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Published: 8th March, 2024


What’s trending at bpacnz this week

The most popular resource on the bpacnz website this week is the Antibiotics Guide. Over the past seven days, thousands of website users in New Zealand clicked on the Guide to check which antibiotic to prescribe, at what dose and duration, and perhaps most importantly, when. For example, antibiotic treatment is usually not necessary in people with sore throats, unless they are at high risk of rheumatic fever as a consequence of group A streptococcus infection.

Other popular resources this week include the Contraception series, in which you can find information and prescribing guidance for all available contraception options; our recently updated article on Melatonin: is it worthwhile for sleep, in which the evidence remains equivocal; and Hypertension in adults: the silent killer, where you can update yourself on the latest guidelines for treating this commonly seen condition in primary care: if your patients are not on dual antihypertensive treatment yet, consider if they should be.

Find the answers to all your clinical questions here, or just stay awhile to browse and perhaps learn something new.

*Sneak peek*

Coming soon: A podcast on navigating the last days of life - a general practice perspective

This is the conversation every health care professional should be part of – how do we talk about dying?

Whenever we're discussing dying, it brings us close to our own mortality. It brings up all kinds of emotions in ourselves. And until we kind of wrestle with those a little bit and get comfortable with it and manage our own demons around that, I don't think we can really move forward. We've got to get comfortable with using the words in getting close to it.

Dr Helen Atkinson, GP and Medical Officer, Harbour Hospice

Influenza vaccine eligibility criteria for 2024

The 2024 influenza immunisation programme commences on 2nd April. Pharmac has announced eligibility criteria for funded vaccination this year. Funded access remains for people aged 65 years and older, people aged under 65 years with long-term conditions or specific mental health conditions or addictions, people who are pregnant and children aged ≤ 4 years who have been hospitalised for, or have a history of, significant respiratory illness. However, people aged 55 – 64 years of Māori or Pacific ethnicity and children aged 3 – 12 years are no longer eligible for funded influenza vaccination this year. Click here for the full list of funded access criteria.

The 2024 Flu kit booklet for health professionals is available here.

New COVID-19 vaccine (XBB.1.5) now available

The Comirnaty 30 microgram XBB.1.5 COVID-19 vaccine is now available for people aged 12 years and older. This vaccine replaces the Comirnaty 30 microgram and Comirnaty BA.4/5 (15/15 mcg) vaccines for both primary and additional doses in people aged ≥12 years. A factsheet is available here.

People aged 30 years and older, people aged 16 – 29 years who are pregnant and people aged 12 – 29 years who are at higher risk of severe illness from COVID-19 remain eligible to receive funded additional doses (previously called booster doses). It is recommended that additional doses are given at least six months apart, or six months after a positive COVID-19 test. Clinical discretion, however, can be applied for some patients, e.g. an interval of three months may be appropriate for patients at high risk of severe disease from COVID-19.

For further information on COVID-19 vaccines, including eligibility criteria, see: or the Immunisation Handbook, here.

The Immunisation Advisory Centre recently hosted a webinar discussing the new vaccine. For those who missed it, the recording can be found here.

New guidance for household contacts: It was announced earlier this week that asymptomatic household contacts of a person with COVID-19 are no longer recommended to test (with a RAT) each day. Contacts need only test for COVID-19 if they develop symptoms. RAT home testing kits are currently free until 30th June, 2024.

Empagliflozin: new indications, updated guidance on use in renal impairment

Boehringer Ingelheim and Eli Lilly have announced some key updates to the approved therapeutic indications and prescribing guidance for empagliflozin (Jardiance). It should be noted, however, that there has been no change to funding restrictions and empagliflozin remains funded only for patients with type 2 diabetes who meet criteria for Special Authority approval. The changes include:

  • New indication for the treatment of adults with chronic kidney disease (where it is used for its dual kidney- and cardio-protective properties)
  • New indication for use in children aged ≥ 10 years with type 2 diabetes as monotherapy if metformin is not tolerated or in combination with other glucose-lowering medicines (under specialist supervision) if glycaemic control remains poor (previously only indicated in those aged ≥ 18 years)
  • The recommendation that empagliflozin should not be used in people aged ≥ 85 years has been removed, however, caution is still advised for those aged ≥ 75 years who may be more at risk of volume depletion
  • Updated recommendations for use in people with renal impairment
    • People with an eGFR < 30 mL/min/1.73 m2 can take a maximum dose of empagliflozin of 10 mg, however, it is not recommended for use in people undergoing dialysis
    • Empagliflozin may be ineffective at reducing glucose levels in people with this degree of renal impairment, therefore additional glucose-lowering medicines may be required
    • Empagliflozin was previously contraindicated for people with an eGFR < 30 mL/min/1.73 m2
  • An expanded warning on ketoacidosis as this is considered a risk in people with, or without, diabetes. N.B. Fournier’s gangrene is also a rare adverse effect associated with empagliflozin; see Bulletin 64.

For a full list of indications for empagliflozin see the New Zealand Formulary

For further information on the management of CKD, see:

For further information on empagliflozin, and type 2 diabetes in young people, see: and

Position statement on the management of heart failure in New Zealand released

A position statement from a collective of New Zealand cardiology experts (the Heart Failure Working Group), endorsed by the Cardiac Society of Australia and New Zealand (NZ Region), and the New Zealand Heart Foundation, has recently been published in the New Zealand Medical Journal. This statement comes in response to developing perspectives around optimal heart failure management in local and international guidelines, as well as evidence that health inequities relating to heart failure continue to widen in New Zealand.

Click here to view the full position statement (N.B. Individuals must subscribe and log in to view this resource, however there is no subscription fee.)

The bpacnz heart failure article has been updated to include this statement, see:

Medsafe Alert Communication: lead poisoning with Ayurvedic products

Medsafe has issued an Alert Communication about lead poisoning associated with the use of Ayurvedic products, which are a form of traditional Indian medicine, typically derived from plants, but they may also contain mineral, metal or animal substances. In recent months, there have been eight notifications of people with lead poisoning with exposure suspected to be from Ayurvedic products. We previously reported on an increase in lead notifications from suspected Kamini use in Bulletin 92.

Medsafe is advising health care professionals to ask patients presenting with unexplained symptoms and signs (e.g. abdominal pain, nausea, vomiting, constipation) about their use of traditional remedies, including Ayurvedic products, and to consider the possibility of lead poisoning in patients taking these products. Contact the National Poisons Centre (0800 764 766) if a patient is suspected to have lead poisoning, and if possible, collect a sample of the implicated product so that it can be tested by Medsafe.

For further information on Kamini, see:

For further information on lead poisoning, including notifying the local Medical Officer of Health, see: and

Latest edition of Prescriber Update released

The March edition of Prescriber Update has been published. Particular items of interest for primary care include:

View the full edition of Prescriber Update here

A focus on suicide prevention: latest suicide data released

Health New Zealand, Te Whatu Ora, has updated the suicide data web tool to include confirmed data from 2019 and suspected self-inflicted deaths up to 2022/23. There were 673 confirmed suicide deaths in New Zealand in 2019; 13% higher than the average rate over the past ten years. Age-standardised rates by ethnicity show that Māori die by suicide at approximately twice the rate of non-Māori. Young people are also over-represented in suicide statistics. There were 565 suspected self-inflicted deaths in New Zealand in 2022/23, with similar demographic trends as previous years; Māori males had the highest rates of death. Although the number of suspected suicides is lower in 2022/23 than the confirmed statistics from 2019, suicide rates are variable and the overall trend over time has not thought to have changed.

In 2017, bpacnz published an editorial on suicide prevention in primary care, with guest commentary from mental health experts in New Zealand. The following is an excerpt: Only a portion of the total number of people who die by suicide are seen in general practice, therefore it is crucial that any opportunity for intervention is acted on. If in the course of a consultation a patient expresses verbally or non-verbally that their mood is low, they should be assessed for suicide risk. This can be done in a formal manner, but it is often best approached as a conversation, using clinical judgement as to how far the questions go. There is no one right way to ask about suicide, and the only wrong way is not to ask at all. The manner and tone of asking is more important than the words used. Be empathic, sensitive and non-judgemental, in a way that invites the patient to share the depth of their concern and despair.

As individuals we cannot prevent every death, but if we can make a meaningful connection with one person, that may make a difference.

For further reading, see: "Suicide prevention: what can primary care do to make a difference".

Cilazapril delisting date moved to 2025

Pharmac has announced that the delisting date for cilazapril has been moved to 1st January, 2025. Stock of the 5 mg presentation is expected to run out by July, 2024; the 0.5 mg and 2.5 mg presentations will expire in October, 2024. Prescribers should be identifying any patients still taking cilazapril and moving them to another option.

For further information on selecting an ACE inhibitor or ARB, see:

News in brief: Family Planning is now Sexual Wellbeing Aotearoa

Sexual Wellbeing Aotearoa is the new name for Family Planning. The name change is intended to better represent the wide range of services offered, including clinical services, contraception, fertility and reproductive health advice, sexuality and relationships education, training and other related resources. Read more about the name change here.

NZF updates for March

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

  • Contraindication removed (type 1 diabetes) from the dulaglutide and liraglutide monographs
  • Chronic kidney disease added as a new indication for empagliflozin. Contraindications and advice in renal impairment have also been updated.
  • Dosing regimen has been updated in the testosterone and esters monograph, including the addition of a transdermal gel (Testogel) which will be funded from 1st April, 2024.
  • Contraindications, contraception and conception, pregnancy advice, pre-treatment screening and patient advice has been updated in the modafinil monograph (used in the treatment of narcolepsy, obstructive sleep apnoea and other sleep disorders)
  • Pregnancy advice has been updated in the CNS stimulants monographs

You can read about all the changes in the March release here. Also read about any significant changes to the NZF for Children (NZFC), here, including the lowering of the approved age for use of empagliflozin.

Paper of the Week: Is orthostatic hypotension a problem in adults with hypertension?

Hypertension is a common clinical finding in general practice, and primary health care professionals are well versed in the importance of lowering blood pressure (BP) to reduce cardiovascular disease (CVD) risk. While the initial approach to treatment for hypertension is well defined, management can sometimes be complicated by the presence of orthostatic hypotension (postural hypotension), where a patient exhibits a sustained drop in systolic BP (> 20 mmHg) or diastolic BP (> 10 mmHg) a short time after standing. This can increase the risk of adverse clinical outcomes, e.g. falls, syncope, dementia, CVD, mortality. However, under-treated hypertension is also associated with adverse outcomes, so management decisions must be balanced.

The American Heart Association (AHA) has recently released a scientific statement on identifying and managing orthostatic hypotension in adults with hypertension. The recommended strategy is:

  1. Identify the pattern of orthostatic hypotension, triggers and any underlying causes
  2. Eliminate these triggers and causes where possible, e.g. withdrawing or reducing doses of medicines not related to hypertension treatment (e.g. amitriptyline), avoiding antihypertensive treatments that have an increased risk of orthostatic hypotension (e.g. alpha-blockers such as doxazosin, vasodilating beta blockers such as carvedilol), reducing aggravating factors (e.g. excessive alcohol intake, volume depletion)
  3. Optimise the antihypertensive regimen: there is no need to set a less stringent BP target as well controlled hypertension appears to be less associated with orthostatic hypotension
  4. Add a tailored treatment strategy for the patient that avoids exacerbating their hypertension (which will therefore reduce the risk of orthostatic hypotension), e.g. maintaining adequate fluid and salt intake, use of compression garments. Short-acting vasoactive medicines (e.g. pyridostigmine, fludrocortisone) may be considered in patients with severe symptoms.

Do you commonly assess for orthostatic hypotension in patients with hypertension or only investigate if they report symptoms such as light-headedness on standing? Are you confident in individualising the management of patients with both hypertension and orthostatic hypotension?

Juraschek SP, Cortez MM, Flack JM, et al. Orthostatic hypotension in adults with hypertension: a scientific statement from the American Heart Association. Hypertension 2024;81. doi:10.1161/HYP.0000000000000236

This Bulletin is supported by the South Link Education Trust

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