July 2026 Clinical Snippets

Clinical Snippets July 2026

1.  Prescriber Update

The latest issue of Prescriber Update includes the following useful updates: 

(i) Undesirable effects of opioids

Opioid data sheets are being updated to include the following potential adverse effects of opioid therapy, particularly long-term high dose treatment:

• Suppression of the hypothalamic-pituitary- adrenal (HPA) axis occasionally causing reversible adrenal insufficiency requiring monitoring and glucocorticoid replacement therapy. Symptoms include fatigue, dizziness, nausea, vomiting and low blood pressure.  Opioids can also cause hyperprolactinaemia in males and females.
• Suppression of the hypothalamic-pituitary-gonadal (HPG) axis leading to low testosterone and oestrogen levels. Clinical symptoms such as reduced libido (both sexes), erectile dysfunction and menstrual irregularities can then occur.
• Sphincter of Oddi spasm which can cause increased biliary pressure, increasing the risk of biliary tract symptoms and pancreatitis.  Administer opioids with caution and with appropriate monitoring in patients with pancreatitis and diseases of the biliary tract.
• Oesophageal dysfunction which manifests as oesophageal symptoms (most commonly dysphagia but also heartburn, regurgitation and non-cardiac chest pain) along with abnormal oesophageal motility following long-term opioid use.
• A 2022 BPAC article covers opioid prescribing in primary care and has some editable resources including a pain management plan and example opioid contract.

(ii) Insulin autoimmune syndrome

• Insulin autoimmune syndrome (IAS) is characterised by recurrent hypoglycaemic episodes, increased serum insulin and the presence of insulin autoantibodies. It usually occurs without exogenous insulin treatment.
• Medicines are a primary trigger of IAS in about half of cases. Medicines and active metabolites that contain a sulfhydryl group (-SH) or thiol group (R-SH) have been associated with IAS. Examples include carbimazole, clopidogrel and captopril.
• Other triggers include viral infections (eg, measles, mumps, rubella, varicella zoster) and haematological conditions (eg, multiple myeloma).
• IAS is a self-limiting condition that typically resolves within a few months. Management may include stopping the causative medicine and supportive treatment, such as dietary modifications (eg, small frequent meals with low carbohydrate content) to reduce the risk of hypoglycaemia.

2. Latest coffee update

Issue 270 of GP Research Review reviewed a study published recently in JAMA exploring whether coffee and tea intake were associated with long-term cognitive function and dementia risk.  This was a prospective cohort study following 131,821 participants across the Nurses’ Health Study and the Health Professionals Follow-up Study who did not have dementia, Parkinson’s disease or cancer at baseline. Data on diet were collected via questionnaires every 2–4 years. Across up to 43 years of follow-up (median 36.8 years), those in the highest quartile of caffeinated coffee consumption had a significantly lower risk of dementia compared to those in the lowest quintile, after adjustments for confounders (141 vs. 330 cases per 100,000 person-years; HR 0.82) as well as a lower rate of subjective cognitive decline (7.8% vs. 9.5%). In the Nurses’ Health Study, those in the highest quartile of caffeinated coffee consumption had higher objective cognitive performance scores. The associations were similar for higher intakes of tea, although decaffeinated coffee consumption was not associated with improved cognitive performance or reduced dementia risk. Benefits were non-linear and most evident at about 2–3 cups of coffee or 1–2 cups of tea daily.  So another reason to keep supporting your local coffee roaster!  Reference: JAMA. 2026;335(11):961–74

3.  Gout -treating to target

A study recently published in JAMA Intern Med. looked at the impact of treat-to-target urate-lowering treatment and cardiovascular outcomes in patients with gout.  This was a primary care cohort study (UK) of more than 109,000 new urate-lowering treatment users with up to five years follow-up.  Achieving a serum urate target below 0.36 mmol/L with therapy was associated with a modest but meaningful cardiovascular benefit with patients who reached the target within 12 months having higher event‐free survival and a lower risk of MACE (major adverse cardiac event) with improved 5-year event-free survival and fewer gout flares. Benefits were most pronounced for patients at high/very high cardiovascular risk, and for those who achieved a serum urate level <0.3 mmol/L.  BPAC published an excellent comprehensive article on all aspects of gout management last year that is well worth a review. 

4. MSD update

MSD update: Telehealth consultations and expiry dates for Work and Income certificates

• The Ministry of Social Development has recently seen examples where a Work and Income client has booked an appointment with a telehealth provider to have an interim Work Capacity Medical Certificate (WCMC) completed until they can be seen by their own GP/practice. This process often incurs an additional cost for the patient.

• Work and Income can provide discretionary benefit extensions for clients if they have a good and sufficient reason for being unable to provide a medical certificate prior to their benefit expiry date. An example of this is where the earliest possible GP appointment is after their current WCMC expires. The extension can be for up to four weeks.

• In the scenario noted above, the client can contact their own GP practice and ask for written confirmation indicating the date and time of their next booked appointment – this can be in the form of a printout from reception. Work and Income can then put an extension in place until the patient is seen, negating the need for the client to seek an interim certificate from another provider.

5. Testosterone for women

The CFPC Tools for Practice #408 examined evidence around the question Can testosterone improve sexual function in pre or post-menopausal women?  The bottom line was in post-menopausal women with hypoactive sexual desire disorder (mostly on estrogen therapy), testosterone improves the number of satisfying sexual events by ~1 more per month over placebo at 12-52 weeks. Absence of benefit in premenopausal women may be due to small study sizes. Versus placebo, testosterone increases risk of acne (7.2% versus 5%) and hirsutism (12% versus 8%).  Current guidance was summarised as:

• May consider off-label testosterone for hypoactive sexual desire disorder after addressing other causes.
• Testosterone gel 1%: One-half pump daily to posterior calf.
• Levels not recommended for diagnosis. If treatment initiated, total testosterone levels at baseline, 3-6 weeks and every 6 months (target ≤2.8nmol/L).
• Onset: 1-3 months. Discontinue if no benefit at 6 months.

6.  Deprescribing PPIs

A recent Research Review Educational Series examines in some detail the rationale for and process involved in stepping down and stopping proton pump inhibitors.  The review outlines best practices for PPI stewardship, including when and how to deprescribe PPIs. It highlights two deprescribing strategies and explains how alginate/antacid combinations can reduce breakthrough symptoms.  Practice points include:

• PPI therapy should be reviewed routinely to confirm ongoing clinical necessity
• In the absence of a long-term indication, a trial of PPI de-prescribing is recommended
• Most patients with a long-term indication for PPI therapy who have twice daily dosing should be considered for a step down to once daily dosing
• Patients with long-term indications (eg Barret’s oesophagus) should not be considered for PPI de-prescribing
• Patients who undergo PPI de-prescribing should be advised that they may experience transient upper GI symptoms due to rebound acid hypersecretion
• Consider dose taper or abruptly stopping PPI therapy when de-prescribing
• Decision to de-prescribe a PPI should be based solely on the lack of indication for continued PPI therapy, rather than concern for PPI-associated adverse events

BPAC has some resources to aid PPI deprescribing; a PPI Audit tool and an earlier article on de-prescribing PPIs in older people.

7.  Ozempic mouth 

A Medscape article published last month summarised information about Ozempic mouth and how to treat it.  Ozempic mouth symptoms (related to use of GLP-1 inhibitors – possibly more common with semaglutide) include dry mouth (most common symptom), bad “sulfur” breath and a metallic/bitter taste in the mouth, tooth sensitivity and increased risk of tooth decay and gum disease.  Symptoms are driven by delayed gastric emptying, reflux, vomiting in up to 24% of GLP-1 inhibitor users, and decreased saliva production.  Delayed gastric emptying may drive sulfur burps via bacterial overgrowth/fermentation.  Good oral hygiene is important with twice-daily brushing for 2 minutes each time and flossing at least once a day recommended as well as regular dental review.  Additional symptom control measures include:

(i) Dry Mouth

• Advise patients to drink plenty of water or herbal tea without sugar.
• Stimulate saliva production with sugar-free gum or pastilles containing xylitol, a sugar alcohol shown to prevent tooth decay. The act of chewing gum itself increases saliva production.
• Recommend over-the-counter oral moisturizing rinses, sprays, gels, or lozenges.
• In severe cases, consider prescribing pilocarpine to boost saliva production.

(ii) Changes in Taste Perception

• Suggest smaller, more frequent meals to better tolerate the effects.
• Consider dietitian counselling to maintain a balanced diet.
• Monitor the patient closely because altered taste perception can lead quickly to nutritional deficiencies.

(iii) Reflux and Vomiting

• Encourage patients to replenish fluids consistently and eat smaller, more frequent meals.
• Suggest sugar-free antacids.
• Help patients identify trigger foods or behaviours to avoid — they might include certain acidic or fatty foods or smoking.
• Advise against brushing teeth right after vomiting when tooth enamel is softened and vulnerable to mineral loss. Instead, have them swish with water immediately and wait at least 30 minutes to brush.
• Recommend using toothpaste formulated for sensitive teeth.
• Consider modifying the medication dose to reduce vomiting.

(iv) Sulfur Burps and Halitosis

• Advise the use of a fluoride-containing antibacterial toothpaste, preferably with zinc, to help neutralize sulfur compounds and kill odor-causing bacteria.
• Recommend tongue scraping and flossing at least once a day.
• Recommend a fluoride-containing mouth rinse.

8. Study of the month

A recent Medscape Impact Factor commentary reviewed an Australian study published in JAMA Network Open titled Regular Flatulence Patterns Among Community-Dwelling Individuals in Australia.  Flatulence patterns in 6416 individuals aged older than 14 years broadly representing the Australian population were recorded using a purpose-designed mobile phone application (Chart Your Fart).  Consenting participants were instructed to enter each passage as close as possible to its discharge over at least 2 weekdays and 1 weekend day. Time of event could be retrospectively edited. The app was designed to make recording simple and discreet. The primary outcome considered was total flatus per day (fls/d) with 360192 outputs recorded. 

Key findings included:

• Mean self-reported flatus frequency: ~5/day
• Men reported more flatus than women; reporting bias possible.
• Peak flatus frequency occurred in ages 26–45; lowest in 14–25 years.
• Flatus rate ↑ through day, peaking pre-bedtime; lowest early morning.

Authors note limitations of this study include failing to quantify emissions made while asleep due to reliance on self-report. Devices inserted into the anus to capture intestinal gas provide rigorous observation of flatulence production, but production is unlikely to be perfectly correlated with output, given conscious control over release and associated sociocultural standards. Furthermore, perception of excess relies on patient self-report. Nonetheless, self-report may also partially explain the observed gender differences. Greater efficiency in expulsion could also confound frequency data, with large variation in individual volume previously observed (33-125 mL/flatus).

Clinical Snippets – March 2026

https://open.spotify.com/episode/0UG8gzNIsEMYMBqg7unimr?si=08fPJi4CQR-SrQP559gahg

Clinical Snippets March 2026

1.  UTI in children

BPAC have published an update on managing urinary tract infection in children.  For rapid reference there is a B-Quick summary available that includes a useful dipstick interpretation algorithm.  Some relevant points include:

(i) Symptoms

• UTI symptoms in young children may be non-specific, e.g. fever, irritability, poor feeding, vomiting
• Older children may report urinary symptoms, e.g. frequent or painful urination, changes to urine colour or smell, abdominal or back pain
• Suprapubic or flank tenderness, palpable bladder or stool in the bowel, abdominal distension, dehydration and/or fever may be present on physical examination

(ii) Red flags for paediatric advice or referral

• Seek paediatric advice for children with a suspected upper UTI, i.e. with UTI symptoms accompanied by fever ≥ 38°C and/or loin or flank pain/tenderness
• Acute paediatric referral is indicated for children:
  • Aged under three months
  • With symptoms or signs of significant systemic illness or sepsis
  • With complicating factors, e.g. an abdominal or bladder mass, impaired renal function, anatomic urinary tract abnormalities, previous renal surgery/implants

(iii) Urinalysis

• Urinalysis is indicated for all children with a suspected UTI. Mid-stream or clean catch urine samples are preferred.  The full article and Starship guidelines describe various methods to facilitate sample collection including the Quick wee method, bladder percussion and the Perez reflex
• Urine dipstick testing can support the diagnosis. However, urine microscopy, culture and sensitivity analysis is required to confirm a UTI and determine microbial sensitivity.
• In children aged over three months, a UTI is unlikely with a negative dipstick test result for both leukocyte esterase and nitrite; consider alternative diagnoses
• In children aged three months to three years, a positive dipstick test result for either leukocyte esterase or nitrite is sufficient to initiate empiric antibiotic treatment and send the sample for microscopy, culture and sensitivity analysis

(iv) Treatment

• Initiate oral empiric antibiotic treatment while awaiting laboratory urinalysis results.  Review antibiotic choice once results are available. If symptoms are not improving and the pathogen is resistant to the empiric choice, select an alternative.  Seek paediatric advice if symptoms do not respond to appropriate antibiotic treatment within 48 hours
• Order of preference for empiric treatment (three-day course standard, up to seven days may be considered in children with more severe symptoms but no red flags for secondary care referral) is cefalexin then nitrofurantoin (can be compounded into a suspension) then if bacteria are known to be sensitive amoxiclav then co-trimoxazole. 

(v) Follow-up:  Request a renal ultrasound (ideally to be performed six weeks after presentation) for:

• Children aged < 12 months with their first UTI
• Children of any age with an atypical UTI who have not previously been investigated with a renal ultrasound 
  • Poor response to antibiotics after 48 hours
  • Poor urine flow/suspected urinary obstruction
  • Abdominal or bladder mass
  • Raised creatinine
  • Hypertension
  • Infection with a non-E. coli organism
• Children of any age with recurrent UTI   (≥ 2 culture-proven UTIs within one year, or ≥ 3 if the symptoms were only mild) who have not previously been investigated with a renal ultrasound

2. Prescriber Update

Some updates from the March Prescriber Update include:

(i)  Gynaecomastia

• Has been reported in association with a wide range of medicines (27 listed as a representation) including omeprazole, digoxin, spironolactone, amlodipine, most statins, isotretinoin, methotrexate, antipsychotics, sertraline, fluoxitene, methyphenidate.  Atomoxetine is currently on the reporting list.
• Onset can be delayed – gynaecomastia can develop weeks to years after starting treatment or adjusting the dose. Dose reduction or discontinuation of the suspect medicine may lead to improvement, particularly when gynaecomastia is identified early. Persistence beyond 12 months may be less likely to resolve without intervention.
• Consider a medicine-related cause in male patients presenting with breast enlargement or other breast tissue changes.

(ii) Fournier gangrene

• Fournier gangrene (necrotising fasciitis) is a rapidly progressive infection affecting the soft tissue and fascia of the perineal, perianal or genital areas.
• Fournier gangrene has been known to occur in patients treated with empagliflozin for type 2 diabetes mellitus and is now known to occur with the use of empagliflozin in patients who do not have type 2 diabetes mellitus (eg when used in heart failure).

(iii) Zoledronic acid in the elderly

• Elderly patients receiving zoledronic acid infusions are at higher risk of adverse reactions and may experience more severe adverse reactions or find them more disabling than younger people.  In particular, acute phase reactions are noted as a cause of concern including fever, joint pain and swelling, myalgia, influenza-like illness and gastrointestinal symptoms (abdominal pain, vomiting and diarrhoea). These usually occur within the first three days after zoledronic administration. Ocular inflammation, such as uveitis, can rarely occur and requires prompt ophthalmologist review.  Administering paracetamol shortly after the zoledronic acid infusion may reduce symptoms (some clinicians recommend a dose 60 mins prior to the infusion and regular administration for up to three days post-infusion).

• Consider the following prior to the zoledronic infusion:

• Inform the patient that acute phase reactions are common and usually resolve in a few days. However, patients should seek medical attention if symptoms are serious or prolonged. 
  • Ensure the patient is adequately hydrated and measure their serum creatinine. Maintain adequate hydration following the infusion.
  • Treat pre-existing hypocalcaemia with adequate intake of calcium and vitamin D.

(iv)  GLP-1 receptor agonists

GLP-1 receptor agonists can cause altered skin sensations.

• Semaglutide (Wegovy) is associated with dysaesthesia, paraesthesia, hyperaesthesia, burning sensation, allodynia and sensitive skin.
• Tirzepatide (Mounjaro) is associated with dysaesthesia.
• Consider GLP-1 receptor agonists as a possible cause in patients presenting with altered skin sensations.

NB Healthcare professionals and consumers are encouraged to report any suspected acute persistent visual loss associated with use of GLP-1 receptor agonists per Medsafe monitoring communication in January 2026.   Cases of retinal vein occlusion and non-arteritic anterior ischaemic optic neuropathy (NAION) have been described in patients taking GLP-1 receptor agonists although the significance of this association is yet to be determined. 

3.  In other news…

(i)  Coffee:  The DECAF randomised clinical trial is a study of 200 patients with persistent AF and baseline coffee intake of 7 cups per week in which patients were randomly assigned in a 1:1 ratio to either regular caffeinated coffee consumption or complete abstinence from coffee and caffeine for 6 months following successful cardioversion.  The consumption group was encouraged to drink at least one cup daily, while the abstinence group avoided all caffeinated and decaffeinated coffee and other caffeine products.  In the primary analysis, AF or flutter recurrence occurred in 47% of the coffee group versus 64% of the abstinence group, with a 17% absolute difference.

(ii)  Paracetamol:  Two recent analyses of reviews and metanalyses regarding prenatal paracetamol exposure and child neurodevelopment, one published in the BMJ and another in The Lancet, have both concluded that current evidence does not indicate a clinically important increase in the likelihood of autism spectrum disorder, ADHD, or intellectual disability in children of pregnant individuals who use paracetamol as directed.  This is in contrast to the Trump administration proclamation in September last year.  The BMJ authors note Any apparent effect observed after in utero exposure to paracetamol on autism and ADHD in childhood might be driven by familial genetic and environmental factors and unmeasured confounders. 

(iii)  Morphine:  Issue 239 of Respiratory Research Review included comment on the Morphine for chronic breathlessness (MABEL) trial undertaken in the UK with results published in The Lancet late last year.  Adults with chronic breathlessness due to cardiorespiratory conditions were randomised to receive oral long-acting morphine 5–10mg twice daily with a laxative (evaluable n=73) or placebo (evaluable n=67) for 56 days.  At 28 days, 88% in the active arm and 99% in the placebo arm had regime adherence of >90%.  However, there was no significant difference between morphine versus placebo for the primary outcome of worst breathlessness at day 28 or at other time points.  There was improved cough at day 56 favouring morphine.  There were more adverse events in the morphine arm than in the placebo arm.  The authors concluded we did not show a benefit of morphine for our primary outcome of breathlessness. However, secondary outcome findings taken together (some evidence of benefit [eg, cough, physical activity], some evidence of no difference [eg, morphine-related neurocognitive or respiratory harms], and newer insights into morphine-related harms [eg, morphine withdrawal, persistence of constipation despite resolution of nausea and vomiting]) alongside acceptable tolerability indicate that further research is needed to fully understand the role of morphine in people living with chronic breathlessness. 

4.  Equity focus

(i)  Issue 118 of Maori Health Research Review examined a recently published observational study on CVD risk assessment by ethnicity in Aotearoa New Zealand.  People aged 25-74 years living in New Zealand on 31 March 2018 who were eligible for CVD risk assessment (n = 1,476,747) were analysed. Between 1 April 2018 and 31 March 2023, 67.1% of men and 65.5% of women had CVD risk assessments undertaken. After adjustment for socioeconomic deprivation and residential district, the odds of CVD risk assessment when compared with Europeans was lower in Māori men with diabetes (aOR 0.77) and without diabetes (aOR 0.73), and in Maori women with diabetes (0.93) and without diabetes (0.89).  The odds of CVD risk assessment was also lower in Pacific men (aOR 0.86 [95% CI 0.78-0.94] with diabetes (aOR 0.86) and without diabetes (aOR 0.72) and Pacific women without diabetes (aOR 0.95) compared with Europeans. The reviewer notes With CVD being a leading cause of avoidable premature death for Māori, this study has importantly quantified an often-invisible step in the CVD prevention continuum. Targeted strategies that redress equity in the wider determinants, in system design and in clinical practice, rather than simply increase screening overall, are needed.

(ii)  Goodfellow Gem #253 summarised a recent NZMJ study looking at cancers potentially attributable to excess body weight in Aotearoa New Zealand from 2019 to 2023.  The authors express concern that excess body weight (EBW) contributes to many cancers in New Zealand and compounds health inequities, with higher proportions of EBW-attributable cancers within Māori and Pacific populations.  Pacific peoples had the highest population attributable fraction (11.8%), and this was highest among Pacific females (16.1%). Māori also had a higher PAF (6.9%) than European/other (4.5%). The cancers most commonly attributable to EBW were colorectal cancer, followed by uterine cancer and breast cancer among postmenopausal females.  The authors conclude A pro-equity, anti-stigmatising approach to prevention, early detection and treatment of EBW is important. Ultimately, sustained reductions in EBW-attributable cancers will depend on preventing EBW.

5.  Recent releases

(i) The Medical Council of New Zealand has recently published Guidance on using artificial intelligence in patient care.  It is important to review the statement in its entirety but some clauses include:

• AI is not a substitute for your clinical judgement, and you remain responsible for all your clinical decisions and actions. AI can make mistakes or reflect bias and may produce inaccurate or fabricated information. Therefore, as far as is reasonably practicable, you should check the accuracy of any AI output and confirm it is appropriate for the individual patient before using it for patient care or including it in patient records.

• Patients should know when AI is being used in their care. For low-risk AI, this can be explained in a simple statement that describes how AI is used in their care and how their data is protected. For high-risk AI that influences clinical decisions, you must explicitly inform the patient.

• There are some specific situations where you need to obtain informed consent for the use of AI, including when:
  • using an AI tool to record the consultation, such as a transcription tool (scribe)
  • the patient’s personal details are shared outside of the primary medical record or used for AI training in a way that could identify them
  • the AI technology plays a significant role in diagnosis, treatment or delivery of care.

In these situations, let the patient know how their care will be affected if they decide against the use of AI. Always document in the patient’s records whether informed consent was obtained.

(ii)  GP2GP:  Some recent reporting in NZ Doctor highlighted potential good news on the horizon for those concerned with clinical notes transfer between practices. 

• PMS providers Medtech and Valentia Technologies say testing and rollout of an upgraded GP2GP patient file-transfer system is underway.
• Medtech expects the upgrade to be available to its customers by the end of June, while Valentia says its rollout to Indici users could be completed by May.

(iii) Meningococcal disease:  The reporting earlier this month of two cases of meningococcal disease in tertiary students in Dunedin has led to a reminder from IMAC that now is a good time to check meningococcal immunisation status for school and university students.   

• The vaccinations Bexsero (B strain) and the quadrivalent MenQuadfi (A,C,W and Y strains) are recommended and funded for those aged 13-25 years inclusive who are entering within the next three months, or are in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, Youth Justice residences or prisons.  Funding covers individuals who turn 13 years of age while living in boarding school hostels.

• IMAC notes that the MeNZB vaccine used in NZ from 2004 to 2011 targeted one type of meningococcal group B disease. Those who received MeNZB are no longer expected to have protection against this type of group B disease.  IMAC provides an FAQ resource on meningococcal vaccines including information on co-administration and duration of effectiveness. 

(iv)  Season 2 of The Pitt was released in NZ in January (Neon) and a Medscape emergency medicine article has several doctors rating the accuracy of the clinical presentations or procedures dominating each episode.  These include:

• A hilar flip during an emergency clamshell thoracotomy to stop a catastrophic lung haemorrhage (realistic)
• Hypokalaemic periodic paralysis masquerading as traumatic paraplegia (zebra)
• Intrarectal manipulation for a coccygeal fracture (without anaesthetic!)
• Management of medication related priapism (OK except for the gentle massage and no 3-way stopcock (for phenylephrine injection and aspiration)

Clinical Snippets November 2025

https://open.spotify.com/episode/0rVqbjPu8l1vJOM2qJMYQP?si=eQu5gna5QjuRSaz0zcas5A

1. NZ Doctor prescribing Spotlight series

NZ Doctor have been publishing a Spotlight series of snapshot reports using hazard detection data from the Conporto Event Detection & Mitigation service that automatically analyses the patient’s medical records and identifies if a risk of harm is likely. 

(i) The first report looked at sodium valproate prescribing in women of childbearing potential without documented history of hysterectomy. Sodium valproate is contraindicated in girls and women of childbearing potential, unless other treatments are ineffective or not tolerated, and effective contraception is in place. It should not be prescribed in pregnancy for epilepsy unless no alternatives exist, or in pregnancy at all for bipolar disorder. Between 14 and 27 April 2025, 187,608 patient interactions were captured and a total of 474 new harm events were detected across 307 medical centres. Over these two weeks, 56 females aged 10–59 years were identified as being prescribed sodium valproate without a history of hysterectomy recorded in their notes. Of these, 29 women did not have any history of epilepsy.  ACC have developed a resource on benefits and risks of anti-seizure medicine prescribing for healthcare professionals to discuss with anyone who could get pregnant. 

(ii) A second report run between 19 May and 1 June 2025 focussed on the “triple whammy” combination – the concurrent use of an NSAID, an ACE inhibitor or angiotensin II receptor blocker, and a diuretic in patients with impaired renal function (eGFR <60).  This combination significantly increases the risk of AKI, especially in patients with impaired renal function, but can also cause harm in those with previously normal renal function.  Māori, Pacific peoples and older adults are particularly vulnerable due to higher rates of chronic kidney disease, heart disease and multimorbidity.  Over the observation period there were 191,140 patient interactions a total of 491 new harm events were detected across 299 medical centres.  Over these two weeks, 57 patients with impaired renal function prescribed all three components of the triple whammy. The event detection system indicates the combination has been newly initiated in patients with renal impairment.  It is important to note that only prescribed NSAIDs are captured – patients may also be taking over-the-counter NSAIDs, which are not recorded and could further increase risk. Advice is to avoid prescribing the triple whammy combination in patients with already impaired renal function and educate patients with impaired renal function of the potential risk of OTC NSAIDs.  

(iii) Another report run between 16 and 29 June 2025 looked at co-prescribing of macrolide antibiotics (particularly erythromycin or clarithromycin) with simvastatin, a known high-risk interaction that is contraindicated.  Macrolides strongly inhibit cytochrome P450 3A4, the enzyme that metabolises simvastatin. This can lead to a 10-fold increase in simvastatin exposure and four-fold increase in atorvastatin exposure, significantly raising the risk of myopathy and rhabdomyolysis. Risk increases with age ≥65 years, higher statin doses and concurrent medicines (eg, azole antifungals, ciclosporin) or comorbidities such as diabetes or renal impairment.  Over the observation period there were 209,108 patient interactions across 295 medical centres, with 517 new harm events identified. Among these, 25 patients were prescribed a macrolide antibiotic while also taking simvastatin.  Advice: Before prescribing or dispensing a macrolide antibiotic check for concurrent statin use, particularly simvastatin or atorvastatin. If a macrolide cannot be avoided, one of the following is recommended:

• Temporarily withhold simvastatin or atorvastatin during the course of macrolide treatment.
• Consider using a statin not metabolised by CYP3A4, such as pravastatin or rosuvastatin.
• Select a macrolide with a lower interaction risk, such as roxithromycin, with caution – warn patients to promptly report symptoms of myopathy, such as muscle pain or weakness.

2.  Carotid artery POCUS

Issue 261 of GP Research Review includes review of a cross-sectional study published in BMC Primary Care investigating the sensitivity and specificity of POCUS for identifying carotid atherosclerosis in primary care, and the prevalence of carotid atherosclerosis in apparently healthy individuals with high or very high cardiovascular disease risk. A total of 199 participants aged 40–69 years with high or very high calculated CVD risk and no prior treatment with antilipemic drugs underwent POCUS of the carotid arteries. The prevalence of carotid atherosclerosis was 69.5%, with higher rates in males and older patients. The sensitivity and specificity of POCUS for detecting carotid atherosclerosis were 96.4% and 90.0%, respectively.  The reviewer’s take home message was that using POCUS in primary care can significantly improve early cardiovascular disease risk assessment and prevention and is another effective point-of-care procedure that can be accurately undertaken in general practice.  I note all family medicine practitioners taking part in the study took part in a 5-step individual carotid artery POCUS course, which took from 2 to 6 months (depending on prior ultrasonographic experience of the practitioner).

3.  Insomnia study

The same issue of GP Research Review summarised the randomised controlled DREAMING study from the Netherlands published in the British Journal of General Practice which aimed to asses the effectiveness of low-dose mirtazapine (7.5-15mg) and amitriptyline (10-20mg) in patients with insomnia disorder. Insomnia Severity Index (ISI) scores were assessed at baseline and again at 6, 12, 20, and 52 weeks.  The conclusions: Compared with placebo, low-dose mirtazapine provided a statistically significant and clinically relevant reduction of insomnia severity at 6 weeks, but not at later time points. Low-dose amitriptyline resulted in a statistically significant but not clinically relevant reduction at 6 weeks. The results do not support the prescription of low-dose amitriptyline and mirtazapine for several months in patients with insomnia disorder in general practice. Based on the results, GPs may consider prescribing off-label low-dose mirtazapine for a period of about 6 weeks in cases where non-pharmacological treatment is insufficient. BPAC has excellent resources on management of insomnia.  

4.  Sepsis

HQSC has released the Clinical Guide to Sepsis management in New Zealand.  There is a section on sepsis management outside the acute hospital setting together with tables of red and amber assessment criteria.  Take home points include relevant to primary care include: 

(i) Refer all people with suspected sepsis outside acute hospital settings for emergency medical care by the most appropriate means of transport (usually via ambulance) if:

• they meet any high-risk (RED FLAG) criteria (see relevant tables) or

• there is a concern that the person would be unable to return with new or worsening symptoms

• one or more moderate- to high-risk criteria are present and there is increased concern for sepsis and/or lack of improvement after a period of observation.

(ii) If a definitive diagnosis is not reached, or the person cannot be treated safely outside an acute hospital setting, refer them urgently for care.

(iii)  For people with infection who do not have any high or moderate- to high-risk criteria who are being treated for infection, provide information about sepsis symptoms and how to access medical care if they are concerned (use dedicated written patient resources).

5. SA updates

Pharmac has announced the requirement for some Special Authority renewals is to be removed from some products from 1^st December, 2025. New patients will still require an initial Special Authority application.  Pharmac states they we will work with Health New Zealand to extend the expiry dates for people with an existing Special Authority approval for these products. 

The affected products include:

• Insulin pumps and continuous glucose monitors (interoperable and standalone) for type 1 diabetes
• Long-acting muscarinic antagonists with long-acting beta₂-agonists (LAMA/LABA inhalers) for respiratory conditions
• Febuxostat for gout
• Budesonide capsules for Crohn’s disease and microscopic colitis
• Epoetin alfa for chronic renal failure

6.    Alzheimer’s Disease advances 

(i) A recent NZ Doctor article noted that new blood tests for biomarkers of Alzheimer disease pathology can allow earlier diagnosis and improve its accuracy.  Biomarkers such as p-tau217 are being used to assist diagnosis in countries like the US, Japan, the UK, and China, and have shown “good agreement” with PET imaging, CSF biomarkers, and postmortem diagnosis, the experts say.  The diagnostic accuracy of these blood tests sits at 90–95 per cent, well above the 60–70 per cent with a purely clinical approach, and they can reduce the need for CSF biomarkers and PET scans by approximately 80–90 per cent. Results are being validated in primary care and real-world settings overseas although the tests are not yet available in New Zealand. 

(ii) Their uptake is expected to grow with a rise in the availability of new disease-modifying treatments for Alzheimer disease.  These expensive anti-amyloid monoclonal antibodies require biomarker-based diagnosis to identify possible candidates for treatment, and their use is controversial due to their modest effectiveness, frequent IV infusion regimen, and serious potential side effects that require regular monitoring with MRIs.  They are not licensed in New Zealand, but they are in clinical use or available in a growing number of territories, including the UK, EU, US and China.  Donanemab and Lecanemab have been licensed in Australia this year but are not subsidised.  Donanemab currently costs approximately $A 4700 per infusion every four weeks over the 18-month treatment course.  

(iii) Advances in diagnosis and management of Alzheimer’s disease are discussed in a recently published  three-part  on-line Lancet series if you are interested in more detail.   In the meantime, your local Health Pathways has a section on Cognitive Impairment that includes available assessment, management and support services advice.    

7.  Interesting bits from Research Review

(i) A New Zealand study NZ comparing NT-proBNP levels in Pacific peoples, Māori, and NZ Europeans with heart failure found that after adjustment for ethnicity, age, sex, body mass index, estimated glomerular filtration rate, ejection fraction and presence of AF, while levels in European and Māori were not statistically different, For each decade of life over 60 years, plasma NT-proBNP levels in patients with HF were a mean 67% lower in Pacific peoples than in aged-matched NZ Europeans suggesting we might have to use different normal ranges according to ethnicity. 

(ii)  A US study looking at varenicline (Champix) for youth nicotine vaping cessation used the standard smoking cessation varenicline regime or placebo with either text messaging support or weekly counselling plus text messaging support in a 12 week trial.  Continuous abstinence rates in the last month of treatment were 51%(V) vs 14%(P) and at 6-month follow-up 28%(V) vs 7%(P).  Results were similar for the text only versus text + counselling groups.  Treatment-emergent adverse events did not differ significantly between groups. Conclusion: Varenicline, when added to brief cessation counselling, is well tolerated and promotes nicotine vaping cessation compared with placebo in youth with addiction to vaped nicotine. Note this would be off-label prescribing in NZ and NZF includes a warning to monitoring for neuropsychiatric adverse effects including suicidality in patients prescribed varenicline.  

(iii) A multicentre, double-blind randomised controlled trial from China published in JAMA Internal Medicine  compared vitamin K2 (185mcg nocte) with placebo for management of nocturnal leg cramps.  The medication was taken every day for eight weeks and those in the K2 arm experienced a significantly lower number of weekly nocturnal leg cramps versus placebo with significantly greater reductions in cramp severity and duration.  There were no reported adverse events.  Vitamin K2 is readily available over the counter or on-line.  There is a possible interaction between Vitamin K2 and warfarin with potential to decrease the INR.