Below are questions that medSask has received with the corresponding response. As we know, COVID-19 is a rapidly evolving topic and information is subject to change. Keep the posted date in mind when looking at the information; it may be a good idea to go to the cited links as the information on those pages may have changed. We will do our best to update information, especially for the common questions.
Please note information is only current as of the date posted.
Canadian Pharmacists Association
- Landing Page
- Practice Resources
- Drug Therapy Resources
- Awareness Resources
- Health Canada approval of remdesivir for treatment of COVID-19
- CTC Chapter: Treatment of COVID-19
- Video for patients: 30-day supply
- Disruption of Immunization Schedules during the pandemic
- Webinar recordings
Saskatchewan College of Pharmacy Professionals
- Regulatory notices (e.g. Exemption to Section 56)
- Days supply limits
- Pharmacies compounding hand sanitizer
Summary of Practice Changes for Community Pharmacists during pandemic (includes example scenarios)
Government of Saskatchewan (including Ministry of Health)
- General info
- Testing, screening, medical directives
- Infection prevention and control
- Blood services
- Facility signage
- Self-assessment tool
- Testing information
- Public Health measures
Government of Canada (Including Health Canada)
- Canadian statistics
- Prevention and risk
- Symptoms and treatment
- Being prepared
- Travel advice
- Self-assessment tool
Non-Insured Health Benefits (NIHB)
A French study found that ~ 5% of the over 500 COVID-19 positive subjects who were inpatients and outpatients of a large university hospital were smokers whereas approximately 25% of France’s general population are smokers. This discrepancy led the researchers to investigate potential explanations. A proposed mechanism of action is that nicotine may act on cell receptors in nerves, immune cells, cardiac tissue, lungs, and blood vessels and block the coronavirus from entering these cells.
While these observations are interesting, they are just that – observations. This was an uncontrolled observational study in which many limitations have been identified. This study serves to generate hypotheses, which is an important step in science. However, it is inappropriate to apply results of such studies in the clinical setting until the results have been replicated in randomized controlled trials.
The researchers are reportedly planning a follow-up clinical study using nicotine patches, pending approval from French health authorities. This study will test nicotine patches in hospitalized COVID-19 patients and frontline health workers who currently smoke.
It is important to remember the proven hazards of smoking and the potential dangers of non-smokers using nicotine replacement products. Evidence indicates that cigarette smoking is harmful to the respiratory and immune systems and that it increases the risk and severity of infection. Smoking cessation is recommended to help combat any respiratory illness and COVID-19 is no exception. It would be dangerous for anyone to start or increase smoking in hopes of preventing or reducing severity of COVID-19 infection. Similarly, at this point, use of nicotine replacement products for the purpose of improving COVID-19 outcomes is not warranted.
Mothers who are infected with the SARS-CoV-2 virus can breastfeed with these precautions:
- wear a mask while breastfeeding
- wash hands before touching baby
- clean breast area with soap and water before each feeding
- if choosing to pump and feed with expressed milk: wash hands and clean all equipment before and after use
- disinfect frequently touched household surfaces
If mothers are too sick to breastfeed:
- expressed milk can safely be fed to the baby
Breastfeeding and COVID-19 (who.int)https://www.who.int/news-room/commentaries/detail/breastfeeding-and-covid-19
Please see PDF regarding pharmacist injections including considerations of:
- injections in general
- parenteral vitamin B12
- long-acting antipsychotic injections
Health Canada has published: Clinical management of patients with moderate to severe COVID-19 - Interim guidance
The National Institute for Health and Care Excellence (NICE) from the UK has published guidelines on CF, COPD and dermatological conditions treated with drugs affecting the immune response.
A couple of weeks ago, Health Canada was recommending against the use of cloth masks but now Health Canada and the Centers for Disease Control and Prevention (CDC) currently suggest the use of masks may be considered an additional measure that may slow the spread of COVID-19. However, the World Health Organization (WHO) recommends use only when caring for someone with suspected or confirmed COVID-19 or if coughing/sneezing.
Recommendations have been changing and are not consistent across organizations regarding the use of cloth masks when in public. As with many aspects of COVID-19, new research is emerging quickly and may point us in a different direction from previous recommendations. A lot of the research has many limitations meaning it is hard to know just what conclusions to take and, therefore, the differing of recommendations among different organizations.
However, agencies agree that:
- Physical distancing and hand hygiene are the most important measures to take to prevent the spread of COVID-19.
- Cloth masks may not protect the wearer from contracting COVID-19 but may protect others if the wearer unknowingly has COVID-19 (asymptomatic).
Reasons agencies had been reluctant to recommend the use of masks include:
- Masks may provide a false sense of security. Wearing a mask does not mean you can be closer to people and/or relax hand hygiene.
- Because people aren’t used to wearing a mask, they are more likely to touch it to adjust, which theoretically may increase the risk of infection. Resist the urge to touch the mask and maintain stringent hand hygiene.
However, so long as we remain cognizant of these points, masks may be effective tools to help slow the spread of COVID-19!
Masks need to be used properly. Be sure to understand correct use by visiting this site.
- wash hands both before putting on and before removing
- the mask needs to fit snugly and cover both the nose and mouth
- do not touch the mask or face while wearing
- change a cloth mask as soon as it gets damp or soiled
- put it directly into the washing machine or a bag that can be emptied into the washing machine and then disposed of
- cloth masks and face coverings can be laundered with other items using a hot cycle, and then dried thoroughly
- non-medical masks or face coverings that cannot be washed should be discarded and replaced as soon as they get damp, soiled or crumpled
- dispose of them properly in a lined garbage bin
- do not discard them in shopping carts, on the ground, etc.
- Non-medical masks or face coverings should not be placed on:
- children under age 2
- anyone who has trouble breathing
- anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance
Health Canada has instructions of how to make sewn and non-sewn masks.
At the moment, there is no specific information about how patients who are immunocompromised are affected by COVID-19. In general, these patients are at higher risk than the general population of contracting COVID-19 and at higher risk of more serious complications if infected by COVID-19.
The benefit provided by and the risk of infection from the immunosuppressant varies from patient to patient. Variables that contribute to the benefit and risk include:
- the immunosuppressant agent itself and the dose (immunosuppressants affect the immune system in different ways)
- the severity of the condition being treated
- other conditions that may increase a patient’s risk of infection
For the most part, patients should continue their immunosuppressive therapies unless otherwise discussed with the prescriber.
Patients should follow the practices recommended by public health agencies to reduce risk of infections:
- Wash hands often with soap and water; if soap and water are not available, use an alcohol-based hand sanitizer;
- Avoid touching eyes, nose and mouth with unwashed hands;
- Maintain safe food practices;
- Practice physical distancing
Should a patient become infected with COVID-19, the immunosuppressant may need to be temporarily stopped; however, this decision needs to be made in conjunction with the prescriber taking into account the variables discussed above.
Examples of medications that may be immunosuppressive can be found here.
Crohn’s and Colitis Canada – COVID-19 and IBD - Mar 18
British Society for Rheumatology – COVID-19 – update for members - March 22
European League Against Rheumatism – Guidance for Patients COVID-19 Outbreak - Mar 17
It’s hard to know in this environment just what drugs are shorted. The distributors are allocating most, if not all, drugs as a responsible measure to help maintain the integrity of the supply chain. Depending on your distributor, inventory available to you may be based on your historical ordering. However, it is understood product needs are not static. If you need an important product that you’ve not ordered in the past or a higher quantity than usual and it’s not available for you to order online, phone the distributor. It is possible the product is not available, in which case you’ll have to treat it as a drug shortage. (See: Drug Shortages Canada for details of the shortage; FAQ from Apr 2 re: general approach to drug shortages; and our Drug Shortages page). However, the distributor may be able to fulfill part or all of your requirements. McKesson has a new option on their phone system, “Critical Rx Emergency Requests”; customers can find more detail in the COVID update posted on PharmaClik, dated 06 Apr 2020.
What are the guidelines and recommendations for appropriate cleaning and disinfection of surfaces in community pharmacies during the COVID-19 pandemic?
Coronaviruses are enveloped viruses. This means they are one of the easiest types of viruses to kill with the appropriate disinfectant product when used according to the label directions.
The recommendations and information included below are general recommendations for cleaning and disinfection.
- SCPP has posted information regarding proper cleaning in the Infection Control Standards and Guidelines. The Guidelines are posted on the SCPP website, and can be found here: https://www.saskpharm.ca/document/5881/REF_Infection_Control_Guidelines.pdf
SCPP: Best Practices: Cleaning of Environmental Surfaces
- Surfaces in the patient care environment (e.g. patient care room, drop off/pick up counters and waiting area) and high-touch surfaces (e.g doorknobs, telephones, computer keyboards, cash registers, pens) must be cleaned and disinfected at least daily;
- Low touch surfaces (e.g. floors, walls and windowsills) can be cleaned and disinfected on a less frequent schedule compared to other surfaces;
- Spills of blood or other body fluids should be promptly cleaned and disinfected
Note: It is most important that an item or surface be free from visible soil and other items that might interfere with the action of the disinfectant (e.g. adhesive products), before a disinfectant is applied, or the disinfectant may not work. Most disinfectants lose their effectiveness rapidly in the presence of organic matter.
Cleaning prior to disinfection will remove the visible soil and ensure the effectiveness of the disinfection step. Products can be purchased with cleaner and disinfectant combined in a single product.
SCPP: Appropriate Cleaning and Disinfection Products
- Detergent and water are adequate for cleaning surfaces
- Low and Intermediate level disinfectants are suitable for most pharmacy. Equipment and surfaces examples include:
- Ethyl or Isopropyl alcohol (70-90%);
- Ethyl or Isopropyl alcohol (70-90%);
- Sodium Hypochlorite (5.25-6.15% household bleach diluted 1:50 provides 1000ppm available chlorine);
- Phenolic, Iodophor or Quaternary Ammonium germicidal detergent solutions (follow product labels for use-dilution);
- 3% Hydrogen Peroxide or 0.5% Improved Hydrogen Peroxide;
- In choosing a disinfectant product, use broad-spectrum virucide-labeled disinfectants with a Drug Identification Number (DIN). Health Canada has a list of disinfectants for use against COVID-19 which can be found here: https://www.canada.ca/en/health-canada/services/drugs-health-products/disinfectants/covid-19/list.html
The Environmental Protection Agency (EPA) in the US also publishes a list of disinfectants which can be found here: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
- When using a disinfectant product, follow product instructions for dilution, wet contact time, and safe use.
- For a concise chart outlining the use, advantages and disadvantages of various low-level disinfectants, see Public Health Ontario – Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings (Page 108) . This document can be found here: https://www.publichealthontario.ca/-/media/documents/bp-cleaning-disinfection-sterilization-hcs.pdf?la=en#page=108
- Public Health Ontario also has a helpful document that speaks to environmental cleaning of clinical spaces. This document deals with disinfectants used on noncritical equipment and hard surfaces. The document can be found here: https://www.publichealthontario.ca/-/media/documents/bp-environmental-cleaning.pdf
We have been using isopropyl alcohol to clean surfaces in the pharmacy. Is it ok to spray surfaces with isopropyl alcohol and then wipe?
Alcohol solutions (including ethyl alcohol and isopropyl alcohol) ranging from 60-95% are effective disinfectants. Generally, disinfection is achieved after 10 minutes of contact**. This may be a problem for alcohol given that it evaporates quickly and immersion/soaking may be required. Since alcohol is flammable, limit its use as a surface disinfectant to small surface-areas and use it in well-ventilated spaces only.
Advantages of isopropyl alcohol include:
- Non-toxic • Low cost • Rapid action • Non-staining • No residue • Effective on clean equipment/devices that can be immersed
Disadvantages of isopropyl alcohol include:
- Evaporates quickly - not a good surface disinfectant • Evaporation may diminish concentration • Flammable - store in a cool well ventilated area • a poor cleaner • Harmful to silicone; causes brittleness • May harden rubber or cause deterioration of glues • Inactivated by organic material
Source: Provincial Infectious Diseases Advisory Committee (PIDAC), Public Health Ontario - https://www.publichealthontario.ca/-/media/documents/bp-environmental-cleaning.pdf
What are the recommendations for using household bleach to clean surfaces?
The recommendation is to use household bleach diluted to 1000ppm available chlorine. Sodium Hypochlorite (5.25-6.15% household bleach diluted 1:50 provides > 1000ppm available chlorine). For disinfection by wiping of nonporous surfaces, a contact time of ≥ 10 minutes is recommended**. It is recommended to allow the surface to air dry naturally.
The WHO has the following information for using bleach in health care settings:
Procedures for preparing and using diluted bleach
To prepare and use diluted bleach:
- use a mask, rubber gloves and waterproof apron; goggles also are recommended to protect the eyes from splashes;
- mix and use bleach solutions in well-ventilated areas;
- mix bleach with cold water (hot water decomposes the sodium hypochlorite and renders it ineffective);
Precautions for the use of bleach
- Bleach can corrode metals and damage painted surfaces.
- Avoid touching the eyes. If bleach gets into the eyes, immediately rinse with water for at least 15 minutes, and consult a physician.
- Do not use bleach together with other household detergents, because this reduces its effectiveness and can cause dangerous chemical reactions. For example, a toxic gas is produced when bleach is mixed with acidic detergents, such as those used for toilet cleaning. If necessary, use detergents first, and rinse thoroughly with water before using bleach for disinfection.
- Undiluted bleach emits a toxic gas when exposed to sunlight; thus, store bleach in a cool, shaded place, out of the reach of children.
- Sodium hypochlorite decomposes with time. To ensure its effectiveness, purchase recently produced bleach, and avoid over-stocking.
- If using diluted bleach, prepare the diluted solution fresh daily. Label and date it, and discard unused mixtures 24 hours after preparation.
- Organic materials inactivate bleach; clean surfaces so that they are clear of organic materials before disinfection with bleach.
- Keep diluted bleach covered and protected from sunlight, and if possible in a dark container, and out of the reach of children.
How should electronics be cleaned?
Here is some additional information about cleaning specific to electronics:
Follow manufacturer’s instructions for use for specific recommendations. Generally:
- Use a disposable soft, non-abrasive, lint free damp cloth or wipe, pre-moistened with a disinfectant.
- Squeeze out excess liquid before use.
- Never spray products directly onto electronic devices
Examples of disinfectants that may be indicated in the manufacturer’s instructions for use:
- Alcohol swabs and wipes (often used for phones, computer mouses, pagers)
- Combination products such as alcohol/quaternary ammonium e.g. CaviWipes®
- Hydrogen peroxide products such as accelerated hydrogen peroxide (AHP) products e.g. Percept Wipe®
Example of a product not usually recommended:
- Sodium hypochlorite (bleach) as it can be corrosive to metals at high concentrations
Do not use compressed air to clean electronic devices as this may aerosolize debris and microorganisms.
Note that cleaning wipes such as CaviWipes®, Lysol®, and Green Works® may leave a residue which can compromise the keys and affect the internal electronics.
Source: Alberta Health Services - https://www.albertahealthservices.ca/assets/healthinfo/ipc/if-hp-ipc-cleaning-disinfection-info.pdf
**Note: Contact times provided are to ensure adequate disinfection for a variety of microorganisms. Data specific to coronavirus suggests that required contact time with alcohol and bleach solutions may be less (9), however given the limited evidence, best practice would suggest using usual Infection Prevention and Control guidelines.
- Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents. Journal of Hospital Infection. 2020 Feb 6.
At medSask, we are working hard to develop documents to help you manage drug shortages during the COVID-19 pandemic. Our existing documents can be found on our website at https://medsask.usask.ca/professional-practice/drug-shortages.php. Specific information about specific medications may not be available yet, so a general process may be applied as follows:
- Ensure there is a valid indication for the drug.
- Substitute a different brand of the same drug:
- Check the Saskatchewan Prescription Drug Plan (SPDP) Formulary for interchangeable brands of the same drug.
- Check the Formulary for a non-interchangeable brand of the same drug in the same dosage form.
- Check Health Canada Drug Product Database for other brands that may be available.
- Check for alternative dosage forms of the same drug.
- Compounding capsules or tablets in the desired doses when other strengths of drug are available or from bulk powders may be another option, especially in instances where there is not a readily available, acceptable substitute or therapeutic equivalent.
- If no other forms of the same drug are available, substitution of another drug in the same therapeutic class can be considered. Check the references below for dose equivalence data, however, this information is not always available:
- If there is not a therapeutic equivalent, check treatment guidelines and recommend a drug from another pharmacologic class.
- Dynamed – includes a specific link to guidelines within therapeutic topics (available at SHIRP)
- With any change to drug therapy, monitor patient for any potential adverse effects or change in desired effect.
CPhA has a guide for assessing and managing drug shortages that provides a detailed description and “checklists” to work through. The guide can be found at: http://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/DrugShortagesGuide.pdf
Other Important Resources to consider:
- Drug Shortages Canada – mandatory drug shortage and discontinuation reporting website
- Canadian Pharmacists Association
Resources for shortages identified during COVID-19 pandemic:
- RxFiles Asthma Chart includes Inhaled Corticosteroids dose equivalency chart
- eCPS: Asthma in Infants and Children; Asthma in Adults and Adolescents; Chronic Obstructive Pulmonary Disease. (available at SHIRP)
- RxFiles ASTHMA & COPD: Inhalation Devices Chart outlining pros and cons of devices
- ISMP Safety considerations and counselling tips for newer inhalation devices
As with all other treatment options, there is not enough evidence to support the use of either hydroxychloroquine or azithromycin, alone or in combination, for the treatment of COVID-19. Colleagues at Tools for Practice have nicely summarized:
"One nonrandomized study found that more hydroxychloroquine/azithromycin patients tested negative for virus at days 3 and 6 but clinical outcomes were not reported. One unblinded randomized trial showed no effect from hydroxychloroquine on viral or clinical outcomes. Without further evidence, hydroxychloroquine is not appropriate for patients with COVID-19 in primary care.”
A joint statement from several Saskatchewan healthcare regulatory bodies has been published reminding practitioners of the lack of evidence and potential for further drug shortage exacerbation if these drugs are used for COVID-19.
8 Apr 2020 - Review of safety concerns of chloroquine, hyroxychloroquine and azithromycin
No. There is no evidence that any supplements or natural health products are effective at preventing or treating symptoms of COVID-19.1 This includes, but is not limited to zinc, essential oils, colloidal silver, plant-based elixirs and formulas, Chaga mushroom blends, ultraviolet lamps, and oregano oil. In fact, the Government of Canada is warning Canadians against taking such products with false or misleading claims.
Your best prevention measures are to reduce risk of transmission (spreading) and to practice healthy behaviours.
Ways to reduce risk of transmission:
- Wash your hands often with soap and water; if soap and water are not available, use an alcohol-based hand sanitizer;
- Practice physical distancing including avoiding unnecessary outings from your house;
- Practise proper cough and sneezing etiquette (into the bend of your elbow);
- Avoid touching your eyes, nose and mouth with unwashed hands;
- Maintain safe food practices; and
- Avoid close contact with people who are sick.
Some healthy behaviours:
- Try to choose nutritious foods. Not sure what that looks like? Eat Well Saskatchewan is a great resource for Saskatchewan residents.
- Be active. Adults should try to be active for at least 150 minutes per week. Kids need more!
- Look online for activities/workouts that interest you that can be done at home.
- Go for a walk, run, rollerblade, bike ride, etc. by yourself or with members of your household.
- Pay attention to your mental health and use resources to help you cope.
- Keep physical distance but stay in touch virtually with your friends and family.
1. Examine.com. Coronavirus disease 2019 (COVID-19).©2011-2020. [updated 27 Mar 2020; cited 27 Mar 2020]. Available at www.examine.com
There is no good evidence at this time to suggest that NSAIDs are causal in worsening COVID symptoms. The idea originated in France from the health minister suggesting that there were grave adverse effects with taking NSAIDs. His comments seem to have stemmed in part from remarks attributed to an infectious diseases doctor in south west France. She was reported to have cited four cases of young patients with covid-19 and no underlying health problems who went on to develop serious symptoms after using non-steroidal anti-inflammatory drugs (NSAIDs) in the early stage of their symptoms.
- Using a medication to reduce fever does not improve or shorten the duration of fever. These agents provide comfort; fever rarely needs to be treated.
- If it is decided to treat fever, until further information is available, preferentially use acetaminophen (Tylenol®) if possible.
- For those already using non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation who develop COVID, weigh the risk versus benefit. The risk of NSAIDs worsening COVID is unproven at this time and based on observation of very few patients; research is actively taking place. NSAIDs do not provide pain relief in everyone and it may be reasonable to discontinue the NSAID (in consultation with doctor or nurse practitioner if it has been prescribed) to determine if it has been helping and/or if other modalities such as massage and exercises can provide similar benefit.
Mar 20 – Health Canada - No scientific evidence that ibuprofen worsens COVID-19 symptoms
Mar 18 – Therapeutics Initiative - Acetaminophen vs. NSAIDs during Covid-19 pandemic
Mar 17 - Canadian Pharmacists Association - Use of NSAIDs in patients with COVID-19: what is the evidence?
April 23 New information:
There is now data from a Chinese study indicating that hospitalized COVID-19 patients with hypertension and on an ACE inhibitor or an ARB had lower risk of all-cause mortality than patients on other antihypertensive medications. This was not a randomized study and more studies are needed to confirm findings.
Angiotensin converting enzyme inhibitors (ACEIs) such as ramipril (Altace), perindopril (Coversyl) and trandolapril (Mavik) as well as angiotensin receptor blockers (ARBs) such as candesartan (Atacand), losartan (Cozaar) and valsartan (Diovan) are agents commonly used in patients with high blood pressure, heart failure, diabetes, and other conditions.
Concerns have been raised on social media that those taking ACEIs or ARBs may be at increased risk of infection and increased risk of more serious complications from COVID-19 compared to the general population. This idea is based on principles of how the medications work and preliminary information about changes that may take place during COVID-19 infection. (See below for more details.)
There is no evidence that those taking ACEIs or ARBs are at any increased risk from COVID-19 and these medications should be continued.
Several agencies and organizations have published statements including:
Hypertension Canada’s Statement on: Hypertension, ACE-Inhibitors and Angiotensin Receptor Blockers and COVID-19. 13 Mar 2020
HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19. 17 Mar 2020
International Society of Hypertension. A statement from the International Society of Hypertension on COVID-19.
European Society of Cardiology Council on Hypertension. Position statement of the ESC Council on Hypertension on ACE-inhibitors and angiotensin receptor blockers. 13 Mar 2020
More detail about the proposed mechanism:
The Council on Hypertension of the European Society of Cardiology states that “Based on initial reports from China, and subsequent evidence that arterial hypertension may be associated with increased risk of mortality in hospitalized COVID-19 infected subjects, hypotheses have been put forward to suggest potential adverse effects of angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). It has been suggested, especially on social media sites, that these commonly used drugs may increase both the risk of infection and the severity of SARS-CoV2 (the virus that causes COVID-19). The concern arises from the observation that, similar to the coronavirus causing SARS, the COVID-19 virus binds to a specific enzyme called ACE2 to infect cells, and ACE2 levels are increased following treatment with ACEIs and ARBs. This speculation about the safety of ACEI or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it. Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.”1
1. European Society of Cardiology Council on Hypertension. Position statement of the ESC Council on Hypertension on ACE-inhibitors and angiotensin receptor blockers. [13 March 2020; cited 19 Mar 2020] https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang