Pharmacist supply of sildenafil: pharmacists' experiences and perceptions on training and tools for supply

Implementation and mixed method evaluation of a unique midwife-prescribed, pharmacist-administered routine antenatal Anti-D prophylaxis model in pregnant people

BACKGROUND

Routine antenatal anti-D prophylaxis, an injected blood product, reduces the risk of rhesus (D) sensitisation in rhesus negative pregnancies. One New Zealand district implemented this service through a unique model using midwives to prescribe and community pharmacists to administer and manage anti-D.

AIM

To describe the model and its implementation and ascertain uptake, cost, acceptability to service users and stakeholders, and potential improvements.

METHODS

An audit compared uptake from October 1, 2021 to May 31, 2023 with the eligible population. A cross-sectional survey of service users, midwives, pharmacists and staff supporting the service delivery was conducted in 2023. A cost analysis was undertaken.

RESULTS

At least one dose of anti-D was administered in 300 of 522 eligible pregnancies (57 %), although this was significantly lower in those with Māori ethnicity (35 %, p = 0.008 versus European ethnicity), or increased parity. Uptake increased over time. All groups surveyed highly preferred (74-86 %) the existing model over alternatives. Service users would highly recommend (95 %) the pharmacy they attended to others eligible for anti-D. Pharmacists were very satisfied with the service and ease of administration but experienced challenges, e.g. service users presenting without the required blood test first and insufficient staffing. Midwife-pharmacist communication was sometimes rated poorly. Courier and pharmacy costs were 3 % and 10 % of the total cost, respectively.

CONCLUSION

Anti-D prescribed by midwives and administered by community pharmacists is convenient for service users, low cost, and the preferred model for service users, midwives and pharmacists. Uptake needs to increase and focus on equity.

Contribution of the community pharmacist workforce to primary care through the lens of medicines classification: comparison of Aotearoa New Zealand and Australia

Introduction Optimal use of the workforce in primary care is critical due to increasing complexity and demand resulting from multi-morbidity in ageing populations. Improving public access to medicines by making them available via a pharmacist without prescription can support self-care while ensuring oversight by a health professional. Aim The aim of this paper was to identify and explore key differences between New Zealand and Australia in medicines classified nationally for pharmacist-only non-prescription supply. Methods Medicines legally classified to allow sale by a pharmacist without a prescription were identified and compared between the two countries as of 1 February 2024. Based on consensus among the research team, notable differences were subjected to qualitative consideration about how medicines classification may be used to extend the role of pharmacists in primary care. Results Overall, New Zealand has a less restrictive approach to classification than Australia providing New Zealanders increased access to medicines via a pharmacist in two key therapeutic areas: sexual and reproductive health and infection. Oral contraceptives, sildenafil, antibiotics for urinary tract infection and two COVID-19 antivirals were classified for supply without prescription via pharmacists in New Zealand but not nationally in Australia, although some alternative legislative mechanisms are emerging at state level. Discussion Medicines classification has an ongoing role in enabling pharmacist contribution to primary care. Medicines classification needs to be considered alongside commissioning of services and other policy to facilitate integration of community pharmacy-provided care within the wider primary care environment. Digital tools supporting information sharing, collaboration and communication are key.

Pharmacist supply of non-prescription sildenafil in Norway: a simulated patient mixed-method study

BACKGROUND

Pharmacist supply of non-prescription sildenafil was initiated in Norway in 2019, and continuous evaluation of the service is warranted.

OBJECTIVES

To map how the service checklist is used, evaluate the counselling and information given in consultations, get an insight into pharmacist assessments during consultations, and explore the pharmacists' experiences with the service.

METHODS

A mixed-method approach of simulated patient visits with feedback combined with qualitative interviews was used. One 24-year-old simulated patient visited pharmacies requesting sildenafil in a scenario that ended before purchase. Visits were audio-recorded and evaluated. Post-visit, pharmacists were invited to get feedback and participate in an audio-recorded interview. Visits, feedback, and interviews were transcribed and analysed by descriptive statistics and systematic text condensation.

KEY FINDINGS

Of 39 visits, 26 were analysed and 13 were excluded because the pharmacists did not give consent. Six (23%) pharmacists asked all the checklist questions, while 15 (58%) asked some of them. None of the pharmacists provided all the guideline counselling points. The counselling most provided was 'See your general practitioner within 6 months for a health check' (N = 7, 27%). Interviews (N = 19) elicited that pharmacists assessed the patients, with adaptations in the use of the checklist. Several barriers affecting the service were identified, including time pressure, pharmacist competence, and the task being uncomfortable and challenging.

CONCLUSIONS

Most pharmacists did not completely adhere to the mandatory checklist on non-prescription sildenafil and the counselling and information given were limited. The pharmacy sector must increase awareness of how best to assess and manage patients requesting non-prescription sildenafil.

Learning From Consultations Conducted by Community Pharmacists in Northern Ireland for Nonprescription Sildenafil: A Qualitative Study Using the Theoretical Domains Framework

INTRODUCTION

Nonprescription sildenafil was introduced to the United Kingdom in 2018 as the first pharmacy service concerning sexual function, an important but often ignored factor for quality of life.

AIM

This study aimed to evaluate pharmacists' views on providing nonprescription sildenafil, their perceptions of the barriers and facilitators to provide this service and strategies to overcome potential barriers, using a theory-based approach.

METHODS

Community pharmacists were purposefully sampled in Northern Ireland, followed by snowball sampling. Face-to-face interviews were conducted between October 2019 and January 2020. The semi-structured interviews used a piloted topic guide based on the 14-domain Theoretical Domains Framework (TDF). All interviews were audio-recorded, transcribed verbatim and anonymized. Transcripts were analyzed deductively in NVivo 13, utilizing the TDF domains as coding categories. Within each domain, content analysis was utilized to identify barriers and facilitators.

MAIN OUTCOME MEASURE

Barriers and facilitators within the TDF domains for pharmacists to provide nonprescription sildenafil.

RESULTS

Ten pharmacists were interviewed to reach data saturation. Eight pharmacists had experience with dispensing nonprescription sildenafil. They valued nonprescription sildenafil as an additional service ("Social/professional role and identity"). Training, concise product guidelines, and private consultation areas were important facilitators ("Environmental context and resources"). The service required trusting clients ("Optimism"), with concerns about abuse and men not visiting their GP. From experience gained, pharmacists became more confident dealing with difficult situations such as patients being vague about their medical history or alcoholism or mental problems as causes for erectile disfunction (ED) ("Skills" and "Beliefs about capabilities"). Pharmacists considered lifestyle and medication causes of ED important but preferred to focus on safe supply. In general, pharmacists were satisfied with the perceived professional recognition, using their clinical knowledge or helping patients resume sexual relationships ("Beliefs about consequences").

CONCLUSION

Pharmacists welcomed nonprescription sildenafil to enhance their role as easily accessible healthcare providers for patients. Gordijn R, Teichert M, Nicolai MPJ, et al. Learning From Consultations Conducted by Community Pharmacists in Northern Ireland for Nonprescription Sildenafil: A Qualitative Study Using the Theoretical Domains Framework. Sex Med 2021;9:100440.

Visual Side Effects Linked to Sildenafil Consumption: An Update

Phosphodiesterase type 5 (PDE5) inhibitors such as Viagra^® (sildenafil citrate) have demonstrated efficacy in the treatment of erectile dysfunction (ED) by inducing cyclic guanosine monophosphate (cGMP) elevation followed by vasodilation and increased blood flow. It also exerts minor inhibitory action against PDE6, which is present exclusively in rod and cone photoreceptors. The effects of sildenafil on the visual system have been investigated in a wide variety of clinical and preclinical studies due to the fact that a high dose of sildenafil may cause mild and transient visual symptoms in some patients. A literature review was performed using PubMed, Cochrane Library and Clinical Trials databases from 1990 up to 2020, focusing on the pathophysiology of visual disorders induced by sildenafil. The aim of this review was not only to gather and summarize the information available on sildenafil clinical trials (CTs), but also to spot subpopulations with increased risk of developing undesirable visual side effects. This PDE inhibitor has been associated with transient and reversible ocular side effects, including changes in color vision and light perception, blurred vision, photophobia, conjunctival hyperemia and keratitis, and alterations in the electroretinogram (ERG). Sildenafil may induce a reversible increase in intraocular pressure (IOP) and a few case reports suggest it is involved in the development of nonarteritic ischemic optic neuropathy (NAION). Reversible idiopathic serous macular detachment, central serous retinopathy and ERG disturbances have been related to the significant impact of sildenafil on retinal perfusion. So far, sildenafil does not seem to cause permanent toxic effects on chorioretinal tissue and photoreceptors as long as the therapeutic dose is not exceeded and is taken under a physician’s direction to treat a medical condition. However, the recreational use of sildenafil can lead to harmful side effects, including vision changes.

Adapting the Auckland Sleep Screening Tool for pharmacy: pharmacists' experience and feedback

INTRODUCTION Insomnia has negative health effects and may indicate underlying serious conditions, but is underdiagnosed and often not discussed with a doctor. AIM This study aimed to explore the utility and workability in New Zealand community pharmacies of a 23-question sleep-screening tool adapted from the Short Auckland Sleep Questionnaire. METHODS A multidisciplinary advisory group (sleep specialist, general practitioner and pharmacists) discussed the tool, pharmacists' capability in managing insomnia and training needs for pharmacists, and recommended management strategies, including referral points. Twelve community pharmacists piloted the tool with people with insomnia who presented in pharmacies, recording the time it took to administer the tool. The pharmacists were then surveyed about their experiences with the tool and possible improvements. RESULTS Ten pharmacists took an average of 12.4 min (range 4-35 min) for each use of the screening tool with 62 people with insomnia. Most pharmacists found the screening tool easy to administer, organised and easy to follow and nine of 10 said it provided better information than their usual consultation. Seven of 10 pharmacists would use it again. Time limitations and low recruitment were potential barriers to usage especially for pharmacy owners. DISCUSSION The screening tool could provide a useful addition to pharmacists' toolkits, aiding information gathering and better than usual practice. The tool was acceptable to most pharmacists, but its use takes time and remuneration needs consideration.

Analysing the landscape for prescription to non-prescription reclassification (switch) in Germany: an interview study of committee members and stakeholders

Background

Non-prescription medicines are increasingly used in Germany, aided by prescription-to-non-prescription reclassification (or switch). This study aimed to examine the barriers and enablers to reclassification of medicines in Germany and provide recommendations for change.

Methods

Face-to-face conversational interviews with purposively selected key informants in Germany were conducted in 2017 by a researcher informed in the area. Interviews were transcribed, coded in NVIVO and systematically analysed using a framework approach.

Results

Twenty-four interviews were conducted with 32 participants including members of the committee considering reclassifications, and representatives from government, industry, health insurance, academia, and pharmacy, medical, and patients’ organisations.

A range of enablers and barriers emerged that influence reclassification including effects on the committee and process, or the desire of pharmaceutical companies to pursue reclassifications. Enabling market factors included the large population and a culture of self-medication. Enabling health system factors include the pharmacy-only category. Some pharmacy factors appeared enabling (e.g. a positive experience after reclassifying emergency contraception) while others appeared to hinder reclassification (e.g. insufficient pharmacy practice research). Some medical factors were enabling (e.g. reported waiting times) and others limited reclassification (e.g. opposition to some reclassifications). Some committee and government openness to reclassification and self-medication reportedly enabled reclassification, while conservatism was considered a barrier, particularly for classifications with special conditions for supply such as initial doctor diagnosis or other complexities. Some improvements to the committee constitution and considerations were recommended. Some participants found the reclassification process after the committee recommendation opaque, with opportunity for delays and political interference.

Industry factors included both enablers such as capability in reclassification, and barriers, such as a perceived low market potential of some reclassifications, and doubt that some candidates would be approved.

A need for more data emerged strongly, both pre-reclassification in applications, and post-reclassification.

Many participants saw merit with reclassification in non-traditional areas such as hypertension, diabetes and oral contraception.

Conclusions

Many factors influence reclassification in Germany. Recommended improvements included aspects of the process and committee consideration, and more data collection. Sufficient market exclusivity linked to data collection could aid the generation of evidence to aid committee considerations and encourage more applications of high quality.

Medicines reclassification from a pharmaceutical industry perspective: An international qualitative study

BACKGROUND

Widening access to medicines through reclassification ('switching') of medicines from prescription to non-prescription is an international trend generally welcomed by community pharmacists. Research has focused on scheduling and committee deliberations affecting reclassification, rather than industry aspects, despite industry's role in driving reclassifications. The research aimed to identify how pharmaceutical industry and product-related factors influence reclassification, and to explore stakeholder acceptability of government or third-party driven reclassifications.

METHODS

Sixty-five in-depth, semi-structured interviews were conducted with 80 key informants (including representatives from regulatory bodies, industry, pharmacy and medicine) in developed countries including the United States, the United Kingdom, Japan, Australia, and New Zealand. The questions explored barriers and enablers to reclassification at the local (micro-), regional (meso-) and global (macro-) levels. Analysis of transcribed interviews entailed descriptive and thematic approaches.

RESULTS

Pharmaceutical industry decisions to drive medicine reclassification reflect characteristics of the company, product, and external environment at all levels. For the company, financial factors, company focus (e.g. on prescription business versus non-prescription business), and capability in non-prescription medicines and reclassification were common influences. Products with significant non-prescription market potential and a well-known prescription medicine brand name most suited reclassification, usually near patent expiry. Barriers included immediate generic entry post-reclassification, and a short-term profitability and/or prescription business focus. Some countries allow government or a third-party (including pharmacy) to drive reclassifications, with examples of successful reclassifications ensuing. Some industry and other participants held concerns about this practice, particularly in the United States. Concerns included insufficient resourcing, and the pharmaceutical company's business, potentially encouraging product withdrawal or legal challenge.

CONCLUSIONS

This study is the first to explore both pharmaceutical industry factors affecting reclassification and acceptability of alternate drivers of reclassification. Factors beyond clinical safety and efficacy and the local reclassification environment can influence reclassification. Pharmacy-driven reclassification might be one alternative.