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Published: 3rd May, 2024


Reflections on the last days of life: what does this mean for you?

Since publishing the first resources in our Last Days of Life series in September, 2023, there have been over 20,000 views. This is clearly a topic that generates much interest and signifies that there has been a need for resources in this clinical area. We have now released a podcast episode, which is a conversation with three outstanding clinicians who champion efforts to improve the standard of end of life care within New Zealand, compered by the team at bpacnz. If you haven’t listened already, we urge you to engage in this important conversation.

As a result of the feedback we have received, we have now published a Reflections page as a space for our readers to share their experiences and thoughts about the role of primary care clinicians in caring for patients in the last days of life. We would like to hear from a wide range of people, including our colleagues with many years of experience, those who may have recently cared for their first patient who died, and those with experiences from other cultures or perspectives. You can remain anonymous if you wish, and if writing isn’t your forte, we are here to help with crafting your thoughts into words. Email:

A brief excerpt from Reflections:

I firmly believe that honesty about a realistic future is the keystone for palliative care, and it needs to be done with skill, empathy and have a definite plan for further events rather than face chaos in times of a sudden medical event. As physicians, we have this responsibility - we know what they do not know. We have a responsibility to be honest, talk about treatment options, and prepare a plan of appropriate palliative care for the future.

Read the full letter and other reflections here

New CKD guidelines now available: KDIGO 2024

New guidelines are available from the Kidney Disease: Improving Global Outcomes (KDIGO) group, providing clinicians with further direction when caring for patients with chronic kidney disease (CKD). This updates the previous 2012 KDIGO guidelines and includes supplementary resources on the “Top 10 Takeaways” for primary healthcare clinicians regarding evaluation and management.

To access the 2024 KDIGO CKD guidelines, click here. An executive summary is also available here.

For further information on identifying and managing CKD in primary care, see: (this article will be updated as required after full review of the new guidelines and expert advice)

bpacnz hypertension article update: consider kidney dysfunction early

Hypertension is a particularly common clinical finding in primary care, so it should come as no surprise that the article “Hypertension in adults: the silent killer” is consistently among our most highly viewed resources. As with all our online content, we aim to progressively revise information over time to reflect changes in the evidence base and expert perspectives.

In a recent update to this resource, we emphasise the significant interconnectedness between the cardiovascular system and the kidneys, and consider the implications this has on evaluation and management. Albuminuria (or proteinuria) is often the first sign of vascular endothelial dysfunction in patients with hypertension, and is strongly associated with an elevated risk of CVD and death. However, unless patients have diabetes, urine ACR testing is often underutilised in New Zealand primary care during initial evaluation patients with hypertension.

Immunisation news: World Immunisation Week, influenza vaccine, RSV vaccine

World Immunisation Week

World Immunisation Week was held on 24th – 30th April. The theme for this year was “Humanly Possible: Immunization for All”. This is a timely reminder to opportunistically check that patients are up to date with their immunisations as part of routine appointments, and to offer vaccination where appropriate. A list of available vaccinations for adults, including for special circumstances, e.g. overseas travel, can be found here.

Anyone for flu vaccine?

The Influenza Immunisation Programme for 2024 started at the beginning of April. The national target is for at least 75% of all adults aged 65 years and over to be vaccinated this influenza season. As of 28th April, the overall vaccination rate in this group is 39%, so good progress is being made towards this target. Health New Zealand, Te Whatu Ora, publishes data on uptake of vaccinations by district, updated weekly; check out how your area is doing here. Ensure patients who meet eligibility criteria for funded vaccination are aware that they can receive a flu vaccine for free.

New article on influenza and COVID-19 vaccinations

We recently published an article outlining the latest information about seasonal influenza and COVID-19 vaccinations; click here to view. The Nuvaxovid® COVID-19 vaccine (Novavax) is no longer available in New Zealand as stock has now expired. Comirnaty™ vaccines remain available. Medsafe is currently evaluating an application for the Nuvaxovid® Omicron XBB.1.5 vaccine; an approval decision is yet to be made.

Patient sheets on managing at home with Cold & Flu and COVID-19

A reminder that you can download and print, send a link or direct patients to information sheets on managing at home with seasonal viral illness or COVID-19.

RSV vaccine for older adults now available

A new vaccine (Arexvy) for the prevention of lower respiratory tract disease caused by respiratory syncytial virus (RSV; covering RSV-A and RSV-B subtypes) is available from 1st May for adults aged 60 years and over. The vaccine is a one dose course administered via intramuscular injection in general practice. It is not currently known whether re-vaccination is required, but evidence suggests that it will provide protection for at least two RSV seasons. The vaccine is not funded; it can be ordered via Healthcare Logistics (HCL). Pharmac has received an application for funding, however, a decision is yet to be made.

N.B. In some countries, the Abrysvo RSV vaccine is recommended for people who are pregnant, however, this vaccine is not currently approved for use in New Zealand. Arexvy is not recommended during pregnancy.

Information for healthcare professionals about the vaccine, including safety and effectiveness, is available from IMAC, here. A Goodfellow Unit webinar hosted by IMAC on RSV is available here.

Patient information from GSK about RSV and Arexvy is available here

Medicine news: dulaglutide/liraglutide, levothyroxine, omeprazole

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

Upcoming webinar on HIV PrEP and PEP prescribing

HealthPathways, in conjunction with The Royal New Zealand College of General Practitioners and the Burnett Foundation Aotearoa, are hosting a webinar on prescribing HIV pre- and post-exposure prophylaxis (PrEP and PEP). This free webinar is aimed at primary care prescribers and will cover:

  • Background on the goals and barriers to eliminating HIV transmission in New Zealand
  • Practical information regarding prescribing of PrEP and PEP in primary care
  • Burnett Foundation Aotearoa resources
  • How to navigate HealthPathways

The webinar will be held at 7 pm on Tuesday, 14th May. Click here to register.

Burnett Foundation Aotearoa and the New Zealand Sexual Health Society are also running a series of free HIV PrEP and PEP education sessions for non-specialist prescribers around the country and online. These CME-accredited sessions will focus on the practical aspects of prescribing HIV PrEP and PEP, e.g. clinical training, time management, prescription repeats. Click here for dates and locations.

Watch this space for an upcoming bpacnz article update on prescribing HIV PrEP and PEP in primary care.

Updated Australian cardiovascular disease risk guidelines

New guidelines are available in Australia on the assessment and management of cardiovascular disease (CVD) risk. This updates the previous 2012 guidelines and includes a new CVD risk calculator, which uses the New Zealand PREDICT risk equations. The guidelines are endorsed by the Royal Australasian College of General Practitioners. A summary of the changes can be found here.

New Zealand cardiovascular risk assessment and management guidelines were published in 2018. Guidance is largely similar, however there are some differences, including younger age groups for risk assessment and definitions of CVD risk categories (over five years) as well as the consideration of insulin use when calculating CVD risk in people with diabetes. We are not aware of any planned updates to New Zealand guidance at this stage.

Read the full guideline here. A summary of recommendations and a factsheet for healthcare professionals is also available.

Australian Prescriber has published a practical summary of the guidelines, available from:

Finasteride associated with psychiatric effects and sexual dysfunction: report from the UK

In April, 2024, the United Kingdom Medicines and Healthcare products Regulatory Agency (MHRA) published a new Drug Safety Update on finasteride (used in the treatment of male pattern hair loss and benign prostatic hyperplasia), reminding healthcare professionals and patients about the potential risk of psychiatric adverse effects and sexual dysfunction associated with its use. In some cases, sexual dysfunction persists after finasteride has been discontinued.

Finasteride is a prescription-only oral medicine in New Zealand. There have been no recent medicine communications from Medsafe regarding finasteride, however, in 2016, a Prescriber Update article was published highlighting post-finasteride syndrome. Any suspected adverse effects thought to be related to finasteride use can be reported to the Centre for Adverse Reactions Monitoring (CARM).

Free cultural competency courses for healthcare professionals

A range of New Zealand based cultural competency courses are available for healthcare professionals through eCALD. These free resources aim to help clinicians strengthen relationships with culturally and linguistically diverse (CALD) patients, and patients from Asian, Middle Eastern, Latin America and African backgrounds. Courses can be completed online in a self-guided manner or via Zoom with an educator, or in-person. Click here for further information, including available courses.

New registered ACC treatment providers proposed

A consultation has been released on “Changes to ACC regulations for Chinese medicine, paramedics and audiometrists”. It is proposed that from late 2024, practitioners of Chinese medicine, paramedics and audiometrists would be able to provide treatment to patients through the ACC Cost of Treatment Regulations. Healthcare professionals and organisations are encouraged to comment on the proposal. The consultation closes Thursday 16th May, 2024 (submissions are made via the Ministry of Business, Innovation and Employment, here).

Read more about the proposal here

World Hand Hygiene Day – 5th May

World Hand Hygiene Day is coming up on Sunday (5th May); a day to remind healthcare professionals of the important role that good hand hygiene practices have in the healthcare setting. The theme for this year is about sharing knowledge and promoting training and education about infection prevention and control. Further information and resources for the global campaign from the World Health Organization are available here.

To support World Hand Hygiene Day in New Zealand, the Health Quality & Safety Commission has produced information and resources for healthcare professionals, including an online quiz and other activities. Click here to access them. Resources are also available from the Australasian College for Infection Prevention and Control.

NZF updates for May

Significant changes to the NZF in the May, 2024, release include:

  • New monograph added on fluticasone furoate + umeclidinium + vilanterol (indicated for maintenance treatment of moderate to severe COPD and asthma in those not adequately controlled with an inhaled corticosteroid and long-acting beta2-adrenergic agonist)
  • Medsafe Monitoring Communication link added to each of the individual calcium channel blocker monographs on the possible risk of new-onset eczema (see Bulletin 97 for further information)
  • Cautions, adverse effects and patient advice updated in the individual quinolone monographs. The therapeutic notes have also been updated.
  • Contraindications updated in the iron monographs
  • New formulations, dosing and advice added to the testosterone and esters monograph (for testosterone replacement in primary and secondary male hypogonadism and hypoactive sexual desire dysfunction in post-menopausal females [unapproved indication])
  • New section added on testosterone and management of menopausal symptoms (N.B. Testosterone cream [AndroFeme] used for these symptoms is an unapproved medicine [Section 29] and is not funded.)

You can read about all the changes in the May release here. Also read about any significant changes to the NZF for Children (NZFC), here.

Paper of the Week: Antipsychotic medicines associated with negative outcomes in people with dementia

The prevalence of dementia is rising both here and globally. Approximately 4% of adults aged over 60 years in New Zealand have dementia, and this rises to 14% in those aged over 80 years. Māori and Pacific peoples also have higher rates of dementia in these age groups, compared to people of European and Asian ethnicities (data available here).

People diagnosed with dementia require significant family/carer support and often pharmacological management. In some cases, antipsychotic medicines may be prescribed to manage target behavioural and psychological symptoms (BPSD), e.g. aggression, agitation and hallucinations. Antipsychotic medicines have limited evidence of benefit for BPSD and are associated with significant risk. “Off-label” use for patients with dementia to increase sedation or manage sleep or anxiety disorders is discouraged.

A study published in the British Medical Journal analysed the link between antipsychotic medicine use in patients with dementia and the incidence of adverse outcomes. The results suggest that patients with dementia who are prescribed antipsychotic medicines may be at higher risk of acute kidney injury, fracture, heart failure, myocardial infarction, pneumonia, stroke and venous thromboembolism, compared to patients with dementia who have never taken antipsychotic medicines. Interestingly, the highest risk of negative outcomes occurs soon after initiating treatment, i.e. within the first week. Given the already increased vulnerability of this patient group, the authors question whether more needs to be done to ensure these medicines are only used when clearly indicated and necessary.

What criteria do you employ when assessing whether antipsychotic medicines are appropriate for a patient with dementia in your care? Do you provide specific information for family/carers about the need for increased monitoring, and potentially the lower threshold for seeking urgent medical attention following initiation of an antipsychotic medicine? Do you assess effectiveness against the target behaviour and have a plan for stopping if risks outweigh the benefits?

Mok PLH, Carr MJ, Guthrie B, et al. Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study. BMJ 2024;:e076268. doi:10.1136/bmj-2023-076268.

For further information on managing behavioural and psychological symptoms in people with dementia, see:

This Bulletin is supported by the South Link Education Trust

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