What role do pharmacists play in flu management?

An article has looked at whether pharmacists could successfully initiate antiviral therapy and refer for more serious conditions in community pharmacy settings

Could pharmacists initiate antiviral therapy in the community pharmacy setting?

While they can now administer flu vaccinations, pharmacists cannot provide antivirals oseltamivir (Tamiflu) andzanamivir (Relenza), which are currently Schedule 4 (prescription only) in Australia.

Studies have been published in Canada, Japan, New Zealand, Norway and the United States on the topic, explain US pharmacists Professor Michael Klepser and Dr Alex Adams in the International Journal of Pharmacy Practice.

“Pharmacy‐based influenza management has been tested for more than a decade in New Zealand and almost nine years in the US,” they write.

“Studies have found the model safe and effective, while increasing access to care for patients. We are unaware of any adverse regulatory action against pharmacists in any jurisdiction related to the model, and we are unaware of any civil actions alleging harm.”

However some concerns have been expressed over pharmacist training, the accuracy of rapid influenza diagnostic tests, and the potential impact on antimicrobial resistance.

One key area of concern voiced by stakeholders is that pharmacists are not trained diagnosticians, and therefore would be unable to distinguish between influenza and pneumonia.

“In most cases, influenza is self‐limiting and resolves untreated in 3–7 days,” Professor Klepser and Dr Adams point out.

Nonetheless, pharmacists need to be trained on two fronts to ensure patient safety, they say.

Firstly, the ability to correctly perform rapid influenza diagnostic tests (RIDTs) as required in the US and, secondly, the ability to identify patients who have factors that predispose the patient to a high risk for complications and those who actually have a more serious condition (e.g. pneumonia).

“Studies have demonstrated that pharmacists have successfully accomplished both of these,” say the authors.

Studies show pharmacists have effectively used evidence‐based protocols to assess patients, determine which patients can safely be treated in the pharmacy, and identify those requiring a referral more appropriate care, they say.

“Pharmacists have been performing such assessments for more than 10 years in some jurisdictions,” they point out, adding that no published studies have reported patient harm from a pharmacy‐based treatment model.

Another concern is that allowing pharmacists to prescribe could worsen over‐prescribing and elicit antimicrobial resistance.

Professor Klepser and Dr Adams argue that pharmacists have a history of successfully engaging in outpatient antimicrobial stewardship initiatives.

“Surveys of pharmacists regarding non-prescription oseltamivir demonstrate a sensitivity to the issue of resistance,” they say.

The authors point out that New Zealand has the longest track record with pharmacist‐managed supplies of oseltamivir, where pharmacists can initiate the antiviral without first using a RIDT.

“An analysis of five years of pharmacist‐managed oseltamivir found no impact on the development of resistance and found no impact on consumer stockpiling.”

Professor Klepser and Dr Adams conclude that pharmacy-based influenza management can lead to broader public health benefits including improved data sharing, early detection of disease outbreaks, and reduced antimicrobial resistance, among others.

Additionally the model could increase capacity to respond to an influenza pandemic.

However they point out that pharmacists must:

  • use an evidence‐based protocol to identify patients appropriate for treatment in the pharmacy,
  • follow‐up in accordance with clinical guidelines, and
  • notify the patient’s primary care provider (if applicable) of any treatment initiated within five business days to ensure care is coordinated.

A 2014 systematic review found oseltamivir reduces the proportion of symptomatic influenza in prophylactic studies.

In treatment studies it also modestly reduces the time to first alleviation of symptoms, but it causes nausea and vomiting and increases the risk of headaches, and renal and psychiatric syndromes.

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