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Published: 19th September, 2025
Contents
New from bpacnz - Recovery at Work: Certificate of Accreditation
Are you a legend in your own field? We are pleased to offer eligible participants a Certificate of Accreditation to acknowledge completion of the bpacnz Recovery at Work education module, supported by ACC. This certificate signifies that the clinician has sufficient knowledge and understanding of the ACC medical certification process and is recognised as a Recovery at Work expert and leader among their peers. Ideally, every medical practice will have at least one clinician with a Recovery at Work Certificate of Accreditation.
To be eligible you must:
It is also recommended to use the Recovery at Work peer group discussion resource for group or individual reflection and to make a plan to complete a Recovery at Work clinical audit.
To check your eligibility and apply for a Recovery at Work: Certificate of Accreditation, click here.
Don’t forget to claim your CPD credits. bpacnz is endorsed by the RNZCGP as a provider of CPD activities, therefore members will receive double credits per learning hour when they read an article on bpac.org.nz, complete a case study quiz or clinical audit or listen to a podcast. Recovery at Work resources are also endorsed by the Royal New Zealand College of Urgent Care (RNZCUC), InPractice and Pharmaceutical Society of New Zealand (PSNZ), and recognised by the College of Nurses Aotearoa (NZ) and many other professional providers.
In case you missed it
Recovery at work podcast
bpacnz has released the final resource in the series supporting clinicians in understanding and applying the ACC Recovery at Work initiative. This panel discussion podcast aims to clarify some of the aspects of the Recovery at Work framework, and to ask representatives from ACC some pragmatic questions. To prepare for this discussion, a group of primary care specialists (general practitioners, urgent care clinicians, nurse practitioners) were invited to share their experiences with the Recovery at Work programme, and their responses formed the basis for this podcast.
Listen here. Our podcasts are now also available on Apple Podcasts and Spotify.
Read the comprehensive Recovery at Work guide, here. A B-QuiCK summary, case study quiz, clinical audit and peer group discussion are also available.
Access criteria for COVID-19 antivirals: determine priority by need
From 1st September, 2025, the access criteria for funded COVID-19 antivirals for people aged 50 – 64 years were amended. All people aged 50 years and over with COVID-19 who are considered by their healthcare professional to be at high risk of hospitalisation or death from COVID-19 are now eligible for funded treatment (as reported in Bulletin 130). Healthcare professionals are advised to use their clinical judgement, including knowledge of COVID-19 epidemiology and risk factors, to prescribe COVID-19 antivirals to patients aged ≥ 50 years based on need. To support prescribers, bpacnz has prepared a brief resource to help in determining which patients are suitable for COVID-19 antiviral treatment. Read the article here.
Coming soon - COVID-19 antivirals: eligibility and prescribing guidance. A comprehensive article about COVID-19 antivirals, including the prescribing of oral nirmatrelvir/ritonavir, is currently in development by bpacnz and due to be published in the coming weeks.
Rewind: Key dates and news items from the last few editions of Best Practice Bulletin
- Medsafe is proposing changes to clozapine prescribing. Consultation closes Wednesday, 8th October, 2025. See Bulletin 130 for further information.
- A webinar on navigating the new Community Referred Radiology programme is being held by the Goodfellow Unit on Tuesday, 30th September, from 7.30 pm. See Bulletin 131 for further information.
Consultation on adult palliative care services
Health New Zealand, Te Whatu Ora, is seeking feedback on a proposal for a new model of adult palliative care services. The goal of the new model is to improve co-ordination, equity and the quality of palliative care services in New Zealand by aligning them around shared principles, clear roles and robust support systems. The model also acknowledges that primary care teams will be among those providing the majority of palliative care services for non-complex patients and will require adequate resourcing and support to achieve this. Consultation closes Friday, 10th October, 2025. This link contains an online survey to complete. To read the full proposal, click here.
Read more about proposed key responsibilities of primary palliative care services
- Whānau-centred care – deliver culturally appropriate palliative care that focuses on the needs of the individual and whānau
- Holistic assessment and planning – creating individualised care plans based on assessment of the physical, psychological, social, spiritual and cultural needs of the individual
- Symptom management – management of pain and other symptoms using pharmacological and non-pharmacological methods, including prescribing medicines in anticipation of symptoms (where appropriate), with an option to discuss with or refer to specialist palliative care services for complex care needs
- Whānau support and education – provide caregivers/whānau with the required education, information and support including home help and carer respite services
- Referral pathways to specialist care – develop clear pathways for timely referral to specialist palliative care services when required
- Access to care and support out of hours – establish plans to ensure after hours care is accessible. This may require collaboration between multiple services.
- Care co-ordination – designation of a lead clinician or co-ordinator who is responsible for developing and delivering individual care plans and managing the transition to different services and care settings
Proposal to fund a new brand of methylphenidate
Pharmac has released a proposal to fund a new brand of modified-release methylphenidate tablets, Methylphenidate Sandoz XR, supplied by Sandoz. It is a generic version of the Concerta brand of extended-release methylphenidate. This would provide another option for people with ADHD and narcolepsy, given the ongoing supply issues affecting methylphenidate (last reported in Bulletin 118). It is also intended to support the anticipated increase in use when prescriber restrictions for stimulant medicines change to allow initiation for patients aged 18 years and over in primary care from February, 2026. If the proposal is accepted, Methylphenidate Sandoz XR would be listed on the Pharmaceutical Schedule and funded with Special Authority approval from 1st December, 2025. It will have the same Special Authority criteria as Ritalin, Rubifen, Rubifen SR and Methylphenidate ER – Teva.
Consultation closes 5 pm, Wednesday, 1st October. This link contains an online form to complete, or feedback can be emailed directly to: consult@pharmac.govt.nz.
Consultations open for nurse prescriber and pharmacist prescriber medicines lists
The Ministry of Health, Manatū Hauora, is seeking feedback on two separate consultations that propose amendments to the specified prescription medicines lists for designated registered nurse prescribers in primary health and specialty teams and pharmacist prescribers. For designated registered nurse prescribers, the addition of 190 prescription medicines and four medicine classes are proposed; click here for details. An additional 21 prescription medicines and one medicine class are proposed for designated pharmacist prescribers; click here for details.
Consultations on both proposals close on Friday, 17th October. You can submit feedback for the nurse prescriber list here, and pharmacist prescriber list here.
Cervical Screening Awareness Month this September
This month is Cervical Screening Awareness Month. The incidence of cervical cancer dropped in New Zealand by almost 50% after the introduction of the National Cervical Screening Programme in 1990. However, cervical cancer remains the third most common gynaecological cancer after endometrial and ovarian cancer. HPV testing is now the primary cervical screening test in New Zealand, replacing the previous cytology-based test (for an overview of HPV primary screening, click here).
The most recent cervical screening coverage data show that approximately 75% of the eligible population received a HPV test within the last three years; slightly below the Programme’s target of 80%. This is a timely reminder to opportunistically check whether eligible patients are up to date with cervical screening. A bpacnz clinical audit is available for identifying patients who are not participating in regular cervical screening.
For further information on administering HPV testing in general practice, click here.
New version of the Immunisation Handbook released
The latest version of the Immunisation Handbook 2025 (Version 5) has been released. Key updates include:
- Addition of new evidence on the reduced risk of Guillain-Barré syndrome following COVID-19 vaccination
- The spacing between the two-dose HPV vaccination schedule for people aged 9 – 14 years can now be reduced to five months to facilitate timely vaccination, if required, e.g. when given as part of a school-based immunisation programme. Generally, the second dose is given 6 – 12 months after the first.
- Inclusion of information about headache and myalgia in regard to adolescents who receive concomitant MenACWY and MenB vaccines
- Written consent is no longer required when administering the Mpox vaccine
- Wording updated in the Zoster chapter to confirm the second dose of Shingrix is funded at any age if the first dose was administered to a person aged 65 years (as reported in Bulletin 128)
- Changes to the recommendations in the Planning immunisation catch-ups chapter
- Links and references updated to reflect the name change from the Institute of Environmental Science and Research (ESR) to the New Zealand Institute for Public Health and Forensic Science (PHF Science); as reported in Bulletin 127
Click here to view a summary of all the changes for this release.
Upcoming webinars
ACC is hosting an upcoming webinar aimed at general practice: Working together to improve outcomes – Primary Care. This will focus on updates about the projects ACC has implemented to challenges identified and discussed during webinars earlier in the year. The webinar will also discuss opportunities for primary care clinicians to help improve return to work outcomes. The webinar will be held on Wednesday, 8th October, at 12 pm (register here). Recordings will be available at a later date.
HealthPathways is hosting a webinar on abnormal uterine bleeding. This free webinar is expected to cover topics including the new national guidelines, understanding the difference between normal and abnormal menstrual bleeding, early detection of endometrial cancer, risk assessment and the impact of co-morbid conditions and primary care procedures, e.g. pipelle biopsy, Mirena insertion. The webinar will be held on Tuesday, 14th October, from 7 pm – 8 pm. Click here to register (a certificate of attendance and CPD points are available). A recording will be available at a later date.
New form for people medically dependent on electricity
Some people rely on electricity for life saving medical equipment, e.g. a ventilator, or other electrical appliances required to safely deliver treatment, e.g. a microwave to heat renal dialysis fluid. The new Confirmation of Medically Dependent Consumer Status form should be used to advise a power company if a person is medically dependent on electricity. This form has been standardised as part of a new protocol regulating what information is shared between electricity retailers and distributors.
The person who is medically dependent on electricity (or their caregiver) prints out and completes Pages 1 – 4 of the new form. They then bring the form to their general practitioner, nurse practitioner or other relevant clinician who certifies their medically dependent status (by completing Page 5 of the form). The clinician is responsible for providing information and support to the patient for using their medical equipment and preparing for emergency electricity outages (e.g. an emergency response plan). After the form is accepted, a power company may occassionally ask for reconfirmation of a patient’s medically dependent status, however, this should not occur more often than once per year (and if it does, the power company will cover the costs if the original form has not yet expired or does not have an expiry date).
A guide for health practitioners is available, here.
Aviation security screening advice for people with diabetes medical devices
Diabetes New Zealand, in conjunction with New Zealand Aviation Security Service (AvSec), has produced an online brochure to provide guidance to people who use diabetes medical devices, such as continuous glucose monitors and insulin pumps, when undergoing airport security screening. AvSec recommends that passengers inform Aviation Security Officers about wireless medical devices (either on their person or in their luggage) as soon as practical when approaching security screening so that they can arrange an alternative screening procedure. These devices often trigger the alarm on walk-through metal detectors. They may also malfunction if exposed to full body scanners or X-ray machines (and therefore should not go through these machines).
When a patient is established on a continuous glucose monitor or insulin pump, provide them with a letter stating that they have diabetes and are dependent on a diabetes medical device – specific information about travelling with the device can be added as necessary, e.g. this device should not go through an X-ray machine (refer to the device user manual). A copy of this letter can be given to customs agents if the patient goes through airport security screening (or any other screening).
The brochure is available here.
Medical Factorium: "Achoo!" Why do people sneeze and is it good for you?
Every now and then, patients ask “why?” and the answer eludes us. In this occasional bulletin segment, we attempt to answer some of those curious questions.
The question: Why do people sneeze and is it good for you?
Read more
We all know that feeling… the slight tickle in the nose and the involuntary inhalation… oh no, a sneeze is on the way. Should you try to hold it in? For some people, breath holding, pinching the nose or touching the roof of the mouth with your tongue can stop the sneeze in its tracks. However, it is generally not recommended as it can cause an excess of pressure within the airways and lungs: let it go! A sneeze can actually be oddly enjoyable or satisfying, seemingly due to the endorphins that are released after the increase in muscle tension generated during the sneeze.
Sneezing or sternutation (from the Latin verb sternuere, meaning “to sneeze”) is an important protective involuntary reflex that results in rapid removal of environmental irritants and pathogens from the airway.1 Once may not be enough, so sneezes often come in twos or threes. For most people, three consecutive sneezes is about the limit before it becomes really annoying, e.g. for those who have seasonal allergies. Some sympathy might therefore be felt for Donna Griffiths from the United Kingdom who in the early 80s, set the world record for the longest sneezing fit lasting 976 days (that’s over 2.5 years).2
Humans are not alone in being able to sneeze. Most mammals including cats, dogs, horses and elephants can sneeze, as well as some other animals, such as chickens. The sneeze reflex can be broken down into two parts:3
- The nasal or sensitive phase begins with an irritant stimulating the nasal mucosa and sending signals via the trigeminal nerve to the sneezing centre located in the lateral medulla
- The efferent or respiratory phase starts after a key number of neurons have been recruited and results in a series of involuntary actions including deep inspiration, eye closing, initial closure of the glottis and increasing intrapulmonary pressure. This is followed by rapid dilation of the glottis with an explosive rush of air out through the mouth and to a lesser extent, the nose.
The spread of infectious diseases has been a hot topic since the COVID-19 pandemic and recent research has reported that a sneeze can deliver between 1,000 – 10,000 particles per second (some references say more) and that these particles are expelled at a speed of approximately 20 m/s (equivalent to 72 km/h) or sometimes even faster.4 In comparison, a cough might generate 100 – 1,000 particles per second at around half the speed of expulsion.
Sneezing is generally triggered by irritation within the nasal mucosa, but many other triggers have been reported such as bright light, cold air, mechanical stimuli, viral infection and an overfull stomach.1, 3 People who sneeze when they look at the sun or any bright light have a photic sneeze reflex or ACHOO syndrome (Autosomal-dominant Compelling Helio-Ophthalmic Outburst).3 ACHOO, which was first described in 1954, is an inherited syndrome with an autosomal dominant pattern and is estimated to affect 17 – 35% of the world's population.3 The reason why light should trigger a sneeze is not exactly known but it is assumed that there is some indirect cross-stimulation of the ophthalmic division of the trigeminal nerve or that involvement of the parasympathetic branches of the oculomotor nerve also trigger congestion and irritation from secretions within the nasal mucosa.3 Whether there is an evolutionary benefit behind this reflex is also unclear.
So, for a reflex that is meant to be protective, sneezing can be a key factor in the spread of infectious diseases and its impact in allergic rhinitis can significantly affect quality of life.1 Can sneezing have other health consequences? A 2019 review of injuries attributed to sneezing from 1948 to 2018 found 52 injury reports that were classified into six main areas of the body - intrathoracic, laryngeal/pharyngeal, ocular/orbital, intracranial/neurological, otologic and other. Most injuries (81%) were in males, likely due to their increased lung capacity generating a more powerful sneeze. A suppressed sneeze is more likely to cause injury, and risk factors were only present in 30% of cases, meaning that a sneeze injury can happen to anyone.5
To sum up: sneezing is an involuntary reflex in response to various triggers that protects the body, so go on and enjoy the sneeze, but be sure to cover your mouth when you do – not everyone wants to share in the fun!
References
- Li F, Jiang H, Shen X, et al. Sneezing reflex is mediated by a peptidergic pathway from nose to brainstem. Cell 2021;184:3762-3773.e10. doi:10.1016/j.cell.2021.05.017.
- Guinness World Records. Longest sneezing fit ever lasted over two years with millions of sneezes. Available from: https://www.guinnessworldrecords.com/news/2023/8/longest-sneezing-fit-ever-lasted-over-two-years-with-millions-of-sneezes-756455.
- Songu M, Cingi C. Sneeze reflex: facts and fiction. Ther Adv Respir Dis 2009;3:131–41. doi:10.1177/1753465809340571.
- Armand P, Tâche J. 3D modelling and simulation of thermal effects and dispersion of particles carrying infectious respiratory agents in a railway transport coach. Sci Rep 2025;15:2202. doi:10.1038/s41598-024-84411-2.
- Setzen S, Platt M. The dangers of sneezing: a review of injuries. Am J Rhinol Allergy 2019;33:331–7. doi:10.1177/1945892418823147.
View previous Medical Factorium items here.
Do you have a clinical oddity that you would like us to investigate, or better yet, can you share a fascinating medical fact with our readers? Email: editor@bpac.org.nz
Paper of the Week: Stepping down antihypertensives in frail older people – is it beneficial?
Hypertension is a common clinical finding among patients in primary care and clinicians are well versed in the importance of lowering blood pressure to reduce cardiovascular disease risk. For most people, dual antihypertensive treatment is recommended to achieve a systolic blood pressure target range of 120 – 129 mmHg. The optimal management approach in older people with frailty is less clear cut, with the risk of falls or orthostatic hypotension often cited as concerns with intensive blood pressure management in this group. Several observational studies have demonstrated potential harms (e.g. cardiovascular morbidity and mortality) associated with multiple antihypertensive medicines and low blood pressure in people with significant frailty. The 2024 ESC hypertension guidelines emphasise the need to individualise antihypertensive treatment in older people (i.e. aged ≥ 85 years) and/or those with significant frailty based on this.
However, a randomised controlled trial (RETREAT-FRAIL) published in the New England Journal of Medicine raises uncertainty about the benefit of “de-prescribing” antihypertensives. It was found that progressively stepping down antihypertensive medicines in adults aged ≥ 80 years with frailty living in aged residential care facilities, did not lower all-cause mortality or reduce other major adverse cardiovascular events (MACE), compared to those who received usual care. The results of this trial suggest that de-escalating antihypertensive treatment in this population is unlikely to have a clinically meaningful effect. Therefore, treatment for hypertension could continue to be offered to older, frail patients for as long as they wish to take it. Treatment intensity (e.g. lower doses or reducing to monotherapy) can be adjusted on an individual basis in response to symptoms or changing treatment priorities.
Do you routinely de-escalate antihypertensive treatment as patients become older and frailer? Or would this generally only be considered if patients were experiencing adverse effects? Do you find that patients are less tolerant of taking multiple antihypertensives as they become older? If antihypertensive treatment is de-escalated, in your experience does the patient’s blood pressure remain controlled?
Read more
- The study population included people aged ≥ 80 years living in aged residential care facilities across France who were taking more than one antihypertensive medicine and had a systolic blood pressure < 130 mmHg. A total of 1,048 residents were randomly assigned to either a step-down group (n = 528) in which a strategy of progressive reduction of antihypertensive treatment was implemented, or usual-care (n = 520). The median potential follow-up was estimated to be 38.4 months (interquartile range: 30.0 – 48.0).
- The study population had a mean age of 90.1 years and were predominantly female (80.7%). Approximately 90% reported some degree of frailty based on an algorithm similar to the Clinical Frailty Scale; 38.5% had severe or very severe frailty. Mean systolic blood pressure was similar between the step-down (113 mmHg) and usual-care groups (114 mmHg).
- In the step-down group, antihypertensive discontinuation began immediately after randomisation, at three- and six-month visits, then every six months thereafter. Only one antihypertensive medicine could be discontinued at each visit. All antihypertensive medicines were discontinued without a reduction in dose, apart from beta blockers and loop diuretics, which were initially reduced to half the dose and then withdrawn one week later.
- If the residents systolic blood pressure increased to ≥ 160 mmHg, the antihypertensive that was last discontinued was re-introduced at half of the original dose. This occurred in seven residents.
- No significant difference was observed between the two groups for the primary end point of death from any cause (adjusted hazard ratio: 1.02; 95% confidence interval [CI]: 0.86 – 1.21), including when the population was adjusted for age, systolic blood pressure, presence of heart failure and frailty score
- The adjusted mean difference in the number of antihypertensive medicines that were stopped between groups was -0.73 (95% CI: -0.85 – -0.66)
- The mean number (± standard deviation) of antihypertensive medicines being taken reduced in the step-down group from 2.6 ± 0.7 to 1.5 ± 1.1, and in the usual-care group from 2.5 ± 0.7 to 2.0 ± 1.1
- The adjusted mean difference in the change in systolic blood pressure between groups was 4.1 mmHg (95% CI: 1.9 – 5.7); the authors note that this was lower than expected
- Analysis of the secondary end points (e.g. composite of major adverse cardiovascular events, death from non-cardiovascular causes, fracture), showed no significant difference between the step-down and usual-care groups
- There was also no significant difference in adverse events, including cognition, balance, activities of daily living or quality of life observed between groups
- Several potential limitations of the study were reported, including that:
- These findings may not be generalisable to all older populations given the study cohort was based in aged residential care facilities and the threshold for de-prescribing antihypertensive medicines may be different for those who live alone or with limited support. The authors did note, however, that the de-prescribing algorithm used in the study could easily be adopted and is universally applicable.
- There might have been closer monitoring for adverse events in residents who had undergone recent changes to their medicine regimen
Benetos A, Gautier S, Freminet A, et al. Reduction of antihypertensive treatment in nursing home residents. N Engl J Med 2025;:NEJMoa2508157. doi:10.1056/NEJMoa2508157.
For further discussion on the management of hypertension in older people, see: https://bpac.org.nz/2023/hypertension.aspx
This Bulletin is supported by the South Link Education Trust
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