How to prescribe during a drugs shortage

With 18 antibiotic active ingredients now scarce, GPs who prescribe unfamiliar alternatives without proper notes put themselves at medicolegal risk.

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As post-pandemic medicine shortages rage on, prescribing second-line or broader-acting antibiotics may become more commonplace in general practice, prompting warnings to minimise medicolegal risk.

Amoxicillin, cephalexin and metronidazole have been the latest and most public victims of the supply chain, but a total of 39 brands of antibiotics are currently unavailable and 18 antibiotic active ingredients are in short supply.

The TGA has created a Serious Scarcity Substitution Instrument (SSSI) for oral amoxicillin and oral cephalexin, and the AMA recommends that liquid formulations be reserved for children and elderly patients.

Beyond antibiotics, about 400 medicines are currently in shortage across Australia. A further 77 are anticipated in the coming months.

The TGA estimates that some won’t be back in normal supply until 2024.

With that in mind, Dr Michael Wright, GP and chief medical officer for medical indemnity organisation Avant, said doctors could take practical steps to avoid any unnecessary medicolegal risk.

“If you are using a treatment that’s less commonly used or is outside of standard guidelines, make sure that you have a suitable knowledge of the medication so that you can explain to patients what the expected side effect profile is,” he told The Medical Republic.

He also advised GPs to take detailed notes about their rationale for choosing a particular medicine if it wasn’t a first-line treatment.

It’s also useful to designate one member of staff to field calls from pharmacists, Dr Wright said.

“Is there someone in the practice who can field those calls so that the message gets through to you, as the prescriber, as quickly as possible?” he said. As a safety net, Dr Wright suggested reminding patients that they can return for review if their condition does not improve.

“It’s also good to have a relationship with your local pharmacy so that you do know what medications may not be available, and also so that they feel free to contact you if there’s something that you prescribed that they don’t have,” he said.

On a broader level though, the shortage reinforces the need for strong antibiotic stewardship.

“One of the skills of doctors is that we not only know when to prescribe, but also when not to prescribe,” Dr Wright said.

“I think that’s an important message.”

The antibiotic shortage is hitting at a time when nearly every state and territory has either proposed or is committed to implementing a pharmacist-led prescribing trial for uncomplicated cystitis in women.

Under the trial, pharmacists can prescribe and dispense first-line antibiotics like trimethoprim – which is currently in limited availability – for a suspected UTI.

“The Pharmacy Guild seems to think that everything can be fixed with a drug,” RACGP president Dr Nicole Higgins said.

“Pharmacists just don’t have the expertise and training to perform the function of prescribing medications, that is a job that should be left to medical practitioners.

“Already, we have seen in Queensland many concerning incidents including a patient in their 50s being prescribed antibiotics for a presumed urinary tract infection who turned out to have a 15cm pelvic mass.”

Queensland is the only state to have fully implemented the program thus far.