New Zealand allowed pharmacists to dispense COVID-19 antivirals and ‘everyone realised it was a win’
With Australians dying from COVID-19 every day and nearly 5,000 people in hospital with the disease, experts believe greater public awareness of antiviral treatments and easy access to the medications are now vitally important.
- There are calls for awareness of COVID antivirals and easier access to the treatments in Australia
- Pharmacy experts suggest looking to New Zealand where the drugs are available without a prescription
- As well as reducing the severity of disease, emerging research suggests the medications can help reduce the risk of long COVID
And some are pointing to an example across the ditch that sees pharmacists dispense the potentially life-saving drugs without the need for a doctor’s prescription.
Late last year, when COVID vaccination drives were well underway, countries around the world turned their attention to the procurement of antiviral treatments.
Along with infection control measures and vaccines, the drugs would become another tool in the pandemic toolkit.
The two approved in Australia — Paxlovid and Lagevrio — are available to a list of high-risk patients via a doctor’s prescription.
But Dean of Pharmacy at the University of Sydney Andrew McLachlan said the concern right now was access.
“I understand that Australia certainly does have quite a lot of these medicines available, but one of the challenges has been the ability to access them,” he said.
“So it’s about awareness that they are available, two the eligibility, and then three, being able to access them in a timely manner.”
The time frame is important because to be effective, both approved COVID antiviral treatments need to be taken within the first five days of infection.
Co-director of the Virus Research Centre at the Westmead Institute for Medical Research Tony Cunningham agreed more could be done to make sure the drugs reached vulnerable patients.
“There needs to be greater awareness,” he said.
“If you fall within those vulnerable groups, then you should be on Paxlovid or Molnupiravir (Lagevrio) within five days and that needs to be well understood.
“I think it certainly needs to be well understood in our aged care facilities where still a lot of deaths are occurring.”
NZ lists treatments as ‘pharmacists only’
In New Zealand, the morning after pill, oral contraceptives, Viagra and medications for urinary tract infections are available from accredited pharmacists without a doctor’s prescription.
Like COVID antivirals, these drugs often need to be taken within a short time frame.
The strategy was designed to keep healthy people out of the often-congested general practitioner system, given pharmacists are more likely to be available at short notice and after standard business hours.
Last week, New Zealand moved COVID antiviral drugs to its ‘pharmacist only’ listing too, meaning patients could now call their local pharmacy and have the medications delivered to their home on the same day.
For experts in pharmacy, the move makes sense.
In Dr McLachlan’s opinion, New Zealand’s approach is “one of the best models around the world”.
“It will be very interesting to see what the uptake will be in that country, and if there [are] any concerns with that approach, 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.”
President of the Pharmaceutical Society of New Zealand and research lead at the NZ Pharmacovigilance Centre at Otago University Rhiannon Braund said the move was a “no-brainer”.
“Like in Australia, we’ve got a real health workforce shortage. Our ministers refuse to call it a crisis, but it really is. And you can’t get in to see a GP for love or money,” she said.
Dr Braund said about 500 accredited New Zealand pharmacists, who had been through specialised training, had been dispensing COVID antivirals autonomously for a week and so far “there has been incredible demand”.
“Over the weekends and late nights, of course, is when we start seeing the big sort of surges of numbers,” she said.
Accessing COVID antivirals in Australia
Australia does have a Schedule 3 medicine listing for ‘pharmacist only’ drugs.
“So a medicine like a Ventolin inhaler, Salbutamol, that’s a pharmacist only medicine. A pharmacist takes a history, makes sure it’s suitable for you and gives you advice,” Dr McLachlan said.
But moving drugs such as antibiotics, contraceptives and antiviral treatments to a listing that does not require a doctor’s oversight can be controversial.
In Australia, Queensland is running a pilot program that would allow medications for some conditions to be dispensed by a pharmacist without a doctor’s prescription and the Australian Medical Association (AMA) has been highly critical of that proposal, saying it would endanger lives.
Vice-president of the AMA Danielle McMullen said that was also the body’s position on COVID antiviral drugs.
“They do remain quite complex medications. There are a number of medication interactions, but what we call contraindications, so reasons people can’t take these medications,” she said.
“And really the patient’s usual GP is best placed to assess whether they’re able to safely take the medications and which of the two medications is best suited to them.”
The Therapeutic Goods Administration (TGA) said prescribers needed to consider a number of factors, including whether changes needed to be made to existing medications, and the fact COVID antivirals are not recommended for those with poor kidney function or those trying to become pregnant.
For those reasons, the drugs currently require a prescription.
“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 told the ABC.
In New Zealand, the move to Schedule 3 did face some pushback from the medical community, but there was also a long track record of moving time-dependent medication to this listing before the pandemic hit.
“Those things allowed us to move forward,” Dr Braund said.
“That’s been the mechanism that’s allowed a whole lot of things to happen, which hasn’t happened in Australia.
“We went through the same teething problems, some of the GPs were really unhappy and then we just got on and did it and everyone realised that actually, it was a win.”
Around the world, there are other examples of innovative ways health authorities are getting these medications to those who need them.
In the United States, there are ‘test to treat’ centres designed to give COVID patients “rapid access” to antiviral treatments.
“People will be able to get tested, and – if they are positive and treatments are appropriate for them – receive a prescription from a qualified health care provider, and have their prescription filled all in one location,” the Department of Health and Human Services announced earlier this year.
In the UK, COVID patients can call the NHS and be assessed for antiviral suitability and the medications will be sent to their home. A similar service is available for Australians who do not have a regular GP.
In Singapore, the eligibility criteria is broader and anyone over the age of 18 who experiences symptoms within those first five days of infection is encouraged to contact a public or private clinic to access antiviral medication.
Scientific officer with the Centre for Outbreak Preparedness in Singapore Dr Khoo Yoong Khean said the ability for COVID antiviral treatments to really help reduce severe disease at a population level relied on sustainable supply.
“Countries with a high supply and a robust health system to distribute the medication will see the benefits of using antiviral treatment early in the disease,” he said.
“The struggle is to ensure low- and lower-middle-income countries have sufficient supply and a good distribution system as well.”
More public messaging required: AMA
COVID patients at risk of severe disease have just five days to test positive, secure and attend a GP appointment and access the medication — no easy feat and a series of events that relies on several factors outside their control.
Dr McMullen believes those who are would be eligible for the treatments, should make a plan with their GP just in case they test positive.
“The demands on general practice are enormous,” she said.
“Really what we need to help us with that is more messaging to the public, that if you are in an at-risk group, so if you’re over 70, or if you’re over 50, with other health conditions, to pre-emptively have the conversation, at least, with your doctor so that you know what to do in the event that you test positive.”
A spokesperson for the Department of Health said the government had taken several steps to promote easy access to the drugs.
“Medicare now covers a long telehealth consultation by a GP for prescribing COVID-19 antiviral treatments,” they said.
“GPs can electronically send prescriptions to pharmacists directly so that medications can be either collected by a friend or family member or delivered to the patient’s home.”
The ABC has covered localised supply issues, including on the Gold Coast, where COVID patients reported having difficulty filling a prescription.
Dr McLachlan said: “Part of the challenge in this space too is that the medicines themselves are really quite expensive to have on the pharmacy shelf just in case a person comes in.”
A Health Department spokesperson said the Government had been “actively encouraging community pharmacies to hold adequate stock” of both Paxlovid and Lagevrio and said there were return policies to ensure the businesses would not be out of pocket.
The Pharmacy Guild of Australia publishes a website that allows patients to search their postcode for pharmacies that have COVID antivirals in stock.
According to a search on Friday afternoon, three pharmacies in the Sydney CBD were carrying the medications.
The Health Department spokesperson said given the COVID antiviral drugs were available on the Pharmaceutical Benefits Scheme, they could be ordered by pharmacists and delivered by the distributor within 24 hours.
“In addition to supply through the PBS, the Government, through the National Medical Stockpile, has deployed supplies of oral antiviral treatments to all state and territory health departments for supply to high priority groups,” they said.
The Government placed antiviral treatments in aged care facilities, Aboriginal health services and the Royal Flying Doctor Service.
Could long COVID risk be considered?
The eligibility criteria in Australia and New Zealand are similar.
People aged over 50 with at least two risk factors that could lead to severe disease, as well as Aboriginal or Torres Strait Islander people aged 30 and older with at least two risk factors are also eligible.
Anyone over the age of 18 who is immunocompromised may also be eligible.
As of Friday, more than 182,300 prescriptions for the COVID-19 oral treatments — Lagevrio (molnupiravir) and Paxlovid (nirmatrelvir and ritonavir) — had been dispensed, according to the Health Department records.
“This is a significant increase from 10 July, when the Government expanded access to treatments and only around 73,000 scripts had been filled,” a spokesperson said.
Dr Cunningham said it was important to consider emerging research into who was at risk of long COVID when deliberating future changes to antiviral eligibility.
“We need to understand more about people who are not in [current] eligibility groups who are likely to get long COVID and be able to treat them as well,” he said.
“You have to treat early to get the viral load down to avoid the immune consequences.
“My prediction is in the future that we’ll be using antivirals more to prevent the ongoing symptoms, ongoing depredations of COVID long term.”