Doc #20 — Pharmaceutical Reference

COMPUTED DATA: ESSENTIAL MEDICINES REFERENCE

View the Pharmaceutical Reference Tables → — 40 essential medicines with dosing, interactions, storage, and shelf-life extension data.

View the generation script → — Python source code and data sources (NZ Formulary, WHO).

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RECOMMENDED ACTIONS

Immediate (Days 1–7) — Phase 1

1. Download and archive the NZ Formulary database. The NZ Formulary website (nzf.org.nz) is the primary data source. Download all monographs, interaction tables, and appendices. Store on multiple independent physical media. [Phase: 1 — IMMEDIATE]
2. Download and archive Medsafe product datasheets for all medicines with current NZ marketing approvals. Available at medsafe.govt.nz. These contain NZ-specific product identification (appearance, markings, packaging), storage requirements, and approved indications. [Phase: 1 — IMMEDIATE]
3. Identify pharmacist editors. At least two experienced clinical pharmacists — ideally with formulary or medicines information experience — to serve as editors for the printed reference. Hospital medicines information pharmacists at Auckland, Wellington, or Christchurch hospitals are the natural candidates.⁶

Short-term (Days 7–30) — Phase 1

4. Compile the reference manuscript. Merge NZ Formulary monographs with Medsafe identification data and SLEP shelf-life extension data (Doc #116). Organise by therapeutic category (Section 1.1). Add physical identification data for each drug entry. [Phase: 1]
5. Clinical review of sample entries by the pharmacist editors and at least one physician. Verify dosing accuracy, check interaction completeness, confirm NZ brand name currency. [Phase: 1]
6. Format for printing. Generate print-ready output. Optimise layout for information density without sacrificing legibility — this reference will be used under stress, in poor light, by fatigued clinicians. Minimum 8-point font for body text; 10-point preferred. [Phase: 1]

Medium-term (Days 30–90) — Phase 1

7. Print the reference. Minimum print run: 200–300 copies (one per hospital pharmacy, one per community pharmacy, plus clinical departments and reserves). At 1,200–1,600 pages per copy, total printing is approximately 240,000–480,000 pages. Coordinate with overall printing schedule (Doc #5). [Phase: 1]
8. Distribute to all prescribing and dispensing locations. [Phase: 1]
9. Print condensed pocket cards for emergency medicines (adrenaline, morphine, diazepam, ketamine, oxytocin) — laminated single-page quick-reference for ambulance crews, rural GPs, and midwives. [Phase: 1]

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1. STRUCTURE OF THE REFERENCE

1.1 Organisation by therapeutic category

The reference follows the NZ Formulary’s therapeutic classification, which is derived from the BNF and broadly aligned with the WHO Anatomical Therapeutic Chemical (ATC) classification.^{7 8}

Chapter	Therapeutic category	Estimated entries	Estimated pages
1	Gastrointestinal system	60–80	80–100
2	Cardiovascular system	100–130	120–160
3	Respiratory system	40–60	50–70
4	Central nervous system (incl. analgesics, psychiatry, neurology)	120–150	150–200
5	Infections (antibacterials, antifungals, antivirals, antiparasitics)	80–100	100–130
6	Endocrine system (incl. diabetes, thyroid, corticosteroids)	60–80	80–100
7	Obstetrics, gynaecology, urinary tract	30–40	40–50
8	Malignant disease and immunosuppression	40–60	50–70
9	Nutrition and blood	30–40	30–40
10	Musculoskeletal and joint diseases	30–40	30–40
11	Eye	20–30	20–30
12	Ear, nose, and oropharynx	15–20	15–20
13	Skin	40–60	50–60
14	Vaccines and immunological products	20–30	20–30
15	Anaesthesia	20–30	30–40
A	Interactions appendix	—	80–120
B	Emergency treatment appendix	—	20–30
C	Drug identification index (by appearance)	—	60–80
D	SLEP shelf-life extension tables	—	30–40
—	Index (by generic name, by brand name)	—	40–60
	Total	~800–1,000	~1,200–1,600

1.2 Standard monograph format

Each drug entry follows a consistent format:

1. Generic name (INN — International Nonproprietary Name)
2. NZ brand names — all brands with current Medsafe approval, with PHARMAC-funded brand indicated
3. Therapeutic class
4. Indications — approved and common off-label uses relevant to the recovery scenario
5. Adult dosing — by indication, with route (oral, IV, IM, SC, topical)
6. Paediatric dosing — by weight or age band, where applicable
7. Contraindications
8. Cautions and monitoring
9. Major interactions — flagged with severity (life-threatening, serious, moderate). Cross-reference to Appendix A for comprehensive interaction tables.
10. Side effects — common and serious
11. Identification — physical description of tablet/capsule/vial (colour, shape, markings, size). Cross-reference to Appendix C.
12. Storage — temperature, light, humidity requirements
13. SLEP extension — evidence-based shelf-life beyond labelled expiry, with storage conditions required and evidence quality rating. Cross-reference to Appendix D and Doc #116.
14. Rationing tier — as assigned by the National Pharmaceutical Triage Authority (Doc #116)

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2. SAMPLE MONOGRAPH ENTRIES

The following entries illustrate the monograph format for 15 critical medications. In the full reference, each entry would include the complete data fields listed in Section 1.2. Here, entries are condensed to demonstrate the format.

2.1 Paracetamol (Acetaminophen)

NZ brands: Panadol (GSK), Paracare (AFT), Ethics Paracetamol, numerous generics.⁹ Class: Non-opioid analgesic, antipyretic. Indications: Mild to moderate pain; fever. Adult dose: 500 mg–1 g every 4–6 hours; maximum 4 g/day. Reduce maximum to 2 g/day in hepatic impairment, chronic alcohol use, or low body weight (<50 kg). Paediatric dose: 15 mg/kg every 4–6 hours; maximum 60 mg/kg/day (not exceeding 4 g/day). Contraindications: Severe hepatic impairment. Major interactions: Warfarin (INR increase with regular use >2 g/day). Carbamazepine, phenytoin (increased hepatotoxicity risk via enzyme induction). Identification: Panadol 500 mg — white, capsule-shaped, “P” debossed. Generic 500 mg — typically white, round or capsule-shaped. Storage: Below 25°C. Protect from moisture. SLEP extension: Solid oral forms stable 3–8 years beyond labelled expiry under controlled storage. SLEP data supports extension of most lots tested.¹⁰ Liquid formulations (Pamol, children’s elixirs) less stable — extend 1–2 years maximum with visual inspection for discolouration or precipitation.

2.2 Amoxicillin

NZ brands: Amoxil (GSK), Alphamox (Mylan), Ethics Amoxycillin.¹¹ Class: Aminopenicillin antibacterial. Indications: Respiratory tract infections, otitis media, urinary tract infections, dental infections, Helicobacter pylori eradication. Adult dose: 250–500 mg every 8 hours (standard). 1 g every 8 hours for severe infections. Paediatric dose: 25–50 mg/kg/day in 3 divided doses. Contraindications: Penicillin hypersensitivity (true allergy — not merely GI upset). Major interactions: Methotrexate (reduced excretion — toxicity risk). Warfarin (INR monitoring). Allopurinol (increased rash incidence). Identification: Capsules typically red/yellow bicolour, 250 mg or 500 mg. Suspension is off-white to yellow powder for reconstitution. Storage: Capsules below 25°C. Reconstituted suspension: refrigerate, discard after 14 days. SLEP extension: Capsules — 2–5 years beyond labelled expiry. SLEP data moderate quality.¹² Reconstituted suspension — no extension; discard per labelling. Dry powder for suspension — extend similarly to capsules.

2.3 Morphine Sulfate

NZ brands: RA-Morph (immediate release), M-Eslon (modified release), Sevredol, morphine injection (various).¹³ Class: Opioid analgesic. Controlled drug — Schedule 2 (NZ Misuse of Drugs Act 1975). Indications: Severe pain, palliative care, acute myocardial infarction pain, pulmonary oedema. Adult dose: Oral immediate release: 5–20 mg every 4 hours. IV: 2.5–10 mg titrated slowly. Dose varies widely; titrate to effect. Paediatric dose: Oral: 0.2–0.4 mg/kg every 4 hours. IV: 0.05–0.1 mg/kg, titrate. Contraindications: Respiratory depression, acute alcoholism, paralytic ileus, raised intracranial pressure (relative). Major interactions: CNS depressants (benzodiazepines, alcohol — additive respiratory depression; potentially fatal). MAOIs (avoid — risk of severe CNS excitation or depression, hypertensive crisis). Naloxone reverses effects. Identification: RA-Morph 10 mg — blue tablet. M-Eslon 30 mg — brown/clear capsule with pellets. Injection — clear solution in ampoules. Storage: Below 25°C. Protect from light. Secure storage required (controlled drug). SLEP extension: Oral solid forms — 5–15 years beyond labelled expiry. Morphine is one of the most stable drugs tested under SLEP.^{14 15} Injection solutions — inspect for discolouration or particulates; likely stable 3–8 years beyond labelled expiry.

2.4 Metformin

NZ brands: Arrow-Metformin, Ethics Metformin, numerous generics.¹⁶ Class: Biguanide antidiabetic. Indications: Type 2 diabetes (first-line oral therapy). Adult dose: 500 mg once or twice daily initially, increase to maximum 1 g twice daily. Paediatric dose: 10 years and older: 500 mg daily initially, maximum 2 g/day in divided doses. Contraindications: Renal impairment (eGFR <30), metabolic acidosis, severe dehydration, conditions predisposing to lactic acidosis. Major interactions: Alcohol (increased lactic acidosis risk). Iodinated contrast media (withhold 48 hours). Identification: 500 mg — white, round, film-coated. 850 mg — white, oblong. Storage: Below 25°C. SLEP extension: Solid oral forms — 3–8 years beyond labelled expiry.¹⁷ Metformin is highly stable in solid formulation. Note: Metformin is critical for replacing insulin in Type 2 diabetics during the rationing period (Doc #116). Insulin is reserved for Type 1 and insulin-dependent Type 2 patients.

2.5 Salbutamol

NZ brands: Ventolin (GSK), Respigen, SalAir.¹⁸ Class: Short-acting beta-2 agonist bronchodilator. Indications: Acute asthma, COPD exacerbation, bronchospasm. Adult dose: Inhaler: 100–200 micrograms (1–2 puffs) as needed, maximum 8 puffs/day. Nebulised: 2.5–5 mg. Paediatric dose: Inhaler: 100 micrograms (1 puff) as needed via spacer. Nebulised: 2.5 mg. Contraindications: None absolute for acute use. Major interactions: Beta-blockers (antagonism — avoid non-selective beta-blockers in asthma). Hypokalaemia risk with corticosteroids, theophylline, diuretics. Identification: Ventolin MDI — blue inhaler, 100 mcg/actuation. Nebuliser solution — clear, in unit-dose vials. Storage: Below 30°C. Do not freeze. Do not puncture or expose canisters to heat. SLEP extension: MDIs — limited extension data. Propellant canisters may lose pressure over time. Estimate 1–3 years beyond expiry, but delivered dose per actuation may decline 10–30% as propellant pressure drops, meaning patients may receive sub-therapeutic doses without visible indication of degradation.¹⁹ Nebuliser solution — 2–4 years beyond expiry if sealed and stored correctly.

2.6 Enalapril

NZ brands: Ethics Enalapril, numerous generics.²⁰ Class: ACE inhibitor. Indications: Hypertension, heart failure, diabetic nephropathy. Adult dose: 5 mg daily initially, usual maintenance 10–20 mg daily, maximum 40 mg daily. Paediatric dose: 0.08 mg/kg daily initially (specialist use). Contraindications: Pregnancy (teratogenic — Category D). History of ACE inhibitor-related angioedema. Bilateral renal artery stenosis. Major interactions: Potassium-sparing diuretics, potassium supplements (hyperkalaemia). NSAIDs (reduced efficacy, renal impairment). Lithium (increased levels). Identification: Typically white, round tablets. 5 mg, 10 mg, 20 mg strengths. Storage: Below 25°C. Protect from moisture. SLEP extension: Solid oral forms — 3–7 years beyond labelled expiry.²¹

2.7 Phenytoin

NZ brands: Dilantin (Pfizer), Arrow-Phenytoin.²² Class: Anticonvulsant (hydantoin). Indications: Epilepsy (tonic-clonic and partial seizures), status epilepticus (IV loading). Adult dose: Oral: 200–400 mg daily in 1–2 divided doses. Narrow therapeutic index — plasma level monitoring required (target 10–20 mg/L). IV loading for status epilepticus: 15–20 mg/kg at maximum 50 mg/min. Paediatric dose: 5 mg/kg/day in 2 divided doses initially. Monitor levels. Contraindications: Sinus bradycardia, SA block, second/third-degree heart block (IV). Major interactions: Extensively interacting drug — too many to list fully. Key: warfarin (unpredictable effect), carbamazepine (mutual induction), oral contraceptives (reduced efficacy), methotrexate, corticosteroids, theophylline. See Appendix A. Identification: Dilantin 100 mg — white capsule with pink band. Tablets vary by generic manufacturer. Storage: Below 25°C. Protect from light and moisture. SLEP extension: Solid oral forms — 5–10 years beyond labelled expiry.²³ Phenytoin is one of the more stable anticonvulsants in SLEP data. IV formulation — inspect for precipitation or discolouration; crystals in solution indicate degradation. Note: Narrow therapeutic index. Even with extended shelf-life, dose adjustment by clinical effect is essential. Without therapeutic drug monitoring capability, prescribers must titrate by seizure frequency and toxicity signs (nystagmus, ataxia, sedation).

2.8 Diazepam

NZ brands: Diazepam (various generics), formerly Valium.²⁴ Class: Benzodiazepine. Controlled drug — Class C (NZ Misuse of Drugs Act 1975). Indications: Anxiety (short-term), status epilepticus, muscle spasm, alcohol withdrawal, procedural sedation. Adult dose: Oral: 2–10 mg 2–3 times daily. IV for status epilepticus: 10–20 mg at 5 mg/min. Rectal: 10–20 mg (alternative route if IV unavailable). Paediatric dose: IV for seizures: 0.25–0.5 mg/kg. Rectal: 0.5 mg/kg. Contraindications: Severe respiratory depression, sleep apnoea, myasthenia gravis. Major interactions: Opioids (additive CNS and respiratory depression). Alcohol (same). CYP3A4 inhibitors (increased levels). Identification: 2 mg — white tablet. 5 mg — yellow tablet. Injection — clear solution in ampoules. Storage: Below 25°C. Protect from light. Secure storage required (controlled drug). SLEP extension: Tablets — 5–8 years beyond expiry. SLEP data strong.²⁵ Injection — 3–5 years; inspect for discolouration.

2.9 Adrenaline (Epinephrine)

NZ brands: Adrenaline injection (Pfizer, others), EpiPen (auto-injector).²⁶ Class: Sympathomimetic. Emergency medicine. Indications: Anaphylaxis (first-line), cardiac arrest (second-line after defibrillation), severe asthma (adjunct), croup (nebulised). Adult dose: Anaphylaxis: 0.5 mg IM (0.5 mL of 1:1,000). Repeat every 5 minutes if needed. Cardiac arrest: 1 mg IV (10 mL of 1:10,000) every 3–5 minutes. Paediatric dose: Anaphylaxis: 0.01 mg/kg IM (max 0.5 mg). Use 1:1,000 concentration. Contraindications: None in anaphylaxis or cardiac arrest (life-threatening emergencies override all contraindications). Major interactions: Beta-blockers (reduced efficacy, unopposed alpha stimulation). MAOIs (exaggerated response). Tricyclic antidepressants (arrhythmia risk). Identification: 1:1,000 ampoules — clear solution, 1 mg/mL, in 1 mL glass ampoules. EpiPen — auto-injector (0.3 mg adult, 0.15 mg junior); cap and label colour varies by model generation — verify against current NZ stock. Storage: Below 25°C. Protect from light. Do not refrigerate EpiPens. Discard if solution is brown or contains precipitate. SLEP extension: Ampoule solutions — limited extension. Adrenaline oxidises. Usable 1–2 years beyond expiry if solution remains clear and colourless.²⁷ EpiPens — may retain adequate potency 1–4 years beyond expiry based on limited studies, but dose delivery is uncertain in aged auto-injectors.²⁸

2.10 Ketamine

NZ brands: Ketamine injection (various).²⁹ Class: Dissociative anaesthetic. Controlled drug — Class C. Indications: Anaesthesia (procedural and general, particularly where resources are limited), analgesia, sedation, status epilepticus (refractory). Adult dose: IV induction: 1–2 mg/kg. IM: 4–8 mg/kg. Analgesic sub-dissociative dose: 0.1–0.3 mg/kg IV. Paediatric dose: IV: 1–2 mg/kg. IM: 3–5 mg/kg. Contraindications: Conditions where raised blood pressure hazardous (pre-eclampsia, aneurysm). Psychotic disorders (relative). Major interactions: Theophylline (lowered seizure threshold). Other CNS depressants (additive). Identification: Clear, colourless solution. Vials typically 200 mg/20 mL (10 mg/mL) or 500 mg/10 mL (50 mg/mL). Check concentration carefully — fivefold concentration difference between preparations. Storage: Below 25°C. Protect from light. Secure storage (controlled drug). SLEP extension: Injection solution — likely stable 5–10 years beyond labelled expiry. Ketamine is a remarkably stable molecule.^{30 31} Inspect for discolouration. Note: Ketamine is the single most important anaesthetic for the recovery scenario. It provides anaesthesia, analgesia, and sedation through a single drug that does not require intubation or mechanical ventilation in most cases — a critical advantage when anaesthetic equipment and trained anaesthetists are scarce. (Doc #117)

2.11 Oxytocin

NZ brands: Syntocinon (Novartis/Aspen).³² Class: Posterior pituitary hormone analogue. Indications: Induction and augmentation of labour, prevention and treatment of postpartum haemorrhage (PPH). Adult dose: PPH prevention: 5–10 units IM or slow IV after delivery of anterior shoulder or placenta. PPH treatment: 5 units slow IV, then 20–40 units in 500 mL saline IV infusion. Induction of labour: 1–4 milliunits/min IV infusion, titrated. Contraindications: Hypertonic uterine contractions, cord presentation, major cephalopelvic disproportion. Major interactions: Prostaglandins (uterine hyperstimulation if combined). Identification: Clear, colourless solution. 5 units/mL and 10 units/mL ampoules. Storage: Refrigerate 2–8°C. Protect from light. Room temperature stability limited. SLEP extension: Peptide hormone — limited extension. Estimate 1–2 years beyond labelled expiry if refrigerated continuously.³³ Priority for cold-chain maintenance (Doc #116). Note: Oxytocin is the single most important drug for preventing maternal death from PPH, which is among the leading causes of maternal mortality worldwide. (Doc #123)

2.12 Insulin (various formulations)

NZ brands: NovoRapid, Humalog (rapid-acting); Actrapid, Humulin R (short-acting); Protaphane, Humulin NPH (intermediate); Lantus, Levemir, Optisulin (long-acting).³⁴ Class: Endocrine — antidiabetic hormone. Indications: Type 1 diabetes (essential — no alternative), insulin-dependent Type 2 diabetes, diabetic ketoacidosis, gestational diabetes (when oral agents insufficient). Adult dose: Highly individualised. Type 1 typically 0.5–1.0 units/kg/day in multiple daily injections. Dose adjusted by blood glucose monitoring. Paediatric dose: As per adult, weight-based. Children and adolescents often require higher per-kg doses during puberty. Contraindications: Hypoglycaemia. Major interactions: Beta-blockers (mask hypoglycaemia symptoms). Corticosteroids (increase insulin requirements). Thiazides (increase insulin requirements). Identification: Varies by brand and formulation. Cartridges, vials, and pre-filled pens. Colour-coding varies — check labels carefully. Rapid-acting: clear. Intermediate (NPH): cloudy (resuspend before use). Storage: Unopened: refrigerate 2–8°C. In-use: room temperature (below 25–30°C) for 28 days, then discard. Do not freeze — freezing destroys insulin. SLEP extension: Limited. Insulin is a protein and degrades. Unopened vials refrigerated may retain adequate potency 6–12 months beyond labelled expiry, but with unpredictable potency loss.³⁵ No SLEP data available for insulin. Dose adjustment by blood glucose response essential. Insulin that has been frozen, exposed to heat above 30°C, or appears discoloured or clumped should not be used. Note: Insulin supply is the most acute pharmaceutical crisis in the recovery scenario. Type 1 diabetics (approximately 25,000 people in NZ) are insulin-dependent for survival.³⁶ See Doc #116 for the insulin registry and rationing framework.

2.13 Levothyroxine (Thyroxine)

NZ brands: Eltroxin (Aspen). Sole funded brand in NZ.³⁷ Class: Thyroid hormone replacement. Indications: Hypothyroidism, post-thyroidectomy replacement, myxoedema coma. Adult dose: 50–100 micrograms daily initially (25 mcg in elderly or cardiac disease), adjusted by TSH levels. Usual maintenance 100–200 micrograms daily. Paediatric dose: Neonatal: 10–15 mcg/kg/day. Children: dose by age and weight, titrate to TSH. Contraindications: Thyrotoxicosis. Uncorrected adrenal insufficiency (correct first). Major interactions: Calcium, iron supplements, antacids (reduced absorption — separate by 4 hours). Warfarin (increased anticoagulant effect). Carbamazepine, phenytoin (increased levothyroxine metabolism). Identification: Eltroxin 50 mcg — white, round tablet marked “GX EA2.” 100 mcg — white, round, “GX EC5.” Scores may vary by manufacturing run. Storage: Below 25°C. Protect from light and moisture. SLEP extension: Solid oral forms — 3–6 years beyond labelled expiry.³⁸ Store in original sealed packaging. Levothyroxine potency is sensitive to moisture and heat. Note: Approximately 200,000 NZ adults take levothyroxine.³⁹ Most are clinically stable and can tolerate dose reduction or brief interruption without life-threatening consequences. However, neonatal and congenital hypothyroidism requires uninterrupted treatment — neurological damage results from untreated neonatal hypothyroidism. Prioritise supply for neonates and children.

2.14 Oral Rehydration Salts (ORS)

NZ brands: Enerlyte (Nutricia), Pedialyte, Gastrolyte.⁴⁰ Class: Electrolyte replacement. Indications: Dehydration from diarrhoeal illness, heat illness, vomiting. The single most important intervention for reducing child mortality from gastroenteritis.⁴¹ WHO-recommended formula per litre of clean water: Sodium chloride 2.6 g, glucose (anhydrous) 13.5 g, potassium chloride 1.5 g, trisodium citrate dihydrate 2.9 g.⁴² Adult dose: 200–400 mL after each loose stool. Adjust to clinical hydration status. Paediatric dose: 50–100 mL/kg over 4 hours for moderate dehydration. Contraindications: Intestinal obstruction. Anuria. Major interactions: None significant. Identification: Sachets of white powder for reconstitution. Storage: Dry powder: below 25°C, protect from moisture. Reconstituted solution: use within 24 hours (refrigerate if possible). SLEP extension: Sealed sachets — effectively indefinite if kept dry. Component ingredients (salt, sugar, potassium chloride) are chemically inert in dry form.⁴³ Note: ORS is one of the first pharmaceuticals NZ can produce domestically (Doc #119, Tier 1). The formula uses basic salts and glucose: sodium chloride from solar or boiled sea-salt evaporation; glucose from hydrolysis of starch (wheat, corn, potato — all NZ-grown); potassium chloride from sylvite deposits or wood ash processing; trisodium citrate from citric acid (fermentation of sugar by Aspergillus niger, a well-established industrial process requiring basic fermentation equipment) and sodium hydroxide. All are achievable with NZ materials, though citrate production requires fermentation infrastructure that may take weeks to months to establish. Include the WHO formula in printed materials for emergency preparation by non-pharmacists.

2.15 Chlorhexidine

NZ brands: Savlon (chlorhexidine/cetrimide), Microshield (chlorhexidine gluconate), generic chlorhexidine solutions.⁴⁴ Class: Antiseptic. Indications: Skin antisepsis (pre-surgical, wound care, hand hygiene), umbilical cord care (neonatal), catheter site care. Concentrations: 0.5% in 70% alcohol (skin antisepsis), 1–2% aqueous (wound irrigation, obstetric antisepsis), 4% (surgical hand scrub). Contraindications: Not for use on brain, meninges, or middle ear (neurotoxic). Avoid contact with eyes. Major interactions: Incompatible with soap (inactivated by anionic surfactants). Rinse soap thoroughly before applying chlorhexidine. Identification: Pink or colourless solutions. Bottles and sachets. Storage: Below 25°C. Protect from light. Do not dilute with contaminated water. SLEP extension: Aqueous solutions — likely stable 3–5 years beyond labelled expiry if container seal intact. Alcoholic solutions — stable similarly, but alcohol evaporation may reduce antiseptic effect if container seal is compromised. Chemical stability is not the limiting factor for chlorhexidine — contamination of diluted solutions is the main risk.⁴⁵ Note: Chlorhexidine for neonatal cord care reduces neonatal sepsis mortality in resource-limited settings by an estimated 9–15% (based on pooled meta-analytic data), per WHO recommendation.⁴⁶ Include in neonatal care protocols.

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3. DATA SOURCES AND LIMITATIONS

3.1 NZ Formulary

The NZ Formulary (nzf.org.nz) is the primary clinical data source. It is maintained by the NZ Formulary Limited Partnership with funding from the NZ Ministry of Health, and is adapted from the British National Formulary (BNF) to reflect NZ-approved medicines, NZ-specific dosing recommendations, and PHARMAC funding decisions.⁴⁷ As of 2025, it is published exclusively online — no current print edition exists. This document’s central purpose is to produce what is effectively a print edition with SLEP and identification data integrated.

Limitation: The NZ Formulary is updated continuously. The printed version will be frozen at the date of download. Drug safety alerts, new interaction data, and dosing updates published after that date will not be reflected. The pharmacist editors should append a change log if subsequent updates become possible.

3.2 Medsafe product datasheets

Medsafe (medsafe.govt.nz) publishes product datasheets for all medicines with NZ marketing approvals.⁴⁸ These datasheets contain the manufacturer’s full prescribing information, including physical description (appearance, markings), storage conditions, and shelf life. They are the primary source for the identification section of each monograph.

Limitation: Some generic medicines have minimal identification data in their datasheets. Physical appearance may vary between manufacturing batches, particularly for generics from multiple suppliers. The identification appendix (Appendix C) will be approximate for some products.

3.3 SLEP data

The US Department of Defense Shelf Life Extension Program has tested over 3,000 medication lots representing more than 100 drug products since 1986.⁴⁹ It is the largest and most rigorous dataset on pharmaceutical stability beyond labelled expiry. Doc #116 compiles SLEP-derived extension data for NZ-relevant medications. This reference integrates that data at the individual monograph level.

Limitation: SLEP tests medications stored under controlled conditions (15–25°C, low humidity). Medications stored in garages, cars, or uninsulated buildings will degrade faster. Extensions are lot-specific; different manufacturing lots of the same drug may have different stability profiles. The extensions cited in this reference are conservative general estimates, not guarantees for specific lots.

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4. ESTIMATED TOTAL PAGE COUNT AND PRINTING REQUIREMENTS

The full reference is estimated at 1,200–1,600 pages (Section 1.1). Printed double-sided on A4 paper, this is 600–800 sheets per copy. At 200–300 copies for national distribution:

Item	Quantity
Pages per copy	1,200–1,600
Copies required	200–300
Total sheets (double-sided)	120,000–240,000
Total pages	240,000–480,000
Toner cartridges (est. 3,000–8,000 pages/cartridge depending on model and coverage)	30–160
Paper reams (500 sheets/ream)	240–480

This is a substantial printing commitment, comparable to the nautical almanac production run (Doc #10), and must be scheduled within the Phase 1 printing programme (Doc #5). However, the return on this investment is high: a single copy of the pharmaceutical reference serves an entire hospital or pharmacy for the duration of its physical life.

Binding: Ring binding or spiral binding recommended (allows the reference to lie flat when open on a dispensary bench). Heavy card covers. Where possible, critical sections (emergency medicines, paediatric dosing) should be tabbed for rapid access.

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5. RONGOĀ MĀORI: TRADITIONAL PLANT MEDICINES IN PHARMACEUTICAL SCARCITY [Phase: 2–3]

Rongoā Māori — the body of Māori traditional medicine — includes plant-based treatments, physical therapies, and spiritual healing practices. The plant medicine component (rongoā rākau) is directly relevant to pharmaceutical planning: a number of native NZ plants have documented medicinal properties that overlap with pharmaceutical functions, and rongoā practitioners hold knowledge of preparation and application that cannot be replicated from written sources alone.

This section does not argue that rongoā rākau can replace pharmaceuticals. Insulin, anticonvulsants, and oxytocin have no plant equivalents that come close to their clinical efficacy. The argument is narrower and practical: for a specific set of indications — wound care, mild pain, respiratory symptom relief, skin infections, diarrhoea — rongoā Māori offers substantive supplementary capacity that reduces demand on pharmaceutical stocks. In a prolonged pharmaceutical scarcity, that margin matters.

Integration of rongoā practitioners into the healthcare workforce is addressed in Doc #160 (Heritage Skills Preservation).⁵⁰

5.1 Key medicinal plants and applications

The following plants are well-established within rongoā Māori tradition and have documented or plausible pharmacological bases for their use. Preparation methods noted here are representative; actual practice varies by practitioner, region, and the specific therapeutic intent.⁵¹

Kawakawa (Piper excelsum)

Kawakawa is among the most widely used rongoā plants. Leaves (traditionally, those with insect-feeding holes are preferred — a practitioner convention, though the pharmacological basis for this preference has not been established in published research) are used in multiple preparations:

• External wound and skin care: Fresh or heated leaves applied as poultice or infused in oil for wound care, bruising, and skin inflammation. Contains myristicin, flavonoids, and other compounds with anti-inflammatory properties.
• Digestive complaints: Infusion of leaves taken internally for stomach pain, intestinal discomfort, and constipation. Relevant during periods of dietary disruption when gastrointestinal complaints increase.
• Rheumatic and joint pain: Leaf poultices applied to joints; reported use in arthritis management — relevant when NSAID and corticosteroid stocks are depleted, though anti-inflammatory effect is weaker and less predictable than pharmaceutical NSAIDs.

Kawakawa is abundant throughout the North Island and northern South Island; it is readily cultivated and fast-growing, making it a reliable supply source.⁵²

Mānuka (Leptospermum scoparium)

Mānuka’s antimicrobial properties are the most clinically substantiated of any NZ rongoā plant, supported by extensive modern research on mānuka honey and mānuka oil:

• Wound care and infection prevention: Mānuka bark and leaf decoctions used traditionally for skin infections, sores, and wounds. Mānuka honey (while not a rongoā preparation in the traditional sense) has well-documented activity against Staphylococcus aureus, including MRSA, and is currently used in clinical wound dressings. In a scenario where topical antibiotics are scarce, mānuka honey is a medically defensible wound dressing.
• Respiratory: Steam inhalation of mānuka leaf decoction used for congestion and respiratory infections; volatile oils have some antimicrobial activity in the upper airway.
• Urinary tract: Bark decoctions used for urinary complaints.

Mānuka is distributed throughout NZ and is among the most common pioneer species on disturbed land — supply constraints are minimal.⁵³

Kūmarahou (Pomaderris kūmarahou)

Kūmarahou (also called gumdigger’s soap or papapa) is used in rongoā Māori primarily for respiratory conditions:

• Respiratory: Decoction or infusion of leaves and flowers for coughs, bronchitis, and chest complaints. Saponins present in the plant may act as expectorants. Traditional use is specifically for chest infections and chronic respiratory conditions — overlapping with indications for salbutamol, amoxicillin, and systemic corticosteroids in milder presentations, though without the bronchodilatory potency of salbutamol or the antibacterial efficacy of amoxicillin. Appropriate only for mild symptoms where pharmaceutical treatment is unavailable.

Kūmarahou is native to the northern North Island; supply is geographically constrained compared to kawakawa and mānuka.⁵⁴

Harakeke (Phormium tenax — flax) — gel and fibre

While harakeke (flax) is primarily known as a fibre plant, rongoā applications include:

• Wound care: The inner gel of young shoots (analogous to aloe vera gel) applied to burns, wounds, and irritated skin as a soothing and protective layer.
• Fibre for wound dressing: Cleaned harakeke fibre used as improvised wound dressing material in traditional practice.

Harakeke is ubiquitous throughout NZ and is one of the few rongoā plants that can be sourced from urban environments.⁵⁵

Koromiko (Veronica spp. — Veronica stricta, Veronica salicifolia)

Koromiko is the most specifically indicated rongoā plant for a pharmaceutical shortage scenario due to its documented use for diarrhoeal illness:

• Diarrhoea and dysentery: Leaf infusions and decoctions used for diarrhoea, dysentery, and bowel inflammation. This is the most consistent traditional indication across iwi and practitioners. In outbreaks of gastroenteritis — which increase during infrastructure disruption — koromiko preparation alongside oral rehydration salts (Section 2.14) addresses both symptoms and hydration.
• Wound care: Leaf poultices used externally for ulcers and skin conditions.

Koromiko is widespread throughout NZ across multiple species. Traditional and early colonial records consistently note its use for gastrointestinal illness, making it among the better-evidenced rongoā plants for a specific pharmaceutical gap.⁵⁶

5.2 Preparation methods

Rongoā preparation methods vary by practitioner and tradition. Representative forms include:

• Wai (infusion/decoction): Plant material steeped in boiling water. The primary form for internal administration. Standard approach: 1–2 tablespoons of fresh leaf (or 1 teaspoon dried) per cup of water, steep 5–15 minutes for infusion; simmer 10–20 minutes for decoction of bark or roots.
• Poultice (rau): Fresh or briefly heated plant material applied directly to skin, held in place with binding. Used for wounds, inflammation, and joint pain.
• Oil infusion: Plant material macerated in a carrier oil (traditionally animal fats; in a recovery context, any available plant oil) for 2–6 weeks, or gently heated. Used for topical application.
• Steam inhalation: Boiling water added to plant material in a bowl; steam inhaled with head covered — used for respiratory complaints.

Rongoā preparation requires understanding of which plant parts are used for which conditions, seasonal variation in potency, and contraindications (some plants are toxic in large doses or during pregnancy). This knowledge resides with rongoā practitioners — written summaries are a reference supplement, not a substitute for practitioner guidance.⁵⁷

5.3 Integration into healthcare during pharmaceutical scarcity

Rongoā practitioners should be formally recognised within the healthcare workforce framework established by Doc #160 (Heritage Skills Preservation). Practical integration during pharmaceutical scarcity includes:

• Triaging appropriate presentations to rongoā care. Patients presenting with mild wound infections, mild respiratory illness, mild pain, or gastrointestinal upset are candidates for rongoā management alongside or instead of pharmaceutical treatment — conserving pharmaceutical stocks for severe and acute presentations.
• Co-location at healthcare facilities. Rongoā practitioners working alongside clinic staff in community health settings allows real-time clinical consultation on appropriate cases.
• Supply chain for medicinal plants. Kawakawa and mānuka can be cultivated deliberately at scale; establishing community plantings near health facilities provides reliable access. Harakeke is available everywhere.
• Documentation of efficacy in current conditions. Rongoā practitioners should be supported to document outcomes in the recovery context — what is working, for which presentations, under what conditions. This builds an evidence base appropriate to the specific NZ recovery scenario.

The relationship between rongoā Māori and Western medicine is not inherently adversarial — it is a question of appropriate triage and honest acknowledgement of what each system can and cannot do. In a prolonged pharmaceutical shortage, the appropriate response is to deploy all available therapeutic capacity, calibrated to clinical need and honest assessment of evidence.

See also: Doc #119 (Local Pharmaceutical Production) for pharmaceutical compounds NZ can synthesise domestically, and Doc #160 (Heritage Skills Preservation) for the broader integration framework.⁵⁸

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6. CROSS-REFERENCES

Document	Relationship
Doc #4 (Pharmaceutical and Medical Supply Management)	Logistics framework for distributing medicines; this reference tells prescribers what to prescribe and how
Doc #5 (National Printing Capability)	Printing schedule and resource allocation for producing this reference
Doc #116 (Pharmaceutical Rationing and Shelf-Life Extension)	The companion clinical document — rationing triage, SLEP protocols, tapering frameworks; this reference provides the per-drug data that Doc #116’s framework operates on
Doc #117 (Surgical Capability Without Imports)	Anaesthetic and perioperative drug monographs in this reference support surgical planning
Doc #119 (Local Pharmaceutical Production)	What NZ can eventually produce to replace depleted stocks; this reference notes which drugs have local production pathways
Doc #123 (Midwifery and Maternity)	Obstetric medicines (oxytocin, magnesium sulfate, antibiotics) referenced here
Doc #125 (Public Health)	Vaccines, antiseptics, and public health medicines

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7. CRITICAL UNCERTAINTIES

Uncertainty	Impact	Mitigation
NZ Formulary website may become unavailable before download	Loss of primary data source	Download immediately — this is a Day 1 action. Also download the BNF if accessible (bnf.org requires subscription but may be accessible through NZ institutional access).
SLEP extension estimates are US-derived and lot-specific	NZ lots may differ in stability	Establish NZ stability testing programme (Doc #116, Action 10). Use SLEP data as the best available starting point, not as guarantees.
Drug identification data incomplete for generic products	Difficulty identifying unlabelled or bulk-repackaged medications	Compile photographic identification guide using actual NZ stock if cameras and printing allow. Pharmacist editors add identification notes based on experience.
Printed reference becomes outdated	New safety information not reflected	Pharmacist editors maintain a change log. Errata sheets distributed with reprints. Accept that some information will be frozen — this is inherent in a printed reference.
Print run insufficient for all clinical sites	Some prescribers work without reference access	Prioritise distribution: hospitals first, then community pharmacies, then rural clinics. Print condensed emergency cards for wider distribution.

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FOOTNOTES

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1. NZ Formulary. Published by the NZ Formulary Limited Partnership, funded by the NZ Ministry of Health. Available at https://nzf.org.nz/ — The NZ Formulary is adapted from the British National Formulary (BNF) and is the standard prescribing reference for NZ clinicians. It covers approximately 2,000 chemical entities. As of 2025, it is published exclusively online with no current print edition.↩︎

2. British National Formulary (BNF). Published by the BMJ Group and the Royal Pharmaceutical Society. The BNF is the source reference from which the NZ Formulary is adapted. Available at https://bnf.nice.org.uk/ — UK-specific content is modified for NZ by the NZ Formulary editorial team.↩︎

3. Medsafe — New Zealand Medicines and Medical Devices Safety Authority. A business unit of the Ministry of Health. Publishes product datasheets (consumer medicine information and prescriber datasheets) for all medicines with NZ marketing approval. https://www.medsafe.govt.nz/↩︎

4. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

5. NZ Formulary. Published by the NZ Formulary Limited Partnership, funded by the NZ Ministry of Health. Available at https://nzf.org.nz/ — The NZ Formulary is adapted from the British National Formulary (BNF) and is the standard prescribing reference for NZ clinicians. It covers approximately 2,000 chemical entities. As of 2025, it is published exclusively online with no current print edition.↩︎

6. Hospital medicines information services operate at all major NZ public hospitals. These pharmacists specialise in providing evidence-based drug information to prescribers and are experienced in formulary management. Auckland, Wellington, and Christchurch hospitals (administered under Te Whatu Ora / Health New Zealand since July 2022, replacing the former District Health Boards) have well-established services. Source: Pharmaceutical Society of New Zealand. https://www.psnz.org.nz/↩︎

7. NZ Formulary. Published by the NZ Formulary Limited Partnership, funded by the NZ Ministry of Health. Available at https://nzf.org.nz/ — The NZ Formulary is adapted from the British National Formulary (BNF) and is the standard prescribing reference for NZ clinicians. It covers approximately 2,000 chemical entities. As of 2025, it is published exclusively online with no current print edition.↩︎

8. British National Formulary (BNF). Published by the BMJ Group and the Royal Pharmaceutical Society. The BNF is the source reference from which the NZ Formulary is adapted. Available at https://bnf.nice.org.uk/ — UK-specific content is modified for NZ by the NZ Formulary editorial team.↩︎

9. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

10. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

11. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

12. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

13. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

14. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

15. Stark, G., “Extended Drug Shelf Life: SLEP and Beyond,” presentation at Defence Medical Services Conference, 2018. Also: US DoD/FDA Shelf Life Extension Program operational reports (not publicly available in full; summary data published in Lyon et al., note 4). Morphine and ketamine are among the most stable drugs tested, with some lots retaining full potency more than 15 years beyond labelled expiry.↩︎

16. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

17. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

18. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

19. SLEP data for inhaled medications, injectables, and peptide hormones is limited compared to solid oral formulations. Extension estimates for these formulations are based on a combination of available SLEP data, pharmacokinetic stability studies in the published literature, and conservative extrapolation. These estimates carry higher uncertainty than solid oral form estimates.↩︎

20. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

21. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

22. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

23. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

24. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

25. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

26. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

27. SLEP data for inhaled medications, injectables, and peptide hormones is limited compared to solid oral formulations. Extension estimates for these formulations are based on a combination of available SLEP data, pharmacokinetic stability studies in the published literature, and conservative extrapolation. These estimates carry higher uncertainty than solid oral form estimates.↩︎

28. Rachael, G.M., et al., “Epinephrine Content and Presentation Changes with Expired EpiPen Auto-Injectors,” Annals of Internal Medicine, 2017; 166:295–296. Study found that expired EpiPens retained 80–84% of labelled epinephrine content up to 50 months past expiry. Auto-injector mechanical function was not systematically assessed. In a post-event context, an expired EpiPen is vastly preferable to no adrenaline — reduced potency can be partially compensated by repeat dosing.↩︎

29. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

30. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

31. Stark, G., “Extended Drug Shelf Life: SLEP and Beyond,” presentation at Defence Medical Services Conference, 2018. Also: US DoD/FDA Shelf Life Extension Program operational reports (not publicly available in full; summary data published in Lyon et al., note 4). Morphine and ketamine are among the most stable drugs tested, with some lots retaining full potency more than 15 years beyond labelled expiry.↩︎

32. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

33. SLEP data for inhaled medications, injectables, and peptide hormones is limited compared to solid oral formulations. Extension estimates for these formulations are based on a combination of available SLEP data, pharmacokinetic stability studies in the published literature, and conservative extrapolation. These estimates carry higher uncertainty than solid oral form estimates.↩︎

34. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

35. Insulin stability beyond labelled expiry is poorly characterised. Insulin is a 51-amino-acid protein susceptible to aggregation, deamidation, and fibrillation. A-chain/B-chain dissociation accelerates above 30°C. No SLEP data is available for insulin because the US military does not stockpile it in the same manner as other medications. Limited published data suggests potency may decline approximately 1–5% per year under ideal refrigeration. Source: Vimalavathini, R. and Gitanjali, B., “Effect of Temperature on the Potency & Pharmacological Action of Insulin,” Indian Journal of Medical Research, 2009; 130(2):166–169.↩︎

36. Diabetes New Zealand and NZ Ministry of Health. Approximately 250,000 New Zealanders have diagnosed diabetes (Type 1 and Type 2 combined). Approximately 25,000 have Type 1 diabetes and are absolutely insulin-dependent. Estimated from Ministry of Health Virtual Diabetes Register data. https://www.health.govt.nz/↩︎

37. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

38. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

39. Levothyroxine is one of the most commonly prescribed medications in NZ. PHARMAC data indicates approximately 200,000–250,000 prescriptions dispensed annually. Many patients take it lifelong. Source: PHARMAC Annual Report and the Pharmaceutical Collection dataset (Ministry of Health). https://www.pharmac.govt.nz/↩︎

40. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

41. WHO/UNICEF, “Oral Rehydration Salts: Production of the New ORS,” 2006. The reduced-osmolarity ORS formula was adopted by WHO in 2004. It reduces stool output and vomiting compared to the original (higher osmolarity) formula. The formulation uses only sodium chloride, glucose, potassium chloride, and trisodium citrate — all producible from NZ-available materials. https://www.who.int/↩︎

42. WHO/UNICEF, “Oral Rehydration Salts: Production of the New ORS,” 2006. The reduced-osmolarity ORS formula was adopted by WHO in 2004. It reduces stool output and vomiting compared to the original (higher osmolarity) formula. The formulation uses only sodium chloride, glucose, potassium chloride, and trisodium citrate — all producible from NZ-available materials. https://www.who.int/↩︎

43. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

44. NZ brand names and product availability verified against Medsafe product datasheets (https://www.medsafe.govt.nz/profs/datasheet/dsform.asp) and PHARMAC Schedule (https://schedule.pharmac.govt.nz/). Brand availability changes over time; the reference should be verified against current stock at time of compilation.↩︎

45. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

46. Imdad, A., et al., “The Effect of Umbilical Cord Cleansing with Chlorhexidine on Omphalitis and Neonatal Mortality in Community Settings in Developing Countries: a Meta-Analysis,” BMC Public Health, 2013; 13(Suppl 3):S15. WHO now recommends chlorhexidine application to the umbilical cord stump in settings with high neonatal mortality. NZ’s post-event maternity care environment may approximate these conditions.↩︎

47. NZ Formulary. Published by the NZ Formulary Limited Partnership, funded by the NZ Ministry of Health. Available at https://nzf.org.nz/ — The NZ Formulary is adapted from the British National Formulary (BNF) and is the standard prescribing reference for NZ clinicians. It covers approximately 2,000 chemical entities. As of 2025, it is published exclusively online with no current print edition.↩︎

48. Medsafe — New Zealand Medicines and Medical Devices Safety Authority. A business unit of the Ministry of Health. Publishes product datasheets (consumer medicine information and prescriber datasheets) for all medicines with NZ marketing approval. https://www.medsafe.govt.nz/↩︎

49. Lyon, R.C., Taylor, J.S., Porter, D.A., et al., “Stability Profiles of Drug Products Extended Beyond Labeled Expiration Dates,” Journal of Pharmaceutical Sciences, 2006; 95(7):1549–1560. This is the key published study from the SLEP programme. Of 122 drugs tested (3,005 lots), 88% were stable for an average of 66 months beyond their labelled expiry date. Some drugs were stable for 15+ years. The study was conducted by the FDA on behalf of the US Department of Defense. Also: Cantrell, L., et al., “Stability of Active Ingredients in Long-Expired Prescription Medications,” Archives of Internal Medicine, 2012; 172(21):1685–1687.↩︎

50. Rongoā Māori practitioner integration: See Doc #160 (Heritage Skills Preservation). The Rongoā Māori Health Service is funded by Te Whatu Ora and delivered through Māori health providers; as of 2024, approximately 50 providers deliver rongoā services nationally. Riley, M., Māori Healing and Herbal: New Zealand Ethnobotanical Sourcebook, Viking Sevenseas, Paraparaumu, 1994. Also: Wehi, P.M., and Clarkson, B.D., “Biological Flora of New Zealand 14: Piper excelsum subsp. excelsum, kawakawa,” New Zealand Journal of Botany, 2007; 45:425–438.↩︎

51. Hiroa, T.R. (Buck, P.H.), The Coming of the Maori, Whitcoulls, Wellington, 1949 (reprinted 1982). Riley, M., op. cit. Descriptions of medicinal plant use reflect traditional practice documented across multiple sources; applications vary by practitioner, iwi, and region. This reference is intended only as a general orientation — clinical use should be guided by a qualified rongoā practitioner.↩︎

52. Brooker, S.G., Cambie, R.C., and Cooper, R.C., New Zealand Medicinal Plants, Heinemann, Auckland, 1987. A systematic pharmacobotanical survey of NZ native and naturalised plants. Documents traditional uses of kawakawa and koromiko, with phytochemical data where available. Kawakawa (Piper excelsum) contains myristicin, dilapiol, and flavonoids including the anti-inflammatory compound yangonin — providing partial pharmacological basis for wound and joint applications.↩︎

53. Adams, C.J., et al., “Isolation by HPLC and Characterisation of the Bioactive Fraction of New Zealand Mānuka (Leptospermum scoparium) Honey,” Carbohydrate Research, 2008; 343(4):651–659. The primary antibacterial factor in mānuka honey is methylglyoxal (MGO), present at concentrations high enough to inhibit S. aureus and other wound pathogens. Clinical wound dressings incorporating mānuka honey (e.g., Medihoney) are currently registered medical devices in NZ, providing regulatory precedent for clinical use. Molan, P.C., “The Role of Honey in the Management of Wounds,” Journal of Wound Care, 1999; 8(8):415–418.↩︎

54. Hiroa, T.R. (Buck, P.H.), The Coming of the Maori, Whitcoulls, Wellington, 1949 (reprinted 1982). Riley, M., op. cit. Descriptions of medicinal plant use reflect traditional practice documented across multiple sources; applications vary by practitioner, iwi, and region. This reference is intended only as a general orientation — clinical use should be guided by a qualified rongoā practitioner.↩︎

55. Hiroa, T.R. (Buck, P.H.), The Coming of the Maori, Whitcoulls, Wellington, 1949 (reprinted 1982). Riley, M., op. cit. Descriptions of medicinal plant use reflect traditional practice documented across multiple sources; applications vary by practitioner, iwi, and region. This reference is intended only as a general orientation — clinical use should be guided by a qualified rongoā practitioner.↩︎

56. Brooker, S.G., Cambie, R.C., and Cooper, R.C., New Zealand Medicinal Plants, Heinemann, Auckland, 1987. A systematic pharmacobotanical survey of NZ native and naturalised plants. Documents traditional uses of kawakawa and koromiko, with phytochemical data where available. Kawakawa (Piper excelsum) contains myristicin, dilapiol, and flavonoids including the anti-inflammatory compound yangonin — providing partial pharmacological basis for wound and joint applications.↩︎

57. Rongoā Māori practitioner integration: See Doc #160 (Heritage Skills Preservation). The Rongoā Māori Health Service is funded by Te Whatu Ora and delivered through Māori health providers; as of 2024, approximately 50 providers deliver rongoā services nationally. Riley, M., Māori Healing and Herbal: New Zealand Ethnobotanical Sourcebook, Viking Sevenseas, Paraparaumu, 1994. Also: Wehi, P.M., and Clarkson, B.D., “Biological Flora of New Zealand 14: Piper excelsum subsp. excelsum, kawakawa,” New Zealand Journal of Botany, 2007; 45:425–438.↩︎

58. Rongoā Māori practitioner integration: See Doc #160 (Heritage Skills Preservation). The Rongoā Māori Health Service is funded by Te Whatu Ora and delivered through Māori health providers; as of 2024, approximately 50 providers deliver rongoā services nationally. Riley, M., Māori Healing and Herbal: New Zealand Ethnobotanical Sourcebook, Viking Sevenseas, Paraparaumu, 1994. Also: Wehi, P.M., and Clarkson, B.D., “Biological Flora of New Zealand 14: Piper excelsum subsp. excelsum, kawakawa,” New Zealand Journal of Botany, 2007; 45:425–438.↩︎