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Published: 9th February, 2024


In case you missed it – Melatonin: is it worthwhile for sleep?

Melatonin is a naturally occurring hormone that regulates circadian rhythm and sleep. Given its important biological functions, there has been interest in melatonin as a medicine, and patients often enquire about whether supplementation can help manage sleep disturbances. Evidence suggests melatonin may provide some benefit for older adults with insomnia when dosed at the correct time, and it is generally well tolerated. However, melatonin is not a first-line treatment and use should not be prioritised over other forms of evidence-based care.

Read the full article here

Other recent resources from bpacnz

February is Ovarian Cancer Awareness Month

This month is Ovarian Cancer Awareness Month (following Cervical Cancer Awareness Month in January). Ovarian cancer is the second most common gynaecological cancer after endometrial and has a higher mortality than all other gynaecological cancers in New Zealand combined.

There is no effective screening test for ovarian cancer; diagnosis relies on the prompt recognition and investigation of suspicious symptoms. While ovarian cancer was historically considered to be a silent disease in its early stages, evidence suggests that 90 – 95% of people diagnosed with ovarian cancer are symptomatic. However, a key diagnostic challenge is that symptoms are often vague and non-specific. Clinicians should be alert for potential symptoms of ovarian cancer and have a low threshold for initiating further investigations (including CA-125) in people with suspicious symptoms.

For further information on ovarian cancer early detection and referral, see:

Updated national concussion guidelines for community sport

ACC, in partnership with seven national sporting organisations, has released updated guidelines on the recognition and treatment of concussion for people participating in community sport. This framework is intended to help foster a consistent standard of care, irrespective of the sporting discipline.

The guidelines include a six-stage graduated return to education/work and sport protocol, recommending that:

  • Stage 1: players should initially undertake 24 – 48 hours of physical and mental rest
  • Stages 2 – 4: during the 2 – 13 days post-injury, players can progressively re-engage in normal daily activities, increase their tolerance for physical and mental activities, before returning to work/study and types of sport-specific training that do not risk head impact. The progression through these stages and the intensity of re-engagement should be guided by symptoms.
  • Stage 5: after at least 14 days, players can re-engage in full contact-based sport specific training if they are asymptomatic. Players must have fully returned to school or work before returning to contact-based training.
  • Stage 6: a minimum of 21 days should have elapsed before players can return to full competition, they should be symptom free during sports training and they should have received medical clearance from a qualified medical practitioner (strongly recommended)

View the full guidelines here. An accompanying press release about the guidelines is available here.

ACC has also released a position statement about no longer accepting “post-concussion syndrome” as a covered injury. Click here to view the statement. This decision, and the evidence behind it, was also discussed in the bpacnz article on concussion.

For further information on the management of concussion in primary care, including for patients who sustain non-sports-related concussion, see:

Spike in lead notifications from suspected Kamini use raises concerns

The National Public Health Service (NPHS), Te Whatu Ora, has received notification of a cluster of cases of lead poisoning with exposure suspected to be from an Ayurvedic product known as Kamini (also referred to as Kamini Vidrawan Ras, KVR). The NPHS is urging clinicians to be alert for further potential cases of lead poisoning associated with this product.

Kamini comes in the form of small pellets, swallowed like tablets.

Reminder. A blood lead level ≥ 0.24 micromol/L is notifiable to the local Medical Officer of Health within the NPHS who will investigate the exposure further. This includes suspected occupational exposure which is assessed by the NPHS before being notified to WorkSafe for further investigation. Lead-based paint is the most common source of blood lead notifications in New Zealand, but traditional medicines and cosmetics have also been reported as sources.

For further information on Kamini, see:

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

Medicine supply news: molnupiravir, ciprofloxacin, testosterone gel

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.

Rapid antigen test for COVID funding extended

Te Whatu Ora, Health New Zealand, has announced an extension to the funding of rapid antigen tests (RATs) for COVID-19 testing. RATs will now be funded up until 30th June, 2024 (replacing the previous date of the end of February). Pharmacies and practices can continue to order RATs as usual (e.g. via the online portal process).

A list of available RAT collection sites is available here.

Which medicines are most likely to cause hyperglycaemia?

Managing a glucose-control regimen in a patient with diabetes, or those at risk of diabetes, can often be a delicate balancing act, made more difficult when medicines for other conditions need to be added, either acutely or long-term. Being aware of the medicines that are most likely to increase glycaemic levels can make treatment decisions a little easier. Medicine-induced hyperglycaemia is usually mild and reversible upon discontinuation of the medicine, and in many cases, may be temporarily accommodated during short-term treatment. However, for some people, alteration of their existing glucose-lowering regimen, or initiating a glucose-lowering treatment, will be required, particularly if the causative medicine is needed long-term.

A recent Medscape commentary identifies the top five medicines that can increase glucose levels (in patients both with and without diabetes), along with some “honourable mentions”, and offers practical management tips for patients taking these medicines:

  1. Corticosteroids
  2. Antipsychotics, particularly clozapine, olanzapine and haloperidol
  3. Thiazide diuretics
  4. Statins, particularly higher potency statins such as rosuvastatin
  5. Beta blockers, particularly metoprolol and atenolol

Also: androgen therapy, antiretroviral therapy, immunosuppressants

When prescribing any of these medicines to a patient with diabetes (or at increased risk of diabetes) in primary care, consider the potential impact that it may have on glucose levels and how this risk can be mitigated. For example, does the risk of hyperglycaemia outweigh the benefit of treatment? Can another medicine be prescribed instead? Is a low dose sufficient? Does a glucose-lowering medicine need to be added to the treatment regimen?

For further information on the management of diabetes in primary care, see:

Updated MCNZ statement on disclosure of harm

The Medical Council of New Zealand has released updated guidance for doctors on disclosure of harm following an adverse event. This follows a consultation process in the latter half of 2023 to seek feedback on proposed changes (as reported in Bulletin 82). The statement is intended to help clinicians understand the purpose of open disclosure of harm and what is expected of them if patient harm occurs.

NZF updates for February

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

  • Therapeutic notes have been updated for Angiotensin-II receptor blockers (pregnancy and breast-feeding advice updated), Cough suppressants (Medsafe Alert Communication added about pholcodine – for further information see Bulletin 84) and Hypertension in pregnancy (section updated)
  • Updated dosing regimen added to the tranexamic acid monograph for menorrhagia
  • Updated contraindications, cautions, hepatic impairment and dosing regimen in the paracetamol monograph
  • New caution added to the phenobarbital monograph (caution when switching between brands in epilepsy)
  • Pregnancy advice section updated in the mebendazole monograph (anthelmintic for threadworms and other gastrointestinal parasites)
  • Medsafe Monitoring Communication link added to the vildagliptin and vildagliptin + metformin monographs on the possible risk of ileus with DPP-4 inhibitors (see Bulletin 91 for further information)
  • New monograph added for zonisamide (Section 29, not funded; generally initiated in secondary care), indicated for focal seizures in people with epilepsy
  • Pholcodine monograph has been archived, as this medicine is no longer available in New Zealand (see Bulletin 84)

You can read about all the changes in the February release here. Also read about any significant changes to the NZF for Children (NZFC), here.

Paper of the Week: Managing dysmenorrhoea in primary care

Dysmenorrhoea, or painful menstruation, affects a significant proportion of menstruating females and is a common cause of absenteeism from education and employment. Given the physical, psychosocial and economic impacts of dysmenorrhoea, it would be expected that managing patients with this condition is a regular occurrence in primary care. However, that is often not the case. A 2016 Australian study found that while most females aged 16 – 29 years experienced dysmenorrhoea at some point, two-thirds did not seek help from health care professionals. Almost 90% reported that they consulted family/friends, social media and the internet for information and advice regarding dysmenorrhoea management, which may expose them to an increased risk of harm and ineffective treatment. Primary health care professionals can ensure that patients know that treatment for dysmenorrhoea is available and encourage those affected to seek help for their symptoms.

A recent article published in the Australian Journal of General Practice reviews the management of dysmenorrhoea in primary care. It is recommended that patients with symptoms of dysmenorrhoea are initiated on regular NSAIDs and/or a combined oral contraceptive, even while possible secondary causes are being investigated. Non-pharmacological strategies such as regular exercise and heat packs may be useful adjuncts to pharmacological treatment.

Do you believe dysmenorrhoea is under-reported among your patients? How do you evaluate and manage a patient presenting with painful menstruation? What non-pharmacological interventions do you suggest to patients with dysmenorrhoea?

Christensen K. Dysmenorrhea: An update on primary healthcare management. Aust J Gen Pract 2024;53:19-22. doi:10.31128/AJGP/04-23-6815

For further information on the diagnosis and management of endometriosis in primary care, see:

For further information on managing heavy menstrual bleeding, see:

This Bulletin is supported by the South Link Education Trust

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