Push to allow pharmacist prescribing of antivirals flipped on its head

In recent days, there has been a renewed push to allow pharmacists to independently prescribe oral antiviral medications for the treatment of COVID-19.
 
The move has the support of the Pharmaceutical Society of Australia and the Pharmacy Guild, but medical organisations, including the RACGP and the AMA remain opposed.
 
The chief concern voiced by doctors is the high number of complex and serious drug–drug interactions associated with nirmatrelvir-ritonavir, which can result in severe or life-threatening side effects or reduce the drugs’ effectiveness, as well as other potential contraindications for both medicines.
 
RACGP Vice President Dr Bruce Willett holds grave concerns should the medicines be down-scheduled and believes the shift is not warranted.
 
‘In Australia, we’ve got a really high functioning healthcare system that’s based on the “first, do no harm” philosophy, and I just see the safety implications [associated with such a move],’ he told newsGP.
 
‘These medications can be quite complicated to prescribe.
 
‘They need a thorough knowledge of the other medications someone’s taking, and also familiarity with the patient’s blood results, their liver function and kidney function, and pharmacists simply don’t have that information at hand.’
 
Dr Willett says the fact molnupiravir has been prescribed at a rate 4.5 times higher than nirmatrelvir-ritonavir – despite the latter being the preferred first-line treatment – shows the how complicated these assessments can be, especially for those who stand to benefit the most from treatment.
 
He is also sceptical about GPs being seen as the main barrier to access, particularly as recent changes to telehealth rules have made it easier for patients with COVID-19 to secure general practice appointments.
 
‘There are three barriers. One is patients knowing about it. One is accessing the GP. And the other one is accessing the medications once the patient has the script,’ Dr Willett said.
 
‘Of those three, I would say accessing the GP is probably the least concerning, and I would suggest that patient knowledge of these medications’ availability is still the biggest.’
 
In addition to providing more support to educate patients on the availability of the antivirals, Dr Willett has proposed a solution that he believes avoids the issues associated with over-the-counter sales.
 
‘Many of us are experiencing [supply] problems with pharmacists, 24–48-hour delays are really common,’ he said.
 
‘A more sensible approach would be to make these medications available as part of a Doctor’s Bag, and to have GPs able to keep these medications on hand in the practice.
 
‘That would solve the access issues and speed up things without compromising safety, unlike a pharmacy-led model.’
 
What about New Zealand?
Proponents of independent pharmacy prescribing of oral antivirals, such as Professor Andrew McLachlan, have pointed to New Zealand as an example that it is safe and effective.
 
The Dean of Pharmacy at the University of Sydney recently told the ABC the approach is ‘one of the best models around the world’, whereas access in Australia remains a challenge.
 
‘It will be very interesting to see what the uptake will be in that country, and if there [are] any concerns with that approach,’ he said.
 
‘But I think the general consensus is that there’s probably more people who are eligible for these treatments at the moment who haven’t been able to access them.’
 
Pharmacy Guild of Australia President Anthony Tassone has also used the example to justify a push towards a pharmacy-led model, but RACGP President Adjunct Professor Karen Price questions the validity of these claims.
 
‘Comparisons to other countries, such as New Zealand, do not take into account the significant differences in models of primary care, variations in required pharmacy training, and differing safety classifications of medicines – it’s like comparing apples with oranges,’ she said.
 
‘These comparisons are inappropriate and should not be used to justify over-the-counter oral antivirals in Australia.
 
‘Pharmacies should keep their focus on the job at hand, which is availability of stock, rather than the provision of oral antivirals without a prescription.’
 
Professor Price has also called for pharmacy organisations to place more emphasis on showing the public where stock is available, as websites like Find a Pharmacy only show sites affiliated with the Guild.
 
‘There should be a website showing where stock is available, as they have previously done for rapid antigen test stocks,’ she said.
 
‘This should be done collaboratively to ensure that all pharmacies are listed nationwide, rather than pharmacists associated with one particular organisation.’
 
Meanwhile, Dr Willett has questioned the logic behind Australia following the example of one or two countries instead of those that still only allow doctors to prescribe the medications.
 
‘The vast majority of countries have decided this is not safe and they’re not doing it,’ he said.
 
‘Even in New Zealand, it’s a very limited number of pharmacists who are actually doing this.
 
‘The rest of the world aren’t doing this, so why do we need to follow a few outliers? There’s no real good reason for that.’
 
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