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Published: 27th June, 2024


Te Rā Aro ki a Matariki: Matariki observed tomorrow

Tēnā koutou katoa. Best Practice Bulletin is coming to you one day early this week as we celebrate Matariki on Friday 28th June: the start of the Māori new year.

Matariki is a time for remembering the deceased (Matariki Hunga Nui) – honouring those we have lost since the last rising of Matariki; celebrating the present (Matariki Ahunga Nui) – giving thanks for what we have; and planning for the future (Matariki Manako Nui) – looking forward to the promise of a new year. Matariki is about coming together and reconnecting with your home and whānau and is often celebrated by sharing kai (food).

Have a go to kōrero, e.g. greet patients into the medical centre with Kia ora or more formally, Tēnā koe (one person), Tēnā kōrua (two people) or Tēnā koutou (three or more people).

To find out more about Matariki, see:

Mānawa maiea te putanga o Matariki
Mānawa maiea te ariki o te rangi
Mānawa maiea te Mātahi o te Tau
Whano, whano
Haramai te toki ata huakirangi
Haumi e
Hui e
Tāiki e!

Celebrate the rising of Matariki
Celebrate the lord of the skies
Celebrate the new year
Unite, unite
And bring forth the dawn
In union
We are one!

New report from bpacnz: Revisiting antibiotic use in New Zealand - how does your prescribing compare?

Excessive and inappropriate antibiotic prescribing accelerates the emergence of antimicrobial resistance, limiting the options available when they are required for managing bacterial infections. New Zealand has previously been identified as having higher rates of antibiotic consumption than many other developed countries, with a significant proportion likely representing inappropriate use.

To help prescribers reflect on antimicrobial stewardship, the Publications team at bpacnz has produced a report on New Zealand antibiotic use between 2019 – 2023. This encompasses the lead up and initial stages of the COVID-19 pandemic; a period of time already shown to be linked to disrupted patterns of medicine use, e.g. opioid prescribing.

Key findings from this new analysis demonstrate that:

  • Following a significant decrease in overall antibiotic use between 2019 and 2020 (as reported previously), dispensing of oral antibiotics is now trending back upwards again. The overall five-year relative decrease in oral antibiotic dispensing between 2019 – 2023 matches what would have previously been expected for an annual decrease in the years preceding COVID-19.
  • Amoxicillin is the most commonly dispensed oral antibiotic. Amoxicillin + clavulanic acid has few first-line indications, yet is the second most commonly used oral antibiotic; most amoxicillin + clavulanic acid use is occurring without prescribers first trialling another option.
  • Nitrofurantoin is now much more commonly used than trimethoprim, suggesting prescribers have appropriately shifted their approach to antibiotic selection for uncomplicated UTIs (in line with changing recommendations)
  • Almost half of all patients dispensed an oral antibiotic received a supply covering more than seven days; this is out of step with recommendations to prescribe shorter courses for many indications
  • There remains significant variation in antibiotic dispensing across New Zealand. Pacific peoples, Māori and those living in socioeconomically deprived areas have higher rates of use than other groups.

These findings indicate a clear need to renew efforts to curb inappropriate antibiotic use in New Zealand, particularly as research shows that modest decreases in overall prescribing does not substantially compromise patient safety (at a population level).

Personalised prescribing data available: If you are a primary care prescriber, you can log in to see your personalised antibiotic prescribing snapshot, including how your prescribing weighs up against your peers and national trends. do you compare?

To view the antibiotic report, click here

Patient information sheets

Antimicrobial stewardship is not only the role of prescribers – increasing patient knowledge and confidence is crucial in preserving the use of antibiotics. We have developed two information sheets that can be given to patients prescribed antibiotics or parents/caregivers of a child prescribed antibiotics.

Medicine news: prescription co-payments, testosterone patches, fluticasone, risperidone

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.

In brief: widened shingles vaccine eligibility criteria from 1st July

Funded access criteria to the shingles vaccine (Shingrix) will be widened from 1st July, 2024 (as reported in Bulletin 97) to include people aged 18 years and over who are immunocompromised due to any of the following:

  • Pre- or post-haematopoietic stem cell transplant
  • Pre- or post-solid organ transplant
  • Haematological malignancy
  • Poorly controlled HIV infection
  • Planned or receiving disease modifying anti-rheumatic drugs (DMARDs) for polymyalgia rheumatica, systemic lupus erythematosus or rheumatoid arthritis
  • End stage kidney disease (CKD 4 or 5)
  • Primary immunodeficiency

Funded access will remain for people aged 65 years.

Interaction between warfarin and tramadol: report from the UK

In June, 2024, the United Kingdom Medicines and Healthcare products Regulatory Agency (MHRA) published a new Drug Safety Update alerting healthcare professionals to the potential interaction between warfarin and tramadol. Elevated International Normalised Ratio (INR) levels have been reported with concurrent use of warfarin and tramadol, which in some cases can cause significant bruising and bleeding.

Advice from the New Zealand Formulary Stockley’s Interaction checker is that, while this reaction is rare, close monitoring of INR levels is sensible when tramadol is prescribed with warfarin, and some patients may need a reduction in warfarin dose. Consider whether an alternative opioid, e.g. codeine, can be prescribed instead.

There have been no recent medicine communications from Medsafe regarding the interaction between warfarin and tramadol, however, in 2006, a Prescriber Update article was published highlighting evidence (locally and internationally) of the interaction. Medsafe advise that if tramadol is prescribed to a patient taking warfarin, close monitoring of INR is recommended due to an increased risk of bleeding, particularly during the first week of treatment. The patient’s INR may remain elevated for several days following tramadol withdrawal. Any adverse medicine reactions thought to be related to warfarin and tramadol use should be reported to the Centre for Adverse Reactions Monitoring (CARM).

For further information on prescribing tramadol appropriately, see:

For further information on prescribing warfarin, see: and

Sodium valproate use in males: evidence update

In 2023, Medsafe issued an Alert Communication on the use of sodium valproate (Epilim) in “people who can father a child” due to a potential increased risk of neurodevelopmental disorders in children after paternal use of sodium valproate at the time of conception (as reported in Bulletins 76 and 89). Healthcare professionals were advised to inform male patients who take sodium valproate to use contraception during and for at least three months after stopping this medicine.

This advice has not changed, however, a recently published Danish study undertaken in a similar population to the original study cohort was unable to find an association between paternal use of valproate at the time of conception and risk of major congenital malformations and neurodevelopmental disorders in children.

At this stage, males taking sodium valproate should continue to be informed about this potential risk, and those who are planning parenthood soon may consider switching to an alternative treatment. A letter for healthcare professionals from the manufacturer about this potential risk is available here.

The risk of adverse effects of antiepileptic medicines for females of reproductive age is already well documented, and precautions around effective contraception for females also apply. Read more here.

Medical Council seeking feedback on new registration pathway for overseas doctors

The Medical Council of New Zealand (MCNZ) is seeking feedback on a new pathway to expedite the registration process for overseas medical graduates. Currently, the MCNZ requests information from the applicant’s medical College before eligible overseas medical graduates with the appropriate specialist qualifications can be vocationally registered in New Zealand. This process may take up to six months.

Under the proposed pathway, the MCNZ would not need to seek information for overseas medical graduates who completed postgraduate medical training in certain specialties in the United Kingdom and Ireland. However, these graduates must have worked for at least two years (of the last five years) in a comparable health system. The relevant specialties currently include anaesthesia, emergency medicine, general practice and internal medicine.*

*The MCNZ requires further information regarding obstetrics and gynaecology, psychiatry and diagnostic and interventional radiology before these specialties will be included in the pathway

Click here for further information. Consultation closes Tuesday 30th July, 2024.

Initial findings on the pre-school oral health initiative published

The Health Promotion Agency has released a report of the first phase of the Oral Health Toothbrush and Toothpaste Initiative (TTI). The initiative which started in December, 2021, aims to improve the oral health of pre-school aged children who are most at risk of poor oral health outcomes by providing them and their family/whānau with free toothbrushes, toothpaste and educational material. Priority groups include pre-school aged children of Māori and Pacific ethnicity and those living in low socioeconomic areas.

Results from the implementation phase (December, 2021 – August, 2023) are positive and show that the TTI is reaching priority groups. Data from the New Zealand Health Survey show that the number of children who are brushing their teeth with fluoride toothpaste at least twice per day is increasing over time. A focus of the next phase of the TTI is to improve uptake of resources to support family/whānau in implementing good toothbrushing practices.

Read the full report here. An infographic summary is also available here.

Checking in on oral health in primary care

Use opportunities (e.g. B4 School Checks, during an immunisation consultation) to check in on, and support, the oral health of young children, particularly those of Māori and Pacific ethnicity or who live in areas of high deprivation; refer to community oral health services as needed. Promote good oral hygiene practices by reminding parents/caregivers that:

  • Children should brush their teeth twice a day with fluoride toothpaste - half a pea-sized amount if aged < 5 years and a pea-sized amount if aged ≥ 5 years
  • At least one of these times, the child’s teeth need to be brushed by an adult (up until age eight years)
  • After brushing, spit but don’t rinse, to maximise the effect of the fluoride

Podcast of the Week: Sleep challenges in toddlers

A recent episode of The Good GP, an Australian podcast series, discusses insights into sleep challenges affecting toddlers for primary care clinicians and offers practical solutions to recommend to parents/caregivers. Sleep is variable for young children and is influenced by multiple factors including medical conditions (e.g. eczema), family dynamics, daytime sleep, screen time, diet and physical activity. Environmental and behavioural techniques are prioritised, e.g. setting up “monster traps” for children with nighttime fears.

Listen to the full podcast here (24 minutes)

Paper of the Week: Working together - Rongoā Māori and Western medicine

Indigenous populations around the world experience worse health outcomes and higher mortality rates compared to non-indigenous groups. A lack of cultural understanding and safety in Western health systems limits healthcare accessibility for indigenous populations and contributes to health inequities. Integrating traditional health practices into Western medicine is a potential strategy to improve healthcare accessibility. In New Zealand, Rongoā Māori, or traditional Māori healing, is considered separate to conventional Western medicine, restricting its integration into clinical practice. However, the inclusion of Māori cultural values in healthcare is viewed as beneficial and may increase Māori engagement in healthcare, adherence to treatment regimens and overall satisfaction with their healthcare experience.

A small study published in the New Zealand Medical Journal examined how Western medicine and Rongoā Māori could be used collaboratively as part of post-surgery follow-up and attempted to identify barriers to this treatment model. Seven themes were identified during the study suggesting that a collaboration between these two health approaches is not only possible in the New Zealand healthcare system, but beneficial for patients.

Is Rongoā Māori something you feel confident discussing with patients? Are there certain aspects of local Rongoā Māori approaches to patient health that can be incorporated into your primary care consultations?

Koea J, Mark G, Kerridge D, et al. Te Matahouroa: a feasibility trial combining Rongoā Māori and Western medicine in a surgical outpatient setting. NZMJ 2024;137:25–35. doi:10.26635/6965.6417

For further information on Rongoā Māori, see: (published in 2008; some content may no longer be current)

This Bulletin is supported by the South Link Education Trust

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