The term prostatitis describes four distinct conditions: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and asymptomatic inflammatory prostatitis. In acute bacterial prostatitis, prompt treatment and appropriate antibiotic choice are crucial to avoid severe complications. Chronic bacterial prostatitis requires a longer course of treatment. Treatment interventions for CP/CPPS vary depending on the symptom(s) most concerning to the patient and focus on improving quality of life. Read the full article here.

B-QuiCK summaries for acute and chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are also available.

HPV testing is now the primary cervical screening test in New Zealand, replacing the previous cytology-based test. HPV Primary Screening is expected to improve cervical screening participation and equitable outcomes, and further reduce the incidence and mortality from cervical cancer over time. bpac^nz has produced a summary to help practices become more familiar with the changes; full information is available on the Te Whatu Ora, Health New Zealand, website.

This comprehensive resource aims to educate and support primary healthcare professionals in delivering community-based care to patients with a terminal condition in the last days of life. A patient management summary sheet to assist other acute healthcare providers should they be required, e.g. ambulance personnel, is also available here.

A series of supporting articles provide practical guidance on managing common symptoms that occur during the last days of life: pain, nausea and vomiting, delirium and psychological symptoms, dyspnoea, excessive respiratory secretions.

The global supply issue affecting GLP-1 receptor agonists now includes liraglutide. Dulaglutide supply issues in New Zealand have been ongoing since September, 2022 (see Bulletins 60, 64 and 82), and in response, liraglutide has been funded since March, 2023, as an alternative glucose-lowering medicine for people who meet eligibility criteria for GLP-1 receptor agonists (Bulletin 66). However, the suppliers of both dulaglutide and liraglutide have now advised that they can only secure enough stock for patients with a current prescription. Supply pressures are likely to continue for the rest of the year.

Pharmac is strongly urging healthcare professionals to consider prescribing other glucose-lowering medicines for new patients diagnosed with type 2 diabetes. Empagliflozin (with or without metformin), an oral SGLT-2 inhibitor, is a suitable alternative to a GLP-1 receptor agonist and the same Special Authority criteria apply.

For further information on the management of type 2 diabetes, including lifestyle interventions, oral glucose-lowering medicines, e.g. empagliflozin, vildagliptin, initiating insulin and monitoring for complications, see: https://bpac.org.nz/2021/diabetes-management.aspx. A B-QuiCK summary is also available here.

Pharmac has announced that the delisting date for cilazapril has been moved from the end of 2023 to mid-2024. This change has been made to allow time for stock to be exhausted. Prescribers should continue to identify any patients still taking cilazapril and switch them to an alternative.

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

There is currently a supply issue affecting all strengths of methylphenidate extended-release tablets (Teva) as reported in Bulletin 84. Resupply is expected throughout November.

Patients prescribed methylphenidate (Teva) can switch to either Concerta or Rubifen SR (only 20 mg strength available) brands. Pharmacists can dispense the Concerta brand for active repeats of methylphenidate (Teva) without contacting the prescriber, Special Authority approval, however, is required (see below) and the prescription must be annotated with the new brand, strength and formulation.

Patients with an existing Special Authority approval for methylphenidate (Teva) are being automatically provided with Special Authority approval for Concerta. If a patient has not received automatic Special Authority approval for Concerta, a waiver (new) application must be completed by the prescriber so a new Special Authority number can be issued.

Also see the Medsafe Prescriber Update article about switching brands of long-acting methylphenidate products.

There is a supply issue affecting stock of Vita-B12 and Panpharma brands of hydroxocobalamin (vitamin B12) injections. The Panpharma brand is currently out of stock and supplies of Vita-B12 are limited.

Supply issues affecting hydroxocobalamin (vitamin B12) injections have been ongoing throughout 2023. Initially three alternative brands (Vita-B12, Cobal-B12 and Cobalin-H) were listed earlier in the year to cover potential shortages, as reported in Bulletin 73. Cobal-B12 and Cobalin-H brands are still available and funded but are not currently approved by Medsafe and so must be prescribed and dispensed under Section 29.

An alternative brand of hydroxocobalamin injections has been secured and is expected to be listed on the Pharmaceutical Schedule from 1^st November, 2023.

The Respigen brand of salbutamol inhaler is being discontinued, as the manufacturing plant has closed. There is limited stock left in New Zealand, which is expected to be depleted within two to three months. Respigen inhalers were previously out of stock earlier this year, as reported in Bulletin 68.

Patients currently prescribed Respigen will need to change to an alternative brand; the SalAir (funded) and Ventolin (partly funded) brands of salbutamol inhaler are still available. Patients changed to the SalAir brand should be made aware that their new reliever inhaler will be grey, i.e. a different colour than they are used to, but reassured that the medicine is the same. There may, however, be a difference in taste or “mouth feel”. Patients accustomed to a using a blue reliever inhaler may prefer the Ventolin brand but they will need to pay a part-charge as it is not fully funded.

Some patients or parents/caregivers may be concerned about the presence of alcohol in asthma inhalers; they can be reassured that asthma inhalers have < 10 mg^* of ethanol per actuation, which will not have any clinical effect – for context a small ripe banana contains approximately 40 mg of ethanol.

^*Respigen has 4.5 mg ethanol/actuation, SalAir has 1.5 mg ethanol/actuation and Ventolin does not contain alcohol

Use the opportunity when changing brands of inhaler to discuss/review inhaler technique.

For further information of management in asthma in primary care, see: https://bpac.org.nz/2020/asthma-children.aspx and https://bpac.org.nz/2020/asthma.aspx

The funded brand of 5 mg and 10 mg oxycodone controlled-release tablets (Sandoz) are out of stock, with resupply not expected until the end of November, 2023. Supply of other strengths of oxycodone are currently unaffected.

The OxyContin brand of 5 mg controlled-release tablets is funded, and some stock will be available in pharmacies soon. However, this brand is not approved by Medsafe and so must be prescribed and dispensed under Section 29. An alternative brand of the 10 mg controlled-release tablets is currently being sourced.

Pharmac advise that morphine long-acting tablets (m-Eslon) or oxycodone 5 mg/5 mL oral liquid may be a suitable alternative for some people. However, a new prescription will be needed, and caution is advised if switching from a controlled-release formulation to immediate-release. Opioid conversion guides are available from the New Zealand Formulary here.

Reminder: Morphine is the first-line strong opioid for moderate to severe pain. Oxycodone is a second-line option if morphine is contraindicated or not tolerated. A range of opioid resources are available from bpac^nz, including:

• Revisiting opioid use in New Zealand: how does your prescribing compare?
• When to consider strong opioids for patients with acute pain
• Understanding the role of opioids in chronic non-malignant pain
• Clinical Audit – Reviewing patients using opioid medicines long-term for non-cancer pain

MMR vaccination is funded for all children in New Zealand and anyone born from 1969 onwards who has not received two doses. Some people born overseas prior to 1969 are considered susceptible to MMR and so may be eligible for funded vaccination (click here for further information). N.B. MMR vaccination is contraindicated during pregnancy.

Opportunistically check whether patients have received both doses of the MMR vaccine and offer vaccination where appropriate. Also ensure that patients with upcoming international travel are fully vaccinated with MMR.

For further information on MMR, see: https://bpac.org.nz/2021/mmr.aspx

• People aged 75 years and older (particularly those living at aged residential care facilities, or people who are at increased risk of frailty if they become even mildly unwell)
• People aged 65 years and older of Māori or Pacific ethnicity (particularly those with chronic and multiple co-morbidities)
• People aged 16 years and older with severe immunocompromise (particularly those who were eligible for a third primary dose)
• People aged 30 to 74 years with significant complex health needs (particularly those with health needs that increase the risk of frailty, e.g. multiple long-term medical conditions, living in aged residential care facilities)

• Although the prevalence of insomnia is higher in females and sleep apnoea is more common in males (prevalence in females is around the same after menopause), COMISA is equally prevalent in males and females
• Sleep disruption and non-specific daytime symptoms are a hallmark of both insomnia and sleep apnoea; people who present with symptoms of sleep disruption should be assessed for both conditions
  • Also ask about sleep disturbances in patients diagnosed with cardiovascular disease or depression as rates of COMISA are higher in these groups
• Symptoms of sleep apnoea may differ between sexes; females often report non-specific daytime symptoms (e.g. fatigue, lethargy, low mood, or symptoms of insomnia), instead of more conventional symptoms, e.g. loud snoring and daytime sleepiness
  • As a result, sleep apnoea is often underdiagnosed in females
  • Non-specific symptoms may be attributed to other causes (e.g. depression), resulting in unsuitable treatment
• Validated questionnaires can be used to assess sleep disruption (e.g. Pittsburgh Sleep Quality Index), insomnia (e.g. Insomnia Severity Index), daytime impact (e.g. Epworth Sleepiness Scale) and risk for sleep apnoea (e.g. OSA50 and STOP-Bang). The Auckland Sleep Questionnaire is another assessment tool produced in New Zealand.
  • The gold standard assessment for sleep apnoea is a sleep study; see local HealthPathways for referral criteria
• Cognitive behavioural therapy for insomnia (CBT-i) is the first-line management option for people with insomnia. A 2023 systematic review and meta-analysis involving more than 1,000 participants found that CBT-i was associated with a significant improvement in the symptoms of insomnia in people with untreated sleep apnoea and in those receiving treatment. A free New Zealand-produced CBT-i programme is available from Just a Thought.
• A combination of lifestyle advice, weight loss and continuous positive airway pressure (CPAP) is recommended for obstructive sleep apnoea. Second-line interventions include devices designed to increase respiratory air flow, e.g. dental splints or limiting time in the supine position.
  • Wearing a facemask to bed is often a significant adjustment and can negatively impact sleep. Patients are likely to require regular support and advice to address any issues affecting adherence including facial irritation, nasal obstruction and feelings of claustrophobia or anxiety.
• In patients with COMISA, treatment for both conditions should be offered, and evidence suggests the order of interventions should be guided by the symptoms of most concern, risk of sleepiness-related accidents and patient preference. However, in practice, initiating CBT-i in patients with COMISA before commencing CPAP may potentially reduce immediate CPAP rejection and increase long-term CPAP use (lifestyle advice and weight management should be initiated concurrently with CBT-i in this situation)
• Avoid prescribing hypnotics for insomnia in patients with comorbid sleep apnoea as they are contraindicated due to the potential for respiratory depression
• Close monitoring of the response to intervention (e.g. increased daytime sleepiness) is recommended in patients at higher risk of negative sleepiness-related effects, e.g. people who are employed to drive or operate heavy machinery
• Referral to a sleep physician is recommended for people with COMISA and significant co-morbidities or complications, e.g. cardiac or respiratory conditions, neuromuscular disease, heavy alcohol or opioid use
• Referral to a sleep psychologist (e.g. a private sleep clinic) may be beneficial for people with COMISA who are shift workers, drive/operate heavy machinery, with severe daytime sleepiness or any other specific circumstances that may require tailored treatment, however, cost may be a barrier