Published: 24th January, 2024
Contents
New from bpacnz: Diagnosing and managing heart failure
The approach to heart failure management has undergone substantial change over recent years, and all primary healthcare professionals should familiarise themselves with the latest recommendations to achieve best patient outcomes.
To welcome back our readers in 2025, we are pleased to announce updated versions of our core articles on heart failure. This two-part series includes:
Key change: In response to robust clinical trial evidence, international guidelines no longer recommend that heart failure medicines should be sequentially introduced only when patients remain symptomatic. Instead, most patients with heart failure should be promptly established on four guideline-directed medical therapy (GDMT) medicines and up-titrated to the highest tolerated or target dose, unless contraindicated. This involves:
- An angiotensin receptor-neprilysin inhibitor (ARNI; preferred) or an ACE inhibitor/ARB if this is not possible; and
- A beta blocker (either bisoprolol, metoprolol succinate or carvedilol); and
- A mineralocorticoid receptor antagonist (MRA); and
- A sodium-glucose co-transporter-2 (SGLT-2) inhibitor
Special Authority restrictions may influence the introduction of the “newer” GDMT medicines, i.e. sacubitril + valsartan (ARNI) and empagliflozin (SGLT-2 inhibitor). However, progress has been made to ensure more patients in New Zealand can utilise the full cardio-protection toolkit; on 1st December, 2024, funded access to empagliflozin was widened to include people with heart failure who meet certain other criteria (previously only those with type 2 diabetes were eligible). Use of all four GDMT options should be prioritised where possible as this maximises prognostic outcomes (e.g. risk of hospitalisation and mortality) and limits disease progression. GDMT confers more than six additional years of life (on average) for a patient aged 55 years, or 1.4 additional years for a patient aged 80 years.
Click here to access a summary of key practice points or go straight to Part 1 (diagnosis) or Part 2 (management).
A B-QuiCK summary is available here.
An updated clinical audit on heart failure management is also available to help ensure patients diagnosed with heart failure are receiving optimal care.
Also new from bpacnz: Clinical Audit: Reviewing the use of menopausal hormone therapy
MHT is the most effective treatment for the vasomotor symptoms and urogenital atrophy associated with menopause, however, it is associated with an increased risk of adverse outcomes such as breast cancer, stroke and venous thromboembolism (VTE). The extent of risk depends on the timing or age at initiation, MHT type, dose, duration of use, route of administration and whether a progestogen is used (and which one). This audit helps healthcare professionals in primary care identify patients who are prescribed MHT to assess whether they have had a review of the benefits and risks when initiating or continuing treatment in the past 12 months.
Click here to view the audit
In case you missed it: Recent resources from bpacnz
Generalised anxiety disorder in adults: Anxiety disorders are the most prevalent mental health condition in the community. Generalised anxiety disorder (GAD) is a predominant form, and often co-occurs with depression and other anxiety disorders. Psychological, e.g. cognitive behavioural therapy (CBT), and pharmacological, e.g. selective serotonin reuptake inhibitors, treatments are equally effective in the management of GAD, but patients engaging with CBT may be less likely to relapse. Read the full article here. A B-QuiCK summary is also available.
Prescribing testosterone in ageing males: Rates of testosterone prescribing in older males in New Zealand continue to increase, however, the long-term risks and benefits of treatment are still uncertain for older males without clinically proven hypogonadism. Therefore, testosterone replacement treatment should be reserved for patients with clinical features of androgen deficiency and early morning serum total testosterone levels below the accepted threshold of normal. Read the full article here. A B-QuiCK summary is also available.
Recovery at work: Reframing the conversation: Navigating discussions around functional capacity and time off work after injury can be challenging, even for experienced clinicians. Beyond considering a patient’s clinical status, this process involves balancing diverse context-specific factors and psychosocial variables. Reintegrating into the workplace is an essential step in recovery, however, evidence suggests many injured patients are being signed off for too long, potentially compromising long-term outcomes.
bpacnz has published a comprehensive guide for supporting primary care clinicians to help patients navigate the ACC Recovery at Work process, including considerations when conducting an initial medical certification consultation, medical certificate definitions, as well as the ACC-mediated supports available if further assistance is required. Read the full article here. A B-QuiCK summary is also available.
Proposal to change regulatory and funding restrictions for ADHD medicines
Pharmac and Medsafe have issued a consultation on a proposal to change the prescriber restrictions for initiating stimulant medicines used for ADHD, with the goal of increased patient access. Submissions close 5 pm, Tuesday, 11th February, 2025. This link contains an online form to complete, or feedback can be emailed to: consult@Pharmac.govt.nz.
It is proposed that from 1st July, 2025, methylphenidate, dexamfetamine and lisdexamfetamine would be able to be prescribed to:
- Patients aged 18 years and over by medical practitioners with a vocational scope of practice of paediatrics, psychiatry or general practice. Nurse practitioners working within their scope of practice could also initiate prescribing.
- Patients aged 17 years and under by medical practitioners with a vocational scope of practice of paediatrics or psychiatry, or nurse practitioners working within paediatric services or child and adolescent mental health services
In December, 2024, Special Authority renewal requirements for stimulant medicines were removed (as reported in Bulletin 112), meaning that if this proposal is approved, both the initiation and ongoing prescribing of stimulant medicines could be managed in primary care for adult patients, with clinicians seeking specialist advice if required.
An associated news release is available here.
New COVID-19 vaccine now available
The Comirnaty JN.1 COVID-19 vaccines have been available since Monday, 20th January, 2025. These vaccines target the JN.1 strain and replace the XBB.1.5 vaccines for both primary and additional doses. There are no changes to the COVID-19 vaccine eligibility: see full eligibility criteria here (Pharmac) and here (Immunisation Handbook).
Reminder: Additional doses are available every six months for previously vaccinated people aged ≥ 30 years. Eligible adults and children who have not yet received a primary COVID-19 vaccination, or are not up to date with additional doses, should be encouraged to do so.
A webinar from IMAC about the Comirnaty JN.1 COVID-19 vaccines is available here. Additional resources are also available from IMAC, here.
COVID-19 update
COVID-19 continues to circulate in the community. The latest data from ESR (week ending 19th January) show a decrease in wastewater detections throughout New Zealand after a peak earlier in January. Reported case numbers are generally declining. Healthcare professionals should continue to remind patients to report positive COVID-19 test results.
Nirmatrelvir with ritonavir (Paxlovid) and remdesivir (Veklury) are still available for people with COVID-19 who are at higher risk of severe disease and meet eligibility criteria. A COVID-19 antiviral access criteria assessment tool is available here.
A patient handout on managing at home with COVID-19 is available here.
Medicine news: atorvastatin, venlafaxine, oxycodone, methylphenidate, itraconazole, cilazapril
The following news relating to medicine supply has recently been announced. These items are selected based on their relevance to primary care and where issues for patients are anticipated, e.g. no alternative medicine available or changing to the alternative presents issues. Information about medicine supply is available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Atorvastatin and venlafaxine temporarily switched to monthly dispensing
Dispensing of atorvastatin (Lorstat; 10, 20, 40 and 80 mg tablets) and venlafaxine (Enlafax XR; 37.5, 75 and 150 mg capsules) has been temporarily switched to monthly since 1st January, 2025, due to supply issues. Stat dispensing of venlafaxine is expected to resume in March; a date for atorvastatin is not currently known.
N.B. Atorvastatin 20 mg tablets are in limited supply; two 10 mg tablets can be dispensed if the 20 mg presentation is out of stock.
Oxycodone oral liquid now Medsafe approved
Oxycodone Lucis oral liquid has been funded since mid-2024 (as reported in Bulletin 105). Originally, this medicine needed to be prescribed for supply under Section 29 of the Medicines Act 1981 as it was not approved by Medsafe. Oxycodone Lucis oral liquid has now been approved by Medsafe, and can be prescribed by any relevant prescriber.
Methylphenidate Rubifen SR 20 mg supply issue
Methylphenidate sustained-release 20 mg tablets (Rubifen SR) are expected to be out of stock until late February. Pharmac advise that stock of Rubifen immediate-release and the Ritalin brand of methylphenidate is available; these may be a suitable alternative for some patients.
A patient information sheet is available here.
Itraconazole 100 mg capsules supply issue
There is a supply issue affecting stock of itraconazole 100 mg capsules (Itrazole) due to a manufacturing problem. Stock is expected to be exhausted in February. An alternative brand (Itracap) is being listed on the Pharmaceutical Schedule from 1st February until stock of Itrazole becomes available again (currently expected May, 2025). Note that the new brand is supplied as a 60 pack as opposed to a 15 pack, and it is not approved by Medsafe and so will need to be prescribed for supply under the Section 29 of the Medicines Act 1981.
Cilazapril delisting date moved to March, 2025
Pharmac has announced that the delisting date for cilazapril has been moved to 1st March, 2025, to allow time for pharmacies to claim. Any remaining stock expired in October, 2024. Ensure that any patients still taking cilazapril are moved to another antihypertensive as soon as possible.
For further information on selecting an ACE inhibitor or ARB, see: https://bpac.org.nz/2021/ace.aspx
Proposal to widen access to medicines for inflammatory bowel disease, eczema and rheumatoid arthritis
Pharmac is seeking feedback on a proposal to fund the oral immunosuppressant medicine upadacitinib for patients with moderate to severe inflammatory bowel disease or eczema who meet eligibility criteria, and to widen access for some patients with rheumatoid arthritis. Consultation closes 5 pm Monday, 10th February. An associated news release is available here.
From 1st May, 2025, it is proposed that:
- Upadacitinib, a Janus kinase enzyme (JAK) inhibitor, once daily tablet, would be funded for patients with either ulcerative colitis or Crohn’s disease who have trialled biologic medicines (e.g. adalimumab, infliximab) and experienced an inadequate response or intolerance, or those who meet eligibility criteria but biologic medicines are contraindicated. Any relevant practitioner could apply for Special Authority approval and this would be valid for six months.
- Upadacitinib would be funded for patients with eczema and a recent (within one month of application) Eczema Area and Severity Index (EASI) score ≥ 16 or a Dermatology Life Quality Index (DLQI) score ≥ 10, who have trialled both topical and systemic treatments and experienced an inadequate response or these treatments are contraindicated. Any relevant specialist or practitioner on the recommendation of a relevant specialist could apply for Special Authority approval and this would be valid for six months.
- Access to upadacitinib would be widened for patients with rheumatoid arthritis to include those who have trialled biologic medicines (e.g. adalimumab, etanercept, rituximab) and experienced an inadequate response or intolerance, or those who meet eligibility criteria but rituximab is not clinically appropriate. Any relevant practitioner could apply for Special Authority approval and this would be valid for six months.
Also included in the consultation is a proposal to widen access to venetoclax and azacitidine from 1st May, 2025, for patients with acute myeloid leukaemia.
In brief: access to denosumab to be widened
Following consultation on a proposal to widen access to the biologic medicine, denosumab (as reported in Bulletin 111):
From 1st February, 2025, denosumab (Xgeva, 70 mg/mL, 1.7 mL vial) will be funded for patients with hypercalcaemia of malignancy who also have severe renal impairment.
From 1st March, 2025, denosumab (Prolia, 60 mg/mL, 1 mL pre-filled syringe) will be funded for patients with osteoporosis who have a contraindication to funded bisphosphonates or who have experienced an inadequate response or intolerance to them. Full criteria can be found here.
N.B. Hypercalcaemia is an approved indication for the Xgeva brand of denosumab and osteoporosis is an approved indication for the Prolia brand.
For further information on bisphosphonates, see: https://bpac.org.nz/2019/bisphosphonates.aspx
Monitoring Communication: anti-CD20 monoclonal antibodies and pyoderma gangrenosum
Medsafe has issued a Monitoring Communication to seek more information from clinicians on the risk of pyoderma gangrenosum, a rare inflammatory skin disease, in patients administered anti-CD20 monoclonal antibodies, e.g. rituximab, ocrelizumab, obinutuzumab. In the September, 2024 meeting of the Medicines Adverse Reactions Committee (MARC), the possible association between anti-CD20 monoclonal antibodies and pyoderma gangrenosum was reviewed. The Committee found weak evidence for a causal link, and recommended that Medsafe gather more information on this risk. Responses can be submitted until 16th July, 2025.
Pyoderma gangrenosum is characterised by a rapidly enlarging ulcer, that is associated with severe pain. Ulcers most commonly appear on the lower legs, although can affect any site of the body. Median time to onset of symptoms is typically three years after treatment initiation. Further information on pyoderma gangrenosum, including images, is available from DermNet, here.
Be alert to potential cases of pyoderma gangrenosum in patients administered anti-CD20 antibodies and report any suspected cases to CARM.
NZF updates for January
Significant changes to the NZF in the January, 2025, release include:
- New cautions added to the medroxyprogesterone acetate monographs (oncology, endocrine and contraception, injection): history of meningioma and increased risk of meningioma with prolonged use of injection or high oral doses (≥ 100 mg). The adverse effects sections of these monographs have also been updated.
- Updated dosing regimen for nicotine
- New indications (unapproved) added for praziquantel: intestinal tapeworm infection (Taenia spp.) and dwarf tapeworm infection (Hymenolepis nana). Patient advice and administration information has also been updated.
- Drugs and sport therapeutic notes updated according to the WADA 2025 prohibited list
You can read about all the changes in the January release here. Also read about any significant changes to the NZF for Children, NZFC, here.
Upcoming Goodfellow Unit webinars
The Goodfellow Unit, University of Auckland, is hosting several free access webinars in the coming months. These webinars are intended to provide topical and relevant health information for primary care clinicians. Continuing professional development (CPD) points are also available. Webinars are often recorded and available to watch at a later date. Upcoming webinars include:
Primary care performance indicators published: immunisation and smoking cessation
Health New Zealand, Te Whatu Ora, announced in December, 2024, that a range of key primary healthcare measures and PHO performance indicators will be reported quarterly. Initially, measures on childhood immunisations at eight and 24 months and smoking cessation are being reported at the PHO and lead district level (2024/2025 quarter one).
The national childhood vaccination rate (fully immunised) at eight months is 80.2%, dropping to 77.6% at 24 months. However, rates vary widely across PHOs, ranging from 25.8% to 93.4%. Nationally, the percentage of current smokers who have been offered smoking cessation or referral in the last 15 months is 27.3%, and this also differs widely between PHOs (from 9.2% up to 69.4%). See how your PHO is tracking, here. (N.B. when comparing data between PHOs, take into consideration the number of eligible people the data is based on).
More primary care indicators are expected to be added in the future, including cardiovascular risk assessment, clinical FTE per thousand people, service use rates, general practice enrolment availability. Click here for further information.
Paper of the Week: Doxycycline post-exposure prophylaxis – another tool to reduce STI rates
The introduction of HIV pre- and post-exposure prophylaxis (PrEP and PEP) has substantially reduced global HIV transmission in high-risk groups, e.g. men who have sex with men. However, it does not protect users from other sexually transmitted infections (STIs). Hence, condom use is still strongly encouraged for those prescribed HIV PrEP and PEP. Another method to reduce STI transmission is doxycycline post-exposure prophylaxis (doxy-PEP). This involves taking a single prophylactic dose of 200 mg doxycycline within 72 hours following a potential transmission event (i.e. unprotected sexual contact) to reduce the likelihood of chlamydia, gonorrhoea or syphilis infection.
In 2024, the New Zealand Sexual Health Society (NZSHS) published a position statement and interim prescribing guidelines regarding the use of doxy-PEP. The statement advises clinicians to consider prescribing doxy-PEP to men who have sex with men and transgender women, who are at high risk of syphilis (and other STIs) and meet specific criteria.
Initial studies have been promising but ongoing research into the efficacy of doxy-PEP for reducing STI transmission is still required given the potential risks, e.g. antimicrobial resistance development, adverse effects associated with doxycycline. An article published in JAMA Internal Medicine examined the effect of doxy-PEP on bacterial STI incidence. People already prescribed HIV PrEP who were considered at risk of a bacterial STI infection were offered doxy-PEP and then underwent regular STI testing. Rates of chlamydia, syphilis and urethral and rectal gonorrhoea infections all declined after doxy-PEP initiation, when compared to STI incidence before prophylaxis implementation. However, no significant change in the rate of pharyngeal gonorrhoea infection was detected. These results further support the use of doxy-PEP in high-risk patient groups but also highlight the need for ongoing surveillance.
How familiar are you with doxy-PEP as a strategy to reduce STI transmission? Have any of your patients enquired about doxy-PEP or have you raised the topic with a patient? Would you consult with a sexual health physician before deciding whether to prescribe doxy-PEP? Do you feel the potential benefits of prescribing doxy-PEP outweigh the risks, e.g. antibiotic resistance?
Read more
- This retrospective cohort study involving more than 11,500 participants (95% male) was undertaken across multiple medical facilities from a single health care system in Northen California
- Participants assigned male at birth already receiving HIV PrEP who had a bacterial STI diagnosis within the past 12 months and reported unprotected sexual intercourse with two or more partners were offered doxy-PEP between November, 2022, and December, 2023
- Participants who did not meet inclusion criteria could also access doxy-PEP through shared decision-making with their clinician
- All participants were expected to undergo STI testing at least quarterly. STI test results were included from November, 2020 (i.e. 24 months before starting doxy-PEP), until the end of the study (or disenrollment).
- Primary outcomes were the number of participants with a positive test result for chlamydia, gonorrhoea or syphilis per quarter, i.e. quarterly positivity. Data for chlamydia and gonorrhoea positivity was also presented by anatomical site.
- Approximately one-fifth of the cohort received doxy-PEP (2,253 participants). This group were slightly older (average age: 40.4 years) and had been receiving HIV PrEP for a longer duration (prescribed HIV PrEP: 4.2 years) compared with the group not receiving doxy-PEP (average age 39.8 years; prescribed HIV PrEP: 3.4 years).
- Half of the intervention group (48.6%) had a record of a bacterial STI diagnosis within 12 months of initiating doxy-PEP
- In the 24 months before starting doxy-PEP, the overall mean quarterly chlamydia positivity for the intervention group was 9.6% (95% confidence interval [CI] = 9.0% - 10.3%). This rate reduced to 2.0% (95% CI = 1.5% - 2.6%) in the 12 months following doxy-PEP.
- Statistically significant reductions were observed for all anatomical locations of chlamydia, i.e. pharyngeal, urethral, rectal
- A reduction in quarterly positivity for syphilis (1.7% [95% CI = 1.4% - 1.9%] to 0.3% [95% CI = 0.2% - 0.6%]) was also reported following initiation of doxy-PEP over the same period
- Mean quarterly positivity for gonorrhoea did decline from 10.2% (95% CI = 9.6% - 10.9%) to 9.0% (95% CI = 8.0% - 10.1%) in participants who were initiated on doxy-PEP, however, only reductions in urethral and rectal gonorrhoea were significant, suggesting that doxy-PEP may be less effective for preventing pharyngeal gonorrhoea infections potentially allowing for the development of resistance
- STI incidence remained stable throughout the study period in the group who did not receive doxy-PEP
- The authors acknowledge that the study cohort may not be an accurate reflection of the general population (i.e. participants in the intervention group were more likely to have private health insurance and therefore increased health care access)
- The global mpox outbreak began in 2022 and is still ongoing. Men who have sex with men are disproportionately affected in developed countries. This may have influenced sexual behaviours of participants during the study period (i.e. less exposure to unprotected sexual contact).
The chief argument against prophylactic antibiotics is antimicrobial resistance. Other potential doxy-PEP concerns highlighted by the NZSHS include doxycycline adverse effects (e.g. nausea, vomiting, oesophagitis) and the long-term effects of regular antibiotic use on the gastrointestinal microbiome. The NZSHS advises that if doxy-PEP is prescribed, steps to reduce the risk of resistance developing need to be taken such as multisite STI testing at least every three months, advising patients on strategies to maximise prophylactic benefit (e.g. taking a single dose to cover bacterial STI risk from multiple sexual contacts over a weekend as opposed to taking separate doses following each sexual contact) and regularly assessing their ongoing need for doxy-PEP. Further laboratory investigations are also recommended if gonorrhoea is identified in a person using doxy-PEP before initiating treatment, e.g. additional culture and antibiotic susceptibilities testing.
Traeger MW, Leyden WA, Volk JE, et al. Doxycycline postexposure prophylaxis and bacterial sexually transmitted infections among individuals using HIV preexposure prophylaxis. JAMA Internal Medicine 2025; [Epub ahead of print]. doi:10.1001/jamainternmed.2024.7186
A doxy-PEP patient handout from the NZSHS is available here
For further information on chlamydia, gonorrhoea and syphilis see: https://bpac.org.nz/2019/chlamydia-gonorrhoea.aspx and https://bpac.org.nz/2019/syphilis.aspx (published in 2019; some content may no longer be current)
For further information on prescribing HIV pre- and post-exposure prophylaxis in primary care, see: https://bpac.org.nz/2024/hiv.aspx
This Bulletin is supported by the South Link Education Trust
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