Pharmacy-only NSAIDs: is it time?

Stakeholders have suggested that NSAIDs could be moved to pharmacy-only in a bid to avoid interactions such as the “triple whammy” with diuretics and ACE inhibitors

Macquarie University researcher Dr Kim Lind and colleagues investigated NSAID use among residents of 68 residential aged care facilities from 2014 to 2017, and analysed concomitant medication use and high risk conditions.

The analysis involved 10,367 residents, of whom 2414 (23.3%) used at least one NSAID; 756 (7.3%) used only oral, 1326 (12.8%) used only topical, and 332 (3.2%) used both topical and oral NSAIDs.

There were 1542 residents (14.8%) who used an NSAID long-term, a majority of whom only used topical NSAIDs 933/1542 (60.5%).

“Age, sex, and health status were associated with greater variation in long‐term topical use relative to oral NSAID use,” the researchers found.

“A majority of oral NSAID users concomitantly used a PPI, which varied according to age, sex, and health status. Among residents with any oral NSAID use, 182/1088 (16.7%) had triple whammy medication use.

“When this rate is applied to Australia’s residential aged care population of approximately 259,000 people, in the order of over 5,000 people in residential aged care may be triple whammy users,” Dr Lind told News Corp national health reporter Sue Dunlevy.

The researchers concluded that, “Targeted interventions to reduce NSAID use among RACF residents, to reduce triple whammy medication use, and increase PPI use for long‐term oral NSAID users are warranted”.

Dr Lind warned that the number of people using the “triple whammy” combination outside residential aged care, in the community, could also be high.

“People expect if you can buy it in a supermarket they are safe,” she said.

“Maybe it is time to move them to pharmacy only.”

Pharmacist and herbalist Gerald Quigley, a regular presenter on Chemist Warehouse’s House of Wellness program, spoke to 2GB’s Luke Grant and said that while there was “nothing new about this” in pharmacy and medical circles, the mainstream media coverage could have helped highlight the issue to consumers.

“If you are controlling your bp with a particular type of medication called an ACE inhibitor – and there are a number of medications that are classed there – and you’re controlling your fluid with a diuretic, if you have got a prescription for a non-steroidal anti-inflammatory, the pharmacist will be warned, and usually the doctor will as well because of their dispensing and medical programs that that combination puts that particular person at risk,” he told Mr Grant.

“And normally and hopefully, that’s picked up very readily and alternatives are found.

“This issue arises sadly when someone innocently buys a pack of those things, ibuprofen or diclofenac or naproxen and there’s a number of different brands available where you can buy them over the counter.

“And over the counter also means, in many instances, Luke, from the local supermarket.”

He said that it was likely that pharmacists could be accused of having a pecuniary interest in making money from the sale of NSAIDs, but a less jaundiced viewpoint was appropriate.

“I think a more broad and hopefully professional view is that at least the pharmacist can keep an eye on these things and intervene if the need arises,” he said.

“Now people are going to sneak under the radar, that’s going to happen. But it’s incumbent on the pharmacist to take therefore a much greater interest in the sale of any of these medications where the simple question is, do you happen to be taking anything for your blood pressure.

“There’s a warning on the side of the box, but do you read a box?”

Mr Quigley also warned listeners about the liver toxicity issues around paracetamol.

“We get the impression it’s so super safe, it’s so safe – look, it’s not,” he said.

A spokesperson for the PSA told the AJP that pharmacists have an important role in supporting responsible self-care, and the provision of non-prescription medicines is a key component of this role.

“A pharmacist can ensure the provision of non-prescription medicines is consistent with the safe and quality use of medicines and appropriate to the needs of the patient,” they said.

“The safe and quality use of medicines is already on the government’s agenda with Health Minister Greg Hunt committing to PSA that this will be made a National Health Priority Area.

“PSA believes this will increase awareness around the important issue of medicine errors and may consider specific issues such as the supply of pain medicines. 

“Pharmacists with their unique expertise in medicines and medicine management are ideally placed to identify and help resolve the issue of medicine-related harm and PSA and the pharmacy profession looks forward to working with the government on this health priority to ensure optimal health outcomes for all Australians.”

As pointed out by Mr Quigley, the issue of access to NSAIDs has been debated before. In February 2018, following the upschedule of low-dose codeine combinations, Ron Batagol and Professor Gregory Peterson said ibuprofen could become a “mainstay” for people seeking to treat pain without a GP visit.

They suggested that restricting ibuprofen to pharmacy-only could help prevent harms to many patients, including those with underlying cardiac or kidney conditions.

An AJP poll held at the time found that nearly three-quarters of pharmacists would like to see greater restrictions on the availability of ibuprofen.

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  1. Andrew Kelly

    I am a little confused by this article. So on one hand there is a submission to the Royal Commission pointing out the rates of the “triple whammy”, which should have been picked up and acted on by pharmacists. So has Dr Lind investigated what steps were taken by pharmacists when they have seen it? The way this article has been written it appears that this needs to be avoided at all costs, yet in the next breath is saying move NSAID’s to pharmacy only so it can be monitored by pharmacists. If it isn’t being done now, how can we be expected to do more of it?

    • Jarrod McMaugh

      A few relevant points

      1) The presence of the three classes of medications that can cause a “triple whammy” do not always lead to adverse outcomes. The outcome is often to monitor, rather than cease, in a care facility setting.
      2) The interaction can occur with two of these classes together
      3) In RACFs, NSAIDS can be “nurse initiated” so the ability of a pharmacist to intervene at this setting is not always present.
      4) In RACFs, utilisation of medicine is a shared-care arrangement, where the prescriber makes final decisions on appropriate interventions based on the advice from relevant team members.

      The first and second point is the most relevant to the consideration of whether NSAIDs should be available only from a pharmacist, since the role of the pharmacists is to apply their **clinical** expertise in determining whether an interaction is likely to lead to adverse outcomes, and to educate a person on what to identify if an interaction were to occur.

      The role of the pharmacists isn’t “just deny” as much as it isn’t “just supply” – every instance requires careful consideration of the relevant factors. The recommendation to schedule NSAIDs as pharmacist-only needs to balance the individual risks against the relative risk in the population.

      With regards to these questions you pose:
      “So has Dr Lind investigated what steps were taken by pharmacists when they have seen it?…. If it isn’t being done now, how can we be expected to do more of it?”
      Point 4 above is relevant. It IS being done now, yet more can be done to improve how this is implemented (ie how these discussions are conducted and funded), and the setting of these conversations (ie in a “clinical rounds” setting rather than non-contextual ad-hoc communications – again, with funding)

      • Andrew Kelly

        Thanks for the response Jarrod, and certainly agree with your comments. I haven’t read the original article Dr Lind was quoted in (paywall!), but the summary given in this article reads to me as if it is binary, and that pharmacists aren’t already providing input on these on a case by case basis.
        As for your point number 3, just another reason why I always argue against them on the NIM list, and most GP’s are pretty happy with this outcome.

      • Ron Batagol

        There are two issues here, often inter-related: i.e. 1.Triple
        whammy risks and 2. The increase in risk of renal damage with dehydration/fluid depletion, even in healthy individuals
        1.The triple whammy risk- highlighted by the then ADRAC Committee in 2003 ADRAC. “ACE inhibitor, diuretic and NSAID: a dangerous combination”. Aust Adv Drug React Bull 2003; 22:
        14-15., and in 2006 “Beware the Triple Whammy” DRAC:

        Thus, even though the “triple whammy” may not cause acute adverse renal effects every time, the potential risk is present, and it is well established that this can occur with short-term use within normal dose ranges.

        2. Also see the comments of myself and two renal specialists in MJA Insight October 2014, after I had TGA add the additional cautionary label regarding fluid depletion and risks of acute renal failure in infants (albeit usually reversible) and in patients who are dehydrated or have poor renal function.


        So, at the end of the day, is there any doubt that NSAIDs should only be sold in pharmacies and removed from supermarkets and other general stores?

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