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Last week, a patient walked into Rachel Lee’s pharmacy in an affluent San Diego neighborhood to ask about her prescription for ivermectin. She had been preparing for this moment since her pharmacy started receiving calls regarding the availability of the drug.
“I was like, ‘Oh great, here it is. This is my first, ”said Lee, who asked that his real name not be used to protect his work at a national drugstore chain.
The prescription did not contain a diagnostic code, which many pharmacists use to ensure that a drug is prescribed for valid medical reasons. The prescribing physician was licensed out of state in Florida. When calling the doctor’s office for more information, an employee said the ivermectin was for COVID prophylaxis. Lee fired the patient.
Many pharmacists across the country find themselves in equally uncomfortable situations. Demand for ivermectin, which in tablet form is used to treat parasitic worms in humans, has increased 24-fold due to the scientifically unsubstantiated belief that it can treat or prevent COVID-19. Before the pandemic, the Centers for Disease Control and Prevention reported an average of 3,600 prescriptions for ivermectin per week. The number of prescriptions began to rise rapidly in early July, spurred in part by marginalized doctors advocating for its use. As of mid-August, the CDC reported more than 88,000 prescriptions per week.
The FDA has not approved ivermectin for this indication, and the National Institutes of Health, the World Health Organization, and even the drug’s maker, Merck, have all said that scientific evidence for its use in the treatment or COVID prevention is insufficient. Nonetheless, some doctors write prescriptions – questionable websites offering them for a fee abound – and celebrities like Joe Rogan and Alex Jones have been promoting them. While some pharmacies fill these prescriptions, many others have to turn away frustrated patients.
“We’re put in a tough spot,” Lee said. “I was very strict with it, just because at the end of the day, it’s my license.”
On September 1, a trio of leading national health care groups – the American Pharmacist Association, the American Society of Health-System Pharmacists, and the American Medical Association – released a joint statement calling for an end to the order, prescription or distribution. ivermectin for the prevention or treatment of COVID-19. The way people intend to use it is dangerous, say pharmacy experts.
Pharmacists see prescriptions for varying doses and for longer periods of time than the currently approved use of ivermectin, said Anne Burns, pharmacist and vice president of practical affairs at APhA. In oral tablet form, ivermectin is approved as a one-time treatment, and sometimes a follow-up dose is prescribed several months later. “We hear about prescriptions for ivermectin for several days to a month, and sometimes longer,” Burns said. (A topical version of ivermectin is also available for some human skin infections.) Burns also noted that APhA recently received a report of a doctor asking to fill a 30-day prescription for ivermectin for itself.
Ivermectin overdoses can cause symptoms ranging from nausea and vomiting to seizures, coma and death. It can also react negatively with other medicines that a person is taking. There are also reports (and memes) of people using veterinary-grade ivermectin, a paste used to deworm horses, cows and pigs. Although the active ingredient is the same, it bears repeating that livestock drugs are dangerous because their extremely high dosage is intended for large animals, and they may also contain inactive ingredients not intended for human consumption.
Despite these risks, prescriptions for human ivermectin are dispensed in pharmacies.
Some are from doctors operating through dubious online groups offering telemedicine services, like Front Line Doctors. Burns warns people that these online options are a suspicious buyer’s market. “There are telemedicine sites that may not be reputable,” she said, and although telemedicine prescribing guidelines differ from state to state, during COVID “there is a lot of relaxation. to operate across state borders ”.
“If you are asked to fill out an online form that results in a prescription, that is a red flag,” she said.
The increased demand has led to shortages of ivermectin tablets in some pharmacies, which is a problem for people who actually need it for its approved treatment. With these shortages comes a glimmer of hope for pharmacists. “I’m reluctant to call a drug shortage useful,” said Michael Ganio, senior director of ASHP, but if a “pharmacy doesn’t have ivermectin in stock, it’s a black and white decision. “for the pharmacist not to fill it.
Pharmacists are not required to fill a prescription that they consider unsafe.
“It’s our responsibility as a profession to keep our patients safe, and whether the patient or the prescriber agrees with that is really not part of the equation,” said Ganio. This means checking the correct dosage, looking for potential interactions with other drugs, and refusing to give a drug when it is not prescribed for a valid medical reason. Ganio said he heard reports of doctors and patients giving pharmacists a hard time, but patients appear to move to the next pharmacy to find a source rather than arguing.
Some pharmacies have filled these prescriptions. Helen Lim, a pharmacist at a CVS near Los Angeles, said that at CVS, the company policy is to refuse people with prescriptions for ivermectin. But she noted that in large drugstore chains, staff fill such a volume of prescriptions that when it comes to requests for ivermectin, “sometimes it just just isn’t taken.”
Pharmacists who are asked to fill prescriptions for ivermectin should decline and respond by educating patients, Ganio said. “Pharmacists, who know the evidence and the guidelines, should be able to talk to the patient to help them understand the evidence, why it is not recommended, why it may be harmful. “
At her San Diego pharmacy, Lee explained to her patient that she was uncomfortable filling her prescription for ivermectin because the FDA had not approved her for this use. She said the same thing to the employee at her doctor’s office. Rather than a fight, the employee said he would simply send the prescription to another pharmacy.
“Ultimately,” said Lee, “it’s up to the pharmacist to dispense.”
Future Tense is a partnership between Slate, New America, and Arizona State University that examines emerging technologies, public policy, and society.
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