The Pharmacy Act, 1996 was amended effective September 1, 2003 giving pharmacists authority to prescribe drugs. At that time pharmacist prescribing was limited to emergency contraception. On March 3, 2010 the Saskatchewan Minister of Health announced his intention to approve regulations and bylaws expanding this authority to other drugs. In the meantime, an Advisory Working Group made up of stakeholders from various areas of drug management (e.g. physicians, nurses, dentists, pharmacists, etc.) developed policies for pharmacist prescribing. The Saskatchewan College of Pharmacists Council approved these policies and drafted corresponding regulations and bylaws. Ministerial approval for enhanced authority for pharmacist prescribing was subsequently granted.

Level 1 of enhanced prescribing authority for pharmacists includes the provision for pharmacists to prescribe Schedule 1 drugs for the treatment of minor, self-limiting and self-diagnosed ailments such as rashes, cold sores and hay fever. Similar minor ailment models have been piloted and implemented in Great Britain within the past decade. Preliminary data from Great Britain suggests that these programs have increased access for the public to healthcare for minor ailments, increased access to physicians for patients with more serious conditions and reduced costs to the national healthcare system. In Nova Scotia, legislation approving expanded prescribing authority for pharmacists including prescribing for minor ailments has just been passed. Similar programs are being considered in many other Canadian provinces.

In a minor ailment program, the pharmacist is the first point of contact for the patient. The patient approaches the pharmacist for advice about treatment of a self-diagnosed condition. If the self-diagnosis is reasonable based on the pharmacist’s assessment and the best treatment option in the pharmacist’s judgement is a Schedule 1 drug, the pharmacist can initiate a prescription. If the pharmacist is unable to confirm the patient’s diagnosis and / or the patient’s symptoms are severe, the pharmacist will refer the patient to a physician or other appropriate healthcare provider. The prescribed drug must be (1) listed in minor ailment guidelines and (2) have an approved indication for the patient’s self-diagnosed condition. The pharmacist is required to record the prescription with the Pharmaceutical Information Program and to notify the patient’s physician of the prescription. Physician or other practitioner authorization is required for repeat or maintenance therapy for most conditions.

The Saskatchewan Drug Information Service (now medSask) was contracted by the Saskatchewan College of Pharmacists to prepare the Minor Ailment guidelines. The first step involved reviewing the literature and consultation with other Canadian pharmacy organizations. From this information, a list of conditions that could potentially qualify as minor ailments and a list of prescription drugs that might be suitable for patient self-care of these conditions were compiled. The next step was consultation with Saskatchewan community pharmacists through nominal group meetings; the first in Saskatoon, Jan. 5th, 2010 and the second in Regina. Jan. 12th, 2010. The groups were asked to (1) select criteria to define minor ailments and prescription drugs appropriate for pharmacists to prescribe for these conditions and (2) to apply these criteria to select specific conditions and drugs to be included in Saskatchewan minor ailment program. The results from the group meetings are summarized below.

Suggested criteria for Minor Ailment conditions

  • Can be reliably self-diagnosed by patient
  • Self-limiting condition
  • Laboratory tests are not required for diagnosis
  • Treatment will not mask underlying conditions
  • Medical and medication histories can reliably differentiate more serious conditions
  • Only minimal or short-term follow-up needed

Suggested criteria for prescription drugs suitable for pharmacist prescribing for patient minor ailments

  • Has an official indication for the self-care condition (2018 update: may use certain products off label if reputable guidelines support the use)
  • Has valid evidence of efficacy for the self-care condition
  • Has wide safety margin
  • Not subject to abuse
  • Dosage regimen for treatment of self-care conditions is not complicated

 Using these criteria, the conditions and Schedule I drugs listed in Table 1 were considered appropriate for the Minor Ailment program.

TABLE 1: Schedule I drugs appropriate for prescription by pharmacists for specified minor ailment or self-care conditions

System

Condition

Drug Class

Specific Rx Drug

CNS

Headache and Migraine

NSAIDs

ibuprofen all strengths
naproxen all strengths
diclofenac

Triptans

(Appropriate for self-diagnosis of recurrences but initial diagnosis should be made by physician)

almotriptan
naratriptan
rizatriptan
sumatriptan
zolmitriptan
eletriptan (non-formulary)
frovatriptan (non-formulary)

Eyes, Ears, Oral

 

 

 

Cold sore

Antivirals (topical, oral)

acyclovir cr/oint/oral
famciclovir 
valacyclovir

Mouth ulceration
(mild)

Corticosteroids (dental)

triamcinolone dental paste

Oral thrush

Antifungals (oral)

nystatin drops

Dermatology

Acne (mild – mod.)

Benzoyl peroxide

benzoyl peroxide (BP) up to 10 %

Antibiotics (topical)

clindamycin phosphate
clindamycin / BP
clindamycin / tretinoin
erythromycin / BP
erythromycin / ethyl alcohol /avobenzone/octinoxate  
erythromycin / tretinoin

Retinoids

adapalene cr 0.1%, 0.3%; gel 0.1%
adapalene 0.1%/BP 2.5%
tazarotene 0.05%,0.1% cr or gel
tretinoin cr or gel all strengths 
tretinoin/avobenzone/octinoxate cr all strengths

Atopic dermatitis (mild – moderate)

Corticosteroids, low  - moderate potency (topical)

hydrocortisone cream 1 %, 2.5 %
desonide 0.05 %
betamethasone valerate
clobetasal butyrate
diflucortolone valerate
hydrocortisone valerate
mometasone furoate
triamcinolone acetate

Diaper rash

Antifungal / corticosteroids (topical)

clotrimazole hydrocortisone 1 % cr / oint

Insect bites

Mild corticosteroids

hydrocortisone 1 % cr/oint

Skin infections
(bacterial)

Antibiotics (topical)

fucidic acid cr/oint
mupirocin cr/oint

Tinea infections (athlete’s foot, jock itch, ringworm)

Antifungal (topical

terbinafine 1 % cr
ketaconazole 2 % cr

Gastrointestinal

Dyspepsia / GERD

H2 Receptor antagonists

cimetidine 300, 400, 600 mg
famotidine 40 mg
nizatadine 150, 300 mg
ranitidine 150, 300 mg

PPIs

esomeprazole 20, 40 mg
lansoprazole 15, 30 mg
omeprazole 10, 20 mg
pantoprazole 40 mg
rabeprazole 10, 20 mg

Hemorrhoids

Corticosteroid combinations (rectal)

HC / zinc sulphate
HC /  zinc sulfate, pramoxine

Genitourinary

Dysmenorrhea

NSAIDs

celecoxib
diclofenac
ketoprofen
mefenamic acid
naproxen sodium

Musculoskeletal

Pain

NSAIDS

diclofenac
diclofenac/misoprostol
naproxen

Cox-2 Inhibitors

celecoxib
meloxicam

Respiratory

Allergic rhinitis

Intranasal antihistamine

levocabastine

Intranasal corticosteroids

beclomethasone
mometasone furoate
fluticasone proprionate

TABLE 2: Schedule I drugs appropriate for pharmacists to prescribe under the circumstances described below:
NOTE: SASKATCHEWAN PHARMACISTS ARE NOT CURRENTLY AUTHORIZED TO PRESCRIBE FOR PHARYNGITIS ALTHOUGH THIS 
CONDITION HAS BEEN APPROVED IN PRINICIPLE BY THE SASKATCHEWAN COLLEGE OF PHARMACY PROFESSIONALS COUNCIL

a) Self-diagnosed recurrences of specified conditions after initial diagnosis or assesment for underlying conditions by physician or nurse practitioner

  • Conditions
    • Uncomplicated lower urinary tract infection (UTI)
    • Erectile dysfunction (ED)
    • Onychomycosis
  • Patient history of previous medical diagnosis of condition and assessment of risk factors is a requirement before pharmacists can prescribe for these conditions, otherwise the patient must be referred to a medical doctor or nurse practitioner (or podiatrist in case of onychomycosis) for initial evaluation and diagnosis.
  • There is limited information on the length of time a prior diagnosis or assessment would be valid, so this will be left up to the judgement of the pharmacist. (For example, anecdotal reports suggest women who have had a previously confirmed episode of UTI would be able to recognize symptoms of a recurrence many years after the initial occurrence.)
  • Check PIP and/or pharmacy records) for medication used to treat previous episodes.
  • Check eHR Viewer if lab tests, culture results are relevant to prescribing.

b)  Pharmacists have access to additional training on assessment and prescribing criteria for these conditions

  • Conditions
    • Pharyngitis
    • Influenza
    • Conjunctivitis
    • Shingles
  • Training on throat swab technique and analysis, relevant physical assessment and antimicrobial stewardship prescribing guidelines for these conditions will be provided for pharmacists.
  • Pharmacist prescribing of oral antiviral agents will be authorized ONLY during an epidemic or pandemic declared by the Chief Medical Health officer for Saskatchewan

 c) Health promotion / wellness services

  • Conditions
    • Contraception, ongoing: hormonal contraceptives (HC)
    • Emergency contraception (EC)
    • Obesity
    • Smoking cessation
  • Comprehensive training on assessment, prescribing and monitoring of HCs, providing EC and family planning counselling (including long acting reversible and permanent contraceptive options) will be provided for pharmacists. When non-hormonal contraception is the most appropriate or preferred option, the patient will be referred to a medical doctor or nurse practitioner.
  • Prescribing for smoking cessation or obesity should be part of an overall lifestyle change program for smoking cessation (e.g., PACT) or weight loss whenever possible to increase the likelihood of successful therapy.

Condition

Drug Class

Specific Rx Drug

Comments

Conjunctivitis, allergic

Antihistamines, mast cell stabilizers (Ophth)

 

ketotifen drops
olapatadine drops
lodoxamide drops
nedocromil drops

Concern about patient ability to differentiate between bacterial and allergic conjunctivitis

Conjunctivitis, bacterial

Antibiotics (Ophth)

erythromycin oint.
trimethoprim-polymixin drops
tobramycin oint., drops

As above. Anecdotal reports of resistance to gentamicin ophthalmic drops.

Contraception, emergency

levonorgestrel
ulipristal acetate

Contraception, ongoing

Hormonal contraceptives

combined estrogen/progestin: oral, dermal patch, vaginal
Progestin-only oral

Erectile dysfunction

PDE inhibitors

sildenafil
tadenafil
vardenafil

Concerns about recreational use, abuse.

Herpes zoster (Shingles)

Antivirals (oral)

acyclovir
famciclovir 
valacyclovir

Suggested as possibly appropriate. No precedent found in the literature

Influenza treatment / prophylaxis

Antivirals

oseltamavir
zanamavir

Concerns about inappropriate use, resistance

Obesity

Lipase inhibitor

orlistat

Obesity not considered a self-limiting condition

Onychomycosis

Antifungal, topical

efinaconazole

Medical guidelines recommend microscopy of nail scrapings to diagnosis and culture if uncertainty

Pharyngitis (Sore throat)

Local analgesics
Antibiotics

benzydamine
penicillin V
amoxicillin
cephalexin
clindamycin
clarithromycin
azithromycin

Concern regarding masking strep throat

Urinary tract infections in women

Antibiotics

co-trimoxazole
fosfomycin tromethamine
nitrofurantoin
trimethoprim

Appropriate for self-diagnosis of recurrences but initial diagnosis should be made by physician.


Participants in the group meetings suggested that the following information should be included in the guidelines:

  • Information used by physicians for diagnosis
  • Time frame for follow-up with patients
  • When to refer patients to family physician
  • Comparisons of drug efficacy, side effects, etc. to help in choice of drug to prescribe.
  • Age restrictions
  • Drug dosage protocols
  • Limitations on quantity of drug prescribed / duration of treatment.

The purpose of the guidelines is to provide community pharmacists with tools to facilitate the decision-making and documentation processes of prescribing for minor ailments self-diagnosed by patients. Each guideline consists of three documents; (1) an overview of pathophysiology, patient assessment and treatment for each condition (2) a treatment algorithm and (3) an assessment and treatment checklist.

1. Overview

  • Brief description of pathophysiology and epidemiology of condition
  • Common symptoms - To assess patient self-diagnosis.
  • Differential diagnosis / when to refer – alternative diagnoses, patient characteristics (e.g. age, concurrent medical conditions), red flag symptoms that could indicate more serious conditions 
  • Non-pharmacological treatment
  • Over-the-counter drug options
  • Schedule 1 drug options appropriate for pharmacist prescribing – points to consider in choosing which agent to prescribe
  • Advice/Monitoring parameters  - special directions for use, onset of effect, when to follow-up with patient, when to refer to physician, advice on prevention, etc.

2. Algorithm

  • Visual treatment decision tree for quick reference

3.  Pharmacist Assessment / Treatment Checklist

  • Checkbox list of criteria for diagnosis confirmation, physician referral and choice of treatment (recommendations and / or prescription)
  • Can be copied to fax to physician
  • Can serve as documentation of patient intervention

Document prepared by Karen Jensen MSc, BSP
Manager, medSask
Updated  Oct 31, 2018