Infants are eligible to receive funded vaccination with DTaP-IPV-HepB/Hib as part of the childhood immunisation schedule at ages six weeks, three months and five months. Pertussis boosters are available at ages four (DTaP-IPV) and eleven years (Tdap [Boostrix]).

Vaccination with Boostrix is recommended and funded for certain groups, including pregnant women during every pregnancy (preferably given during the second trimester, but also funded during the third trimester) and people aged over 65 years. Click here for full eligibility criteria.

Pertussis vaccination (with Boostrix) is also recommended, but not funded, for some groups, including close contacts of young infants and general practice staff; read more here. Vaccination for these groups is recommended at least every ten years (some workplaces may require more frequent vaccination).

Opportunistically check whether patients (particularly children) have completed their course of pertussis vaccination and offer immunisation where appropriate.

Pharmac has provided updated information regarding ongoing supply issues affecting both Concerta and Teva brands of extended-release methylphenidate. Prescribers are now advised to consider writing a generic prescription for methylphenidate extended-release for patients, rather than specifying a brand name. When prescribing methylphenidate extended-release by brand, a new prescription is required to dispense an alternative brand, whereas when prescribed generically, pharmacists can dispense whichever brand of methylphenidate extended-release they have stock of. Be aware, Concerta and Teva brands of extended-release methylphenidate have different Special Authority forms (see item below); a new Special Authority number may be required when switching between these brands.

N.B. This advice only applies to 12-hour extended-release methylphenidate products (i.e. Concerta and Teva). Other brands of methylphenidate have different medicine release profiles (e.g. 8-hour modified-release Ritalin LA) and cannot be used interchangeably without consideration of patient response.

Clinical advice for prescribers is available here.

The stock situation for methylphenidate is frequently changing; check the Pharmac website and the methylphenidate monograph on NZF for up to date information.

Reminder: From 1^st December, 2024, lisdexamfetamine will be funded with Special Authority approval for patients with ADHD (as reported in Bulletin 112). The availability of lisdexamfetamine will provide patients who have ADHD with another funded option if they have not experienced adequate symptom improvement with other funded medicines, if supply issues are restricting access to another funded medicine (or they are not suitable), or if there is concern about the patient diverting or misusing other funded medicines.

From 1^st December, 2024, the Special Authority renewal requirements for stimulant medicines will be removed (as reported in Bulletin 112). There will be new Special Authority forms for each medicine:

• SA2412: Methylphenidate extended-release (Concerta [extended-release], Ritalin LA [modified-release])
• SA2411: Methylphenidate (Teva [extended-release], Rubifen [immediate-release], Rubifen SR [sustained-release], Ritalin [immediate-release], Ritalin LA [modified-release])
• SA2410: Dexamfetamine
• SA2415: Lisdexamfetamine

Patients with an existing or recently expired (within two years) Special Authority approval will be automatically issued a new approval without an expiry.

Pharmac has announced that Estradiol TDP Mylan will be the main funded brand of oestradiol patches from 1^st July, 2025, and from 1^st December, 2025, it will be the only funded brand of oestradiol patches available in New Zealand. Estradiol TDP Mylan has received provisional approval from Medsafe and it is expected that full approval will be granted prior to 1^st July, 2025.

Many patients may already be familiar with this brand of oestradiol patches as they have been available and funded as an alternative product to the Estradot brand due to the ongoing supply issues. However, there may be some hesitancy and worry about switching brands. Give patients plenty of warning that their brand is changing next year; the packaging will look different, but they should be reassured that there has been no change to the active ingredient. General patch information for use in healthcare settings is available here (UK-based) and includes useful tips such as using surgical adhesive tape on the edges of the patch if adherence to the skin is a concern. Information from the NZF on safe use of transdermal patches is available here.

Further information on the brand change is available here. Pharmac has released a statement providing further background on this change, including that there will be consideration of an option to apply for access to other brands.

For further information on menopausal hormone therapy, see: https://bpac.org.nz/2019/mht.aspx

Dispensing of diltiazem long-acting 120 mg capsules (Diltiazem CD Clinect) will temporarily switch to monthly from 1^st December, 2024, due to a supply issue. Other strengths and brands are not currently affected. Stat dispensing is expected to resume once stock returns to normal (new stock is expected mid-January, 2025).

Pharmacists should dispense short-dated stock first, where possible. Contact the supplier directly in situations where dispensing short-dated stock is not appropriate.

Information for pharmacists from the supplier is available here.

Prescribers should be aware that all patients taking cilazapril should be moved to another antihypertensive option as stocks will soon be exhausted. Data show that there are still a small number of patients remaining on this medicine. Stock of the 0.5 mg and 2.5 mg expired in October, and stock of the 5 mg presentation is expected to run out this month. All strengths of cilazapril are being delisted on 1^st January, 2025.

For further information on selecting an ACE inhibitor or ARB, see: https://bpac.org.nz/2021/ace.aspx

There is a supply issue affecting stock of Beta Scalp due to shipping delays. There are alternative products listed, e.g. clobetasol propionate scalp application (Dermol) and hydrocortisone butyrate scalp lotion (Locoid), however, limited supply is available as these products are also affected by shipping delays. A re-supply date for the three scalp preparations is not currently known.

• Updated guidance for epilepsy and other seizure conditions. New subsections have been added to address non-epileptic seizures and situations where patients are withdrawing from anti-seizure medicines or have experienced a seizure following a period of well-controlled epilepsy.
• The stand-down period following a single transient ischaemic attack has reduced from four to two weeks for private vehicle drivers and from six months to four weeks for commercial drivers, however, these minimum periods rely on appropriate assessment and treatment being initiated
• Updated guidance for several cardiovascular conditions including angina, myocardial infarction, cardiac failure and cardiomyopathy
• Private class drivers will no longer require a supporting cardiologist assessment before a health practitioner assesses their fitness to drive following acute myocardial infarction and coronary artery bypass surgery
• The stand-down period following a cardiac arrest has been extended to six months for private vehicle drivers. Commercial drivers now have a minimum stand-down period of six months (previously considered permanently unfit to drive).
• Updated considerations for patients with diabetes, including related health conditions, medicines and stand-down periods following episodes of hypoglycaemia
• Updated guidance for visual acuity, substandard vision, monocular vision and colour vision
• Changes to the language used in the hearing section to avoid discrimination of patients with hearing loss. Removal of the need for NZTA involvement in situations where the patient has been found to have hearing that is below 40 dBHL (unable to hear words from three metres away) who require an alternative solution (e.g. hearing aids), particularly if the driver is applying for P, V, I or O endorsement.
• Inclusion of suicidal behaviour, other mental health conditions and other factors that could impact ability to drive safely that should be considered as part of a fitness to drive assessment, as well as new criteria for considering fitness to drive in those with severe chronic mental health conditions
• Information on sleep conditions has been consolidated into a new section and has been updated to reflect Austroroads’ (the association of the Australian and New Zealand transport agencies) recommendations
• The type of cognitive test(s) used to determine an ageing patient’s fitness to drive is at the discretion of the health practitioner, however, these should be appropriate and fit for purpose
• When considering the impact of prescribed medicines on safe driving, it is recommended that the clinician also checks the 25 individual drugs/medicines listed in the 2023 change to the Land Transport (Drug Driving) Amendment Act 2022. For some drivers there may be a defence under Section 64 of the Land Transport Act 1998 if the medicines are taken as prescribed, however, it should be noted that all liability is not waived.
• Further explanation on acceptable reasons for seatbelt exceptions and details that should be included on exception certificates. Remind patients that they should always carry their exception certificate when driving.
• Additional information has been included about driving after surgeries requiring general anaesthetic as well as guidance on considerations that should be made following surgery and recommendations for patients
• Throughout the guide there are several statements instructing practitioners to provide recommendations to patients in writing in addition to standard verbal advice, such as if a patient is being advised that they are unfit to drive or if they should not drive at night or in peak traffic. Appendix 5 of the guide provides a letter template that could be used when advising a patient not to drive, or if conditions have been imposed and Appendix 6 is a template that can be used if notification to NZTA is required.

From July, 2023, to July, 2024, almost 10,000 adults and over 3,000 children (aged 0 – 14 years) participated in the survey. The results show that:

• There has been no notable change in daily smokers compared to the last reporting period (6.9% versus 6.8%). The stalled decrease goes against previous trends which show a decline in smoking rates over time; from 9.4% in 2020/21, 8.6% in 2021/22 to 6.8% in 2022/23.
• Vaping/e-cigarette use has increased; 11.1% of people were daily vapers/e-cigarette users, up from 9.7% the previous year. Daily vaping is particularly prevalent among people aged 18 – 24 years (26.5%) and Māori (28.8%) and Pacific (21.5%) adults.
• More people experienced psychological distress and unmet need for mental health support. 13% of adults experienced high or very high levels of psychological distress in the four weeks leading up to the survey, up slightly from the previous year (11.9%). This rate was highest among young adults; approximately one in five (22.9%) people aged 15 – 24 years had high or very high levels of distress. More people (10.7%) experienced unmet need for mental health care and addiction services, compared to the previous year (7.4%).
• One in four children (27.0%) lived in a household where food ran out often or sometimes (up from one in five [21.3%] in the previous year), and this was more common in children of Māori (34.3%) and Pacific (54.8%) ethnicity
• Fewer than half of adults (46.6%) met weekly physical activity guidelines. One-third of adults were obese (similar to the previous year).
• Approximately one-third of adults and children did not brush their teeth with fluoride toothpaste at least twice per day. Nearly half of adults (44.9%) had unmet need for dental care due to cost (similar to the previous year).
• Time taken to get an appointment continues to be the most common reason for not seeing a general practitioner, with one in four adults (25.7%) citing this as a barrier, up from one in five (21.2%) in the previous year. There was a slight increase in the number of adults who visited a general practitioner (75.6%), compared to the previous year (73.2%).

More than 2,400 people have requested an assisted death since the End of Life Choice Act 2019 came into force in November, 2021. Of those, 970 people have received an assisted death. The Ministry of Health was required to review the Act within three years of its initiation. As a result of this review, the Ministry has detailed how the Act is achieving its purpose and complied a set of recommendations that could improve how it is implemented.

Summary of findings and recommendations:

• Overall, the Act is performing well in achieving its primary purpose of allowing people with a terminal illness (who meet criteria) the option to receive an assisted death and the level of compliance with the Act is high
• Although there is some level of subjectivity, the definitions for eligibility and limitations for requesting an assisted death are clear
• The current workforce is effectively implementing the Act and is well supported by the Assisted Dying Service; funding allows travel to people if required
• Several areas of improvement have been identified, resulting in 25 specific recommended changes to the Act, and a list of other minor recommendations for Parliament to consider. Some areas of recommendation are:
• Striking more of a balance between the current requirement that medical practitioners cannot raise the topic of assisted dying and the right for people to be aware of assisted dying and for information to be available
• Clarifying thresholds and definitions for detecting pressure on a person to request assisted dying and assessing competence of a person to make an informed decision
• Clarifying enforcement pathways for potential breaches of the Act related to core duties, procedural requirements and professional misconduct or non-compliance
• Improving protection of the privacy of people who access and provide assisted dying services, and the specific medicines used for the process
• Adding provisions for certain aspects of the process such as transferring care to another medical practitioner, setting and changing dates of assisted death, re-applying
• Clarifying obligations of health practitioners to provide details of an assisted dying service if requested, including if there is a conscientious objection; also clarify what a practitioner can conscientiously object to
• Requiring care facilities (e.g. hospitals, hospices, residential care homes) to provide reasonable access to assisted dying services if requested
• Requiring medical and nurse practitioners who provide assisted dying services to have held a practising certificate for a minimum of five years, and to complete specified training
• Changing requirements around which practitioners can fulfil which roles within the process, e.g. a wider range of practitioners can provide an assessment of competence, nurse practitioners can perform the same role as the attending practitioner (and not have to operate under instruction)

Note that these are recommendations based on the outcome of the Ministry of Health review, and do not constitute actual changes to the Act; these points will be debated in Parliament.

Screening

• Opportunistically screen adults during routine consultations for modifiable stroke risk factors such as unhealthy dietary patterns, increased body weight, smoking and physical inactivity, and check their blood pressure
• Identify social determinants of health which may contribute to stroke risk by impacting a patient’s ability to access care, treatment or engage in appropriate lifestyle changes, e.g. financial barriers, food insecurity, education, transport limitations
• Primary care clinicians in New Zealand already regularly consider these barriers, but the capacity to address them remains a challenge; many are dependent on system-level changes. Supporting the improvement of health literacy (e.g. using clear/understandable language, tailoring educational resources) is one practical step that all practices can take to help their patients understand and reduce their own stroke risk.

Lifestyle changes

• The AHA has previously promoted “Life’s Essential 8” factors for improving and maintaining cardiovascular health: eat better, be more active, quit tobacco, get healthy sleep, manage weight, control cholesterol, manage blood sugar and manage blood pressure. The 2024 guideline re-emphasises their importance while providing further guidance in the context of stroke prevention.
• The Mediterranean diet is preferred for adults with no prior cardiovascular disease (CVD), and in those at high or intermediate risk (ideally supplemented with nuts and olive oil). It is also recommended that, in addition to engaging in regular moderate to vigorous physical activity, all patients should be screened for prolonged sedentary behaviour (involving low energy expenditure while sitting, reclining or lying while awake) and advised to avoid these patterns, if applicable.

Antihypertensive management

• High blood pressure is one of the most significant modifiable risk factors for stroke, but many patients with hypertension are undertreated, i.e. not started on treatment or not reduced to a low enough target
• Most patients requiring pharmacological management should be initially prescribed at least two different antihypertensives rather than the conventional method of starting with only one antihypertensive. Hypertension is almost always caused by a combination of pathophysiological processes, so using medicines with different mechanisms of action is thought to improve treatment efficacy.

For further information on diagnosing and managing hypertension, see: https://bpac.org.nz/2023/hypertension.aspx

Managing diabetes

• Treatment with a GLP-1 receptor agonist is recommended for patients with diabetes and high CVD risk or established CVD due to their capacity for supporting glycaemic control and weight loss. However, due to increased demand, worldwide supplies of GLP-1 receptor agonists are limited and as of May, 2024, no new patients can be initiated on funded dulaglutide or liraglutide in New Zealand.
• There is less compelling evidence for the efficacy of SGLT-2 inhibitors in reducing stroke risk among patients with diabetes versus GLP-1 receptor agonists

For further information on managing diabetes, see: https://bpac.org.nz/2021/diabetes-management.aspx

Antithrombotic treatment for specific high-risk patients

• Patients with antiphospholipid syndrome or systemic lupus erythematosus without a history of stroke or unprovoked venous thromboembolism should receive antiplatelet treatment. In addition, vitamin K antagonist treatment (i.e. warfarin) is suggested rather than direct oral anticoagulant (DOAC) use for patients with antiphospholipid syndrome and prior venous thrombosis.

Controlling stroke risk in pregnancy

• Pregnancy-related stroke prevention is largely achieved by managing hypertension
• All pregnant patients with blood pressure measurements ≥ 160/110 mmHg should receive prompt antihypertensive treatment both during pregnancy and up to six weeks post-partum
  • In New Zealand, recommended antihypertensives during pregnancy include labetalol, nifedipine and methyldopa

Other aspects of women’s health

• Endometriosis, premature ovarian failure (before the age 40 years) and early-onset menopause (before age 45 years) all increase stroke risk and should be considered during routine assessment of vascular stroke risk factors
• The guideline also advocates for increased awareness of transgender health; many transgender women take oestrogen for gender-affirming treatment, and this has been demonstrated to increase stroke risk