by prescribers in primary care for over ten years. Keep checking regularly to ensure you are up to date with the latest recommendations.

Medicine supply issues: morphine oral liquid, olanzapine depot injections, prochlorperazine tablets

The following issues relating to medicine supply, of particular interest to primary care, have recently been announced. This information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.

Pertussis immunisation reminder

The Immunisation Advisory Centre (IMAC) has reminded healthcare professionals about the importance of maternal pertussis vaccination, in a recent email to the sector. Maternal immunity may be lower than pre-COVID-19 levels due to a combination of factors, including lower vaccination rates and a period of low pertussis circulation. Cases of pertussis are now on the increase, including three infant deaths this year, and IMAC notes that a predicted pertussis outbreak is now overdue.

Tdap (Boostrix) immunisation is recommended and funded for pregnant women during every pregnancy and for all children. As outlined in Bulletin 70, it is also recommended but not funded for close family contacts of young infants and in some cases for those at higher risk of complications, e.g. patients with COPD. The exact duration of protection is unknown, but many groups (e.g. lead maternity carers, primary care clinicians, early childhood workers) are recommended to have a booster dose at least every ten years; see the Immunisation Handbook for further information.

A factsheet for healthcare professionals on recommended and funded vaccines during pregnancy is available from IMAC, here

All suspected cases of pertussis must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before isolating, treating and notifying.

Immunisation Register transition delayed

The transition to the Aotearoa Immunisation Register (AIR) will now occur on 2nd December, 2023, instead of the previously announced date of 25th November, 2023 (as reported in Bulletin 87). From 2nd December, all vaccinations will be recorded in either your PMS or the AIR vaccinator portal. The National Immunisation Register (NIR) and COVID-19 Immunisation Register (CIR) will no longer be used to record vaccinations or to view a patient’s immunisation status or history.

For further information, see:

Clinical workforce for HPV testing expanded

Since 12th September, 2023, HPV testing, which detects the presence of high-risk HPV types known to cause cervical cancer, has been the primary cervical screening test in New Zealand. HPV testing can be performed from a vaginal swab sample (with the option of self-testing) or liquid-based cytology sample. Early feedback suggests that the option of self-testing has already increased participation among people who have previously been reluctant to receive screening.

Initially, only doctors and midwives, or other healthcare professionals (e.g. nurses, nurse practitioners) who had completed NZQA training in cervical screening were able to facilitate HPV self-testing. This has now been extended as part of a phased workforce expansion programme to include enrolled nurses, registered nurses and nurse practitioners who have not completed NZQA training in cervical screening if they meet certain criteria (see below). This group will be referred to as HPV screen-takers and will be eligible to facilitate HPV self-testing upon completion of the “HPV Screen-taker Learning Pathway”. A summary of the new Learning Pathway can be found here.

N.B. HPV screen-takers cannot take a cervical LBC sample; if a LBC sample is required or preferred by the patient, referral to an accredited cervical sample taker is needed, click here for a HPV screen-taker decision flowchart.

For information on cervical cancer, including new cervical screening recommendations, see: A brief HPV testing summary guide for general practice is also available here.

Rural telehealth service launched

An after-hours telehealth service (by Ka Ora Telecare Limited) is now available for people in rural communities across New Zealand. The service, which operates from 5 pm to 8 am during weekdays, and 24 hours during weekends and on public holidays, can be accessed by patients by calling 0800 2KA ORA (0800 252 672) or via referral from the patients rural general practice. The service is available to all people who live rurally (or who are currently visiting a rural area), regardless of whether they are enrolled with a rural practice.

Patients will be initially triaged by a kaiāwhina or nurse and if needed, referred through to a clinician. There is no charge for a nurse consultation, however, a patient co-payment is required if a telehealth consultation with a clinician is needed. If a patient has a Community Services Card or is aged ≥ 65 years, they will be charged a lower fee ($19.50); there is no charge for children aged under 14 years. Click here for further information.

RNZCGP statement on smoking and vaping

The Royal New Zealand College of General Practitioners (RNZCGP) has released a position statement on smoking and vaping. Views have been developed and grouped into three sections: (1) Protecting rangatahi (young people); (2) Supporting people who smoke or used to smoke; and (3) Protecting all people from the potential harm of vaping. In summary, the RNZCGP believes that vaping can have a role in aiding smoking cessation, however, the availability of vapes is currently too wide; restrictions and regulatory changes are required to reduce potential harms and prevent younger people from starting vaping. Read the full statement and specific recommendations here.

The Asthma and Respiratory Foundation NZ has recently published guidelines for healthcare professionals on supporting young people and adolescents to quit vaping, covering screening and assessment, behavioural support, pharmacotherapy and follow-up. Read the full guideline here.

Upcoming ACC webinars

ACC is hosting two upcoming webinars that may be of particular interest to primary care:

In case you missed it. ACC recently hosted webinars on how to invoice under the Rural General Practice Services contract and on how to complete an ACC45 Injury Claim Form. If you missed it, recordings of the webinars can be viewed here and here.

Pancreatic Cancer Awareness Month

November is Pancreatic Cancer Awareness Month. Pancreatic cancer can be particularly aggressive and has a high mortality rate; in 2018, it was the fourth most common cancer-related death in both males and females in New Zealand. Primary care clinicians can facilitate the early detection of pancreatic cancer; however, this can be challenging as symptoms and signs are often absent in the early stages or are non-specific.

For further information on pancreatic cancer, see: and

Paper of the Week: Running away from depression

The annual Movember campaign for men’s health is currently in full swing. This movement raises awareness for men’s mental health and suicide prevention as well as prostate and testicular cancer. While growing a moustache is synonymous with Movember, another way to show support for men’s health, particularly mental health, is by running (click here for details). During the COVID-19 lockdown, many people turned to running as a way of coping with the increase in stress and isolation. Maintaining the momentum now that life is slowly returning to “normal” can be a challenge.

It is well established that regular exercise can help to prevent or treat various conditions, e.g. hypertension, diabetes. There is also mounting evidence that exercise may be at least as effective as standard treatment strategies for mild to moderate depression. A recent study published in the Journal of Affective Disorders compared the effects of running and antidepressant medicines on the mental and physical health of people diagnosed with either depression or anxiety disorder. The authors found that remission rates were comparable between those running and those taking antidepressant medicines, however, unsurprisingly, people in the running intervention group showed significant improvements in physical health outcomes, e.g. body weight, waist circumference, systolic and diastolic blood pressure.

Given that not everyone who is prescribed an antidepressant experiences meaningful symptom improvement, and they are associated with adverse effects (e.g. gastrointestinal or anticholinergic adverse effects, sexual dysfunction), it seems reasonable that exercise should be strongly emphasised to all patients as part of their treatment strategy for depression or anxiety. If they are physically capable and motivated to take up running, this would be a preferable activity.

How likely are you to recommend running to patients with depression or anxiety? Is there something specific about running that makes it an effective treatment for depression, e.g. endorphin release? Are there other types of exercise that you think would achieve the same results that you could recommend to patients who are not able to run? Have you given a written prescription for exercise before (see below)?

Verhoeven JE, Han LKM, Lever-van Milligen BA, et al. Antidepressants or running therapy: Comparing effects on mental and physical health in patients with depression and anxiety disorders. Journal of Affective Disorders 2023;329:19–29. doi:10.1016/j.jad.2023.02.064

Consider giving patients a written prescription to take away with them after recommending regular exercise, e.g. 30 minutes of walking, daily and 30 minutes of resistance training, twice weekly. The act of filling out and giving the patient the prescription may help to reinforce that the exercise component of management is just as important as medicines.

This Bulletin is supported by the South Link Education Trust

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