Saskatchewan Drug Information Services (SDIS)

Guidelines for Minor Ailment Prescribing

I Background

The Pharmacy Act, 1996 was originally amended effective September 1, 2003 giving pharmacists authority to prescribe drugs which at that time 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, stakeholders from various groups involved in drug management (e.g. physicians, nurses, dentists, pharmacists, etc.) were involved in the Advisory Working Group which developed the policies for pharmacist prescribing. The Saskatchewan College of Pharmacists Council approved these policies and drafted the regulations and bylaws awaiting ministerial approval.

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 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.

II Developing the Minor Ailment Guidelines

The Saskatchewan Drug Information Service was contracted by the Saskatchewan College of Pharmacists to prepare the Minor Ailment guidelines. The first step was to review the literature and consult 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 the conditions and drugs which would be appropriate for the Saskatchewan minor ailment program. The results from the group meetings are summarized below.

Criteria for Minor ailment conditions

• Can be reliably self-diagnosed by patient
• Self-limiting condition
• Lab 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

Criteria for prescription drugs suitable for pharmacist prescribing for patient minor ailments

• Has an official indication for the self-care condition
• 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 conditions

TABLE 2: Schedule I drugs appropriate for prescribing by pharmacists for self-diagnosed recurrences of specified conditions after initial diagnosis 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.

III Guideline Format/Content

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, Saskatchewan Drug Information Service
April 28, 2010