Pharmacy groups say lack of GP access is harming covid patients, but the RACGP says supplies are a bigger issue.
The Pharmacy Guild has called for covid antivirals to be available over the counter, saying GP wait times are endangering people with covid.
Australia should look across the Tasman for evidence that pharmacists can prescribe covid antivirals safely, the Guild says, as it opens yet another front in the war over expanded scope of practice.
But doctors have binned the approach, saying pharmacy supply issues were more to blame and that Paxlovid and Lagevrio (nirmatrelvir-ritonavir and molnupiravir) should instead be part of the Doctor’s Bag.
“Drawing comparisons with other countries like New Zealand is like comparing apples and oranges,” said RACGP president Adjunct Professor Karen Price, “It doesn’t take into account significant differences in models of primary care, variations in required pharmacy training, and differing safety classifications of medicines.”
The Pharmacy Guild has sent its proposal to Health Minister Mark Butler. That proposal is still under discussion, according to the Guild, adding that the minister can act immediately under section 89A of the National Health Act 1953 to make a pharmaceutical benefit available via an approved community pharmacy without a prescription.
“The essence of the proposal has been to highlight what is currently happening with pharmacist prescribing in New Zealand, Canada and the United States, the skills and competencies of pharmacists in Australia and what regulatory changes would be necessary to allow it to occur in Australia,” Anthony Tassone, the Guild’s Victorian branch president, told TMR.
“The undergraduate teaching of pharmacy students in Australia is internationally regarded, and Monash University has consistently ranked in the top pharmacy schools in the world,” he added.
The TGA told the ABC on the weekend that covid antivirals required a prescription in Australia because of the wide range of factors a prescriber needs to consider.
“However, should new evidence become available, including through an application from a member of the public or peak body to amend the Poisons Standard, then the decision-maker will consider whether to place covid-19 antiviral treatments in Schedule 3,” the TGA said.
In New Zealand, this change encountered some resistance from the medical community, but the country’s track record in moving urgently needed medicines to Schedule 3 helped, according to Pharmaceutical Society of New Zealand president Dr Rhiannon Braund, whereas Australia didn’t have this record.
Meanwhile, the Pharmaceutical Society of Australia, which backs pharmacist prescribing in a team environment, said community pharmacists in Scotland had been able to supply antivirals like molnupiravir to high-risk covid patients since January 2022.
“Scotland’s utilisation of the pharmacist workforce to provide timely access to antivirals has had a very positive impact on the health of patients who are at risk of hospitalisation,” said PSA national president Dr Fei Sim.
In practice, covid-positive patients would not attend a pharmacy in person and pharmacists would hold a phone or telehealth consultation just as a GP would, Mr Tassone said.
“A pharmacist would undertake a history of the patient including determining their age, whether there is evidence of a positive covid test result, when the symptoms commenced, and other medicines and medical conditions – particularly those that may put them at greater risk of complications from covid – amongst other questions,” he told TMR.
“This process will enable the pharmacist to establish which of the two oral covid-19 treatments to supply to the patient if treatment is deemed appropriate.”
Mr Tassone dismissed the idea that the government’s recent policy reversal on longer telephone consults, reinstating them for covid antiviral prescribing only, demonstrated the complexity and time required to prescribe them safely.
“The length of time a pharmacist would spend with each patient would be determined by their individual circumstances, their condition and any other health conditions which may have to be factored into the consultation,” he said. “There are other services and programs offered by pharmacies that require consultations of upwards of 20 minutes, and pharmacists would spend the necessary amount of time to ensure the appropriate supply of oral covid-19 treatments.”
Professor Price rejected the Guild’s position.
“Prescribing isn’t just about giving a drug and comparing with checklists,” she told TMR. “It is about treating the ‘whole’ patient. It’s not a simple process and it can take over an hour because there are numerous factors that may impact a patient’s eligibility which a GP has to consider.
“It requires a knowledge of a patient’s medical history and liver and renal function. This includes a patient’s health history, any existing conditions, current medications which may have contraindications, and whether a patient is pregnant or planning to get pregnant. This information is simply not available to pharmacists, nor do the pharmacists have the medical training to interpret it.
“Patients who are prescribed covid antivirals require clinical follow-up to check for adverse reactions and side effects,” she added. “This is not going to be able to be facilitated in pharmacy. How will pharmacists be able to assess patients for this medicine if the positive patient cannot go into the pharmacy? This would be an infection control issue. GPs already have telehealth item numbers in place to assess the patients and workflow to prioritise these patients.”
Professor Price acknowledged that access to antivirals is a major problem but allowing pharmacists to prescribe was not the answer.
“We know many patients who struggled to access these medicines did so because community pharmacists are not required to stock them and sometimes take 24 hours to supply,” she said. “It would make much more sense to add these medicines to the Doctor’s Bag and for residential aged care facilities to keep supplies, including Paxlovid. This is an easy way to increase access without compromising safety.
“Many GPs also have relationships with local pharmacies and insight into local availability of these medicines, and so they will help to direct patients where to access them when they can,” Professor Price said. “Pharmacy groups should work together to ensure stock is available or that there is fast access to supply on the same day in all pharmacies.”
