60-day dispensing – will it be a disaster?

Imagine this, here is your medication for the year. Now imagine if you get two slices of cake instead of one? You will only need to go back for more cake six times a year rather than 12, but you still get the same amount of cake.

Cake is probably not a good analogy as some people may choose to eat it all at once!

Back in August 2018, the Pharmaceutical Benefits Advisory Committee (PBAC) was asked to consider two matters

  • increasing the supply of some medication to 12 months instead of the current 6 months, and
  • to increase the maximum dispensed quantity from one month to two month’s supply.

Following discussion, PBAC recommended, based on both clinical safety and cost-effectiveness, that 143 medications used to treat stable chronic conditions (eg., heart disease, hypertension, dyslipidemia, HRT, glaucoma) would be suitable for 60 day supply. PBAC also acknowledged the financial and convenience benefit for patients. The choice of writing 30 or 60 day prescriptions would be left to the prescriber.

Research suggested that longer prescriptions may improve compliance. This systematic review by King, et al in 2018 concluded “There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions.” This makes sense if you run out medication then the inconvenience of getting more may outweigh the decision to continue. A study by Batal, etal from Colorado in 2007, found 60-day statin dispensing produced lower lipid levels compared to 30 day dispensing. Every time you run out of medication there is an opportunity to make it permanent.

So what happened to 2018 recommendation?

In 2019, on the back of Pharmacy Guild lobbying, the then Health Minister Greg Hunt scrapped the plan. The Guild was worried about loss of dispensing fees and less frequent pharmacy visits. Just to be clear the Pharmacy Guild is a lobby group representing the financial interests of retail pharmacy owners.

Reported in the Sydney Morning Herald of March 2019 “

“In a strongly worded email to members on Wednesday night, the Guild’s president George Tambassis said the changes would have “a devastating impact on the viability of community pharmacy businesses” and came “without any consultation”. The Guild, according to The Herald Sun last week, had apparently been so enraged by the 60 day dispensing threat, it donated $250,000 to the Victorian branch of the ALP and asked it be used to fund a campaign against Mr Hunt in his Flinders electorate during the 2019 Federal election.

How can the Pharmacy Guild have such a sense power with politicians? Some would say it due to donations to political parties. This article “How and why the Pharmacy Guild is so good at leaning on politicians” documents the amount of donations in 2020 to be $770,000. This is to both the major political parties, and some of the minor parties such as One Nation and Katter’s Australian Party. This article in The Conversation looks further into the history of the Pharmacy Guild lobbying politicians.

Move ahead to 2023, and 60 day dispensing is back in the news. In fact come September 1st, it will become a reality for some PBS prescriptions as announced by the Labor Health Minister Hon Mark Butler. He goes on to say,

“This reform delivers important cost of living relief to Australians, and every dollar saved by the Government will be reinvested straight back into community pharmacies to secure the ongoing strength of the sector and ensure our trusted pharmacists play an even larger role in the healthcare of Australians.”

This means that instead of paying the monthly dispensing fee of $7.82 paid every month to the pharmacy, it will be paid every 2 months. This is a saving of $46.92 over 12 months. Several articles suggest the savings for an average patient will be $160 per year

The Consumer Health Forum of Australia think it a good idea, “Every dollar saved at the pharmacy is money that can be spent on groceries or rent.”

If you listen to the propaganda from the Pharmacy Guild, this simple change is expected to cause the sky fall in the pharmacy in Australia. For examples, closure of pharmacies, loss of 100’s of jobs, further shortages of essential medication, hoarding, increased wastage of medication, increase in overdoses, in fact the current Guild president, Trent Twomey, has even, tearfully, expressed his feelings about an uncaring Government.

Now thinking through some of the Guild claims

60 day dispensing is only an option for stable and chronic medication. Patients will not get 60 days of antibiotics and analgesia. Anyone who prescribed 60 days of antidepressant medication to a patient who is suicidal is likely to be in hot water.

I know from my previous job in a Poison Information Centre, that small children do occasionally get into a grandparent’s medication cabinet. To minimise harm, medication is required to be supplied in a child-proof containers or blister packs. Most grandparents know to keep medication safe from small visitors. Have a read of this article from the Raising Kids Network if your need a reminder. If you want to make your house even safer read this Safety Checklist from the NSW Poisons Information Centre.

Hoarding already happens, clearly shown in this photo of someone’s mediation form a home medication review pharmacist visit.

I have also seen medication wastage when people return unused bottles of medication no longer required. The RUM Project do a great service removing unwanted medications from home medication cabinets. Inevitably, there maybe some increase in wastage of medication needs to be changed. That is why the 60 day dispensing applies only to stable and chronic medication. Returning to evidence, King et al study did suggest there is “some evidence from six studies that longer prescriptions are associated with increased medication waste, but the results were not always statistically significant and are of very low quality.”

What can be done to prevent it? I can look at MyHR and if I see 25 dispensings in 12 months, I can ask the patient why? Can’t this be checked at the time of dispensing? I can ask a patient to bring in all their tablets when I do a care plan review. When I do, I often get a surprise to discover the number of often costly herbal, vitamins alternative medication a patient may also be taking. And yes, sometimes multiple boxes of the same medication.

How to overcome hoarding? Should patients pay more for medication, obviously not a popular suggestion given the patient contribution has only been dropped $30. Highlighting the actual cost of medication may make patients respect the value of medication.

I do think that seems wasteful to just throw away these medications. Maybe we need to rethink this strategy, after all if a capsule or tablet is still in date and sealed in a blister pack surely it can be reused. If the is returned there is the ethical dilemma is can a pharmacist resell it to someone else? There is also the unsolved historical tampering of Tylenol capsules with potassium cyanide back last century.

Surprisingly, your doctor can already prescribe 60 or 90 or 120 days (or more) of medications. You can already get four months of the oral contraception on a PBS prescription. Some medication may be cheaper to get as a private prescription in 60 days or more pack size. For example Chemist warehouse will sell 30 Omeprazole for $7.99 whether you have a private or PBS prescription. So for medication which are under the $30 threshold, a private prescription may be a cheaper alternative.

The specter of empty shelves has been raised. But come September 1st, there will be no tsunami of new prescriptions when everyone comes in with a 60 day prescription. As Minister Butler points of the 325 medicines affected “only seven of them are experiencing supply shortages” Today, I prescribed 12 acute care scripts and 16 chronic disease scripts of which 14 would be suitable for 60 days supply, and 4 Webster scripts which where it wont make a difference to stock levels. That was a typical day prescribing for me.

For an explanation as to why Australia has drug shortages this article form the Medical Republic discusses where we sit in the global pharmaceutical supply chain. In October 2022, the PBS introduced a Medicines Supply Security Guarantee. Manufacturers will be required to hold a minimum of either 4 or 6 months’ of stock in Australia. The 60-day dispensing change may mean that this may strategy need to be tweaked.

60 day dispensing means less foot traffic which may less opportunity for those incidental sales. But if you really need a hair dye, perfume or vitamin you can always make another journey. Have you ever wondered why the retail pharmacy dispensary is at the back of the shop? It’s a bit like Coles and Woolworths putting the milk against the back wall. You have to pass claustrophobia-inducing aisles of shampoo, dental treatments, toilet paper, nappies, hair dyes and vitamins before you get to the dispensary. IN many pharmacies you then have to walk back to the front counter to pay. Did I forget the sunscreen? Pharmacy makes profit on more than just dispensing, in fact given the size of the shelves in some, I think that the front of shop provides more profit.

The Pharmacy Guild of Australia has conducted a financial analysis on the the lost profitability and estimate $170,000 per annum will be lost. I’m not convinced that loosing $46.92 over 12 months per patient really equates to that. I doubt their workings will be made public.

Someone suggested that the pharmacies will need to but an extra fridge and expand dispensary shelves. There is a small number of medications on the PBS list that need to be kept cold, correct me but I spotted dulaglutide and semaglutide (which are routinely in short supply) and calcitonin and teriparatide injections (which I have never prescribed)

Patients who are disabled, don’t have access to transport or distant from a pharmacy will be grateful they don’t have to make a monthly journey for medications.

By reducing the daily dispensing load, pharmacists will have a greater opportunity to do the things they have been trained for – to discuss medication with the patient and deal with the simple health problems that people visit a pharmacy for.

Will retail pharmacists go broke and sack 100’s of works as having been suggested by a number of pharmacists and the Guild? The Seventh Community Pharmacy Agreement has a clause which provides safety net to these small businesses called the Remuneration adjustment mechanism. This was negotiated in 2020 and is set to run until 2025. I am not sure if these are any other small businesses in Australia who have a similar safety net. No adjustment was required in 2022–23 as the number of prescriptions was within 5% of estimated prescriptions.

Maybe there are too many pharmacies in some areas of Australia and the economic challenge will cull those with marginal profitability?

I do some issues which are surmountable;

  • updating prescribing & dispensing programmes with the new 60 day option
  • Manufacturers increasing pack sizes
  • Confusion for some patients on polypharmacy who have some medication in 30 days supply and some in 60 day supply

None of these are a roadblock to health care savings for those on multiple medications.

The good news is 90 days dispensing is not on the cards. Minister Butler has brushed this suggestion aside at least for the time being.

To end a reassuring message from Chief Medical Officer, Professor Michael Kidd

Unintended pregnancy

– Why I provide a medical termination service

It has been estimated that 44 percent of all pregnancies worldwide are unintended, of these around 56 percent end up choosing abortion, 32 percent choose to continue to birth a baby, and 12 percent in miscarry. 

An unintended pregnancy, may be one which is mistimed, unplanned or unwanted. It may have happened following interpersonal violence, coercions, intoxication, inability of a partner to understand “No”, or just not thinking through the consequence of sex. Of you may have missed the sexual education lecture at school which tells “you have sex to make babies”. Even if contraception is remembered, the chosen form can fail. This diagram shows the effectiveness of methods used.

And, of course, unintended doesn’t mean not wanted. An Australian study by Taft et al published in 2018, used interviews from 2013 women. A total of 69% had been pregnant during the past ten years, including 362 unintended pregnancies. Most unintended pregnancies (246 or 68%) were reported as wanted whilst 94 or 26% were described as unwanted.

A woman has the option to continue or end her pregnancy. In Queensland, where I work, you can legally end a pregnancy up to 22 weeks. The legislation does have additional requirements beyond 22 weeks.

Safe abortion, is not an option for many woman throughout the world. Lack of access may be due to a legal, religious, ethical and cost barriers. For example, abortion is illegal in countries such as Andorra, Philippines, El Salvador, Laos and Iran. Other countries have enacted barriers to access and this includes the United States, where recent changes have meant some states no longer permit an abortion. Many countries permit abortion under strict conditions eg. “when the pregnant woman was raped, when the pregnancy is the result of incest/sexual activity with a family member, or when the woman’s life would be endangered by continuing the pregnancy.” This obviously places even more pressure on these women to then prove the rape, incest or their life is endangered. A recent Deutsche Welle report out of Europe confirms this.

A US study by Troutman et al has shown that unintended pregnancies are often higher among adolescents, lower income, minority, and single women who have poverty rates twice that of other groups, making the financial impact of an unplanned conception even greater. There is belief that unintended pregnancies trap a woman in a cycle of poverty.

Studies of unintended pregnancy can have consequences for both the woman and the child.

For example, this recently published meta-analysis from the JAMA written by Nelson et al included thirty-six studies including 524 522 woman. Compared with intended pregnancy, unintended pregnancy was significantly associated with higher odds of

  • depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio (aOR) 1.59 [95% CI, 1.35-1.92]
  • post partum depression (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70]
  • Interpersonal violence (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91]
  • preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31]
  • low infant birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21]

Other additional adverse pregnancy outcomes are associated with unintended pregnancy, such as

  • less attendence at antenatal clinics
  • higher rates of miscarriage
  • premature rupture of membranes
  • complications during delivery with consequence for maternal and neonatal 

You can argue that having an unintended pregnancy takes away a woman’s choice to remain in the workforce, can place additional strain on family dynamics and additions financial burden for the family and society. In some societies, an unintended pregnancy can lead to less food being available impacting on childhood growth and development.

Both medical and surgical termination have a large literature which show they are safe and effective. However, for either it is important to know there can be a failure rate and a Plan B is necessary for these occasions.

A person who has had an abortion may have many different thoughts and feelings afterwards. Some of these could be relief, regret, loss, anger, happiness, sadness, overwhelmed or empowered. There is no right or wrong emotion when it comes to an abortion experience, and varying emotions afterwards are valid and okay. The Turnaway Study, a large and long term prospective US cohort study, did find serious consequences of being denied a wanted abortion on women’s health and wellbeing this included higher risk of anxiety and loss of self-esteem. Interestingly, woman who were able to obtain an abortion went onto have a subsequent pregnancy when they were ready. Reinforcing how having a choice empowers a woman.

Finally, if abortion is not an option, then the child can be offered for adoption or allowing extended family or foster family to provide care.

You can find more information about abortion options and contraception choices through Children by Choice, Family Planning Qld (or (True) and Marie Stopes.

Read this link for more information on contraception failure around the world.

Drug shortages

I have written in the past about drug shortages in Australia. Well actually made a list of them as of 5/11/22. Rechecking the shortage list today there are only 377 drugs that are in short supply in Australia.

The latest critical shortage is warfarin.

Warfarin is an anticoagulant medication used to “thin” the blood by blocking production of vitamin K depending clotting factors. Its has an interesting history, being discovered as the cause of haemorrhagic disease in cattle that were fed spoiled sweet clover.

Its human use is for prevention of blood clots. This can happen when the heart is not beating normally, as in atrial fibrillation, although warfarin has mostly been supplanted by new (and more expensive) medication called NOACs, short for novel anticoagulant drugs. These are also the agent of choice for treating and preventing thromboembolic disease such as deep vein thrombosis and pulmonary emboli. The NOAC advantage over warfarin is their action which is more predictable and not needing a regular INR check to determine the blood clotting timer.

Warfarin’s primary use for a patients may have had a heart valve damaged by rheumatic heart disease, in which Australia’s First Nation people are overrepresented, or may have been born with an abnormal heart valve, one damaged by infection or by the aging process. Having a metallic valve in your heart leads to a couple of annoying things, a constant ticking noise that I’m told you get used to. This may be reassuring as you know your heart is still beating!

Another problem is as red cells pass though the valves they get bashed around a little which reduces their life span leading to haemolysis. A patient may have anaemia with a raised reticulocyte count with a dip in haptoglobin.

The most dire consequence of having a metal valve is developing a blood clot on the artificial valve. If a clot breaks off the valve and blocks an artery in the brain, well, you can imagine is not good. Starved of blood, the brain tissue dies causing a stroke which may be fatal or disabling. That is why some people get a bioprosthetic valve which has a much lower risk of forming a clot. However, these bioprosthetic valves have a limited life so a young person may get a metal valve….and a life of warfarin. Having worked in northern Australia, I have met many young Aboriginal patients who live with the consequence of overcrowded housing, rheumatic heart disease, artificial heart valves and warfarin. Unfortunately, having seen the immense sadness that accompanies a young death or disabling stroke when warfarin has been omitted from the daily regimen.

Is there an alternative?

With no medication having an artificial metal heart valve gives you thromboembolism risk of 4% per year! With warfarin that risk can be reduced to 0.5% per year. Unfortunately, UptoDate authors specifically say NOACs should not be used. There is inadequate information to judge their safety. Although there is certainly research on these drugs, for example apixiban may have merit for pigs! Looking further brings disappointment with this statement calling an end to the promising PROACT Xa study early “due to lack of evidence supporting noninferiority of apixaban to warfarin for valve thrombosis and thromboembolism,”

You could have subcutaneous injections of a low molecular weight heparins but these may need to be given twice a day. For some who may not be able to get warfarin this may the only alternative.

Now, where did I hear this critical shortage? On Facebook, of course in a newspaper report. Unfortunately, the story didn’t mention the number of young indigenous patients through Northern Australia who have no alternative apart from injections.

Certainly not the drug company which sponsors warfarin didn’t let me know.

The current sponsor for warfarin tablets in Australia is Viatris Pty Ltd. The company’s motto from their website is “Viatris empowers Australians to live healthier at every stage of life by providing access to high quality, trusted medicines.”

Except of course when we can’t provide said medicines.

In Australia, warfarin brands seem to have passed around number of sponsors. I can recall GSK, Boots, Sanofi, Aspen, Mylan. It has always been argued that prescribing generic warfarin will lead to variable INR levels requiring dose changes to keep the INR in the narrow therapeutic range required to reduce clot risk. Still a generic tablet probably better than no warfarin tablet.

So what to do?

Maybe if drug companies actually copped a fine for non supply maybe this will make a difference. Currently, there is only a fine if the drug company sponsoring the medication doesn’t inform the TGA there is a shortage.

In the meantime, if you are on warfarin, and you can’t take the alternatives, keep in contact with your GP and pharmacist.

Podcasts I still listen to

Podcasts seem to come and go. I looked back at my 2017 list and realised that my listening tastes have changed a little. I also realised some of the original podcasts have disappeared or not updated.

Here is my updated list of Medical Podcasts I listen to.

Australian Prescriber podcasts

Broome Docs by Casey Parker and Justin Morgenstern. I like the idea of a podcast where ideas are being bounced around rather than some didactic voice droning on.

Don’t forget the Bubble for paediatric stuff

IM Reasoning Drs. Art Nahill and Dr. Nic Szecket, have a passion for teaching clinical reasoning. Sadly, now archived.

The GP Show by Dr Sam Manger happily continues along with emphasis on lifestyle medicine.

BMJ Podcasts

The GoodGP by Dr Tim Koh, Dr Krystyna DeLange and Dr Sean Stevens, in collaboration with RACGP WA.

GPSA podcasts which are useful given I working a clinic with GP registrars.

Coronacast Norman Swan and Teagan Taylors podcast about Covi-19 has been on my list for the last few years. The non-covid podcast ABC Health Report is also my list. From an Europe perspective Coronapod has also been useful.

Dr David Puder is a US psychiatrist whose podcast Psychiatry & Psychotherapy Podcast explores mental health which is not my forte.

The Purple Pen. The title of the podcast comes from the colour pen that Australian hospital pharmacists sometimes use for annotating drug charts and prescriptions. I never used a purple pen!

Every Day Medicine is hosted by a gastroenterologist who has conversations with specialists. Somethings I do yell out whilst riding “oh here’s someone else telling me how to do my job” but mostly they are okay

Nature Podcast which is not just medicine

Most of the major medical journals offer a podcast on recent articles with author interviews.


Medical Journal of Australia


The Lancet

A few non Medical podcasts have entered my ears on my cycle to and from work via Antenna Pod or Spotify and a pair of Jabra 75’s.

Hardcore history by Dan Carlin has been on my list for a while.

History Rome and then Revolutions by Mike Duncan

History of Byzantium by Robin Pierson followed Mike Duncan’s History of Rome with the story of the Eastern Roman Empire.

Fall of Civilisations by Paul Cooper

Tides of History by Patrick Wyman

The Rest is History by Tom Holland (whose books I have on shelf) with Dominic Sandbrook is eclectic entertaining sparring.

And if you don’t like the historical theme

ABC Conversation with Richard Fidler and Sarah Konawski

7 am – an Australian alternative news and political commentary

The Daily – from the New York Times, although I do skip some of the more Americo-centric content.

Mirena, an international quandary

As I live in Australia, my patients can use a Mirena for 5 years. But if I was working in the USA last year, my patient could confidently keep it in for seven years.

This year the FDA has extended the insertion time to eight years. Europe seems to be following the extended use trend. That’s three years longer than women are recommended to use it in Australia.

I am a little confused because the device available in both the USA and Australia appears to be identical (made in Finland, I think) and both contain 52 mg of levonorgestrel. I wonder when Bayer Australia and the TGA can catch up with evidence? So I asked….

Dear Doctor

The approved length of use label for Mirena (52 mg levonorgestrel) differs in countries around the world. Bayer Australia is currently reviewing the extended use data for Mirena. We are planning to submit an application to the Therapeutic Goods and Administration (TGA) for an extension to the approved length of use for Mirena for the indication “contraception.” It is a major submission and the timelines and expected approval date are not known at this time. The approved length of use for Mirena for all indications in Australia is up to 5 years. Bayer does not recommend the use of its products in any manner inconsistent with the approved local labelling. Any use outside of the approved local label is at the clinical discretion and the responsibility of the healthcare professional.

So what happens after a Mirena is inserted? Once inserted there is an initial rapid release of levonorgestrel of 21 mcg/day after 24 days. This rate then decreases progressively to approximately 11 mcg/day after 5 years and 7 mcg/day after 8 years. By way of contrast the oral levonorgestrel tablet contains 30mcg.

The Contraceptive efficacy and safety of the 52-mg levonorgestrel intrauterine system for up to 8 years: findings from the Mirena Extension Trial

This study was funded by Bayer. The trial authors persuaded 362 women with an Mirena in to just keep on going after 5 years. 223 carried on with life out to 8 completed years. This group provided the trial data. I can imagine they said just said “let us know when you get pregnant”?

All the trial women were under 36 years old and half had already had at least one child. Two pregnancies were recorded, on of unknown location which resolved spontaneously,(presumably miscarried) and another ectopic which was managed with methotrexate.

For years 6 to 8, the 3-year Pearl Index (95% confidence interval) was 0.28 (0.03–1.00) with a 3-year cumulative failure rate of 0.68% (0.17–2.71). Pearl Indexes for years 6, 7, and 8 were 0.34 (0.01–1.88), 0.40 (0.01–2.25), and 0.00 (0.00–1.90), respectively.

The contraceptive efficacy of Mirena has been studied in 5 major clinical studies with 3330 women using Mirena. The Pearl Index was approximately 0.2% at 1 year and the cumulative failure rate was approximately 0.7% at 5 years. I think that should give women a degree of confidence with extended use. The paper uses 5-year cumulative failure rate of 0.16% to 1.1% as a comparison.

Could extended use impact a desired pregnancy when you decide to have another baby? From this study 24 reported a posttreatment pregnancy within 1 year, giving a 12-month return-to-fertility rate of 77.4%. They also noted no difficulties removing the device.

During extended use beyond 5 years and up to 8 years, participants reported a decrease in the mean number of bleeding or spotting days with approximately half of the women experiencing amenorrhea or infrequent bleeding. This makes me think that when I use a Mirena for menorrhagia and additional contraception isn’t required, then maybe it is okay to just leave it in until the bleeding pattern becomes unacceptable once more rather than place an arbitrary date on removal.

This study confirms finding from an earlier study from May 2022 using a similar device called Liletta which also contains 52 mg of levonorgestrel. This one is not available in Australia.

This Brazilian study from 2018, followed women even longer and suggested some had contraception and cycle control out to 15 years from a single device.

So, what am I doing?

I could stick to 5 years, but I explain the new study, highlighting the numbers and giving my patients of option of gaining saving money and getting 16 years of effective contraception from just two devices.

Every silver cloud may have a dark lining!

Have you noticed the number of silver impregnated bandaids and dressings that are being flogged in supermarkets and pharmacies. I don’t mean the super expensive Aquacel Ag, but plain boring bandaids that Mum or Dad apply to stop tears from a little graze after toddlers trips over their feet.

Would you be surprised that bacteria are developing ways of living in a silver rich environment underneath that shiny expensive dressing?! And would you believe that the more they are used on wounds that aren’t really infected the more likely that bacteria will be trained to grow in a silver rich environment?

Evolution apparently!

Silver has been employed long ago as an antimicrobial agent. The Persians used silver to keep their drinking water fresh. If you want to know what we else we can thank the Persians for, have a listen to this Podcast by historians Tom Holland and Dominic Sandbrook.

Getting back to more medical orientated information Alexander reviewed the medical history of silver. In summary, silver in various forms has been used for its microbicidal properties, with minimum toxicity to human cells to prevent and treat burns and chronic wound infections. Argyria, the deposition of silver in skin and tissues is a complication of silver therapy. Unfortunately, the skin takes on a blue grey rather than a cool shimmering silver.

In microorganisms, silver ions damage cell walls, can interfere with cellular metabolism and create reactive oxygen species which interferes with DNA replication and other cellular activities. This is discussed more in this paper by Sim et al.

Hosny and his colleagues reported on one hundred and fifty clinical isolates obtained from patients with burns and wounds being treated in a Cairo hospital. All except two isolates were multidrug-resistant. Nineteen silver-resistant bacterial isolates (12.6%) were detected. These were Klebsiella pneumoniae (n=7), Staphylococcus aureus (n=4), Escherichia coli (n=2), Enterobacter cloacae (n=2), Pseudomonas aeruginosa (n=2) and Acinetobacter baumannii. All of these bacteria have the potential to make people very sick.

Silver ions can also delay normal wound healing by killing those fibrocytes and keratocytes which are trying to close the gap in the skin.

And, I’m not sure if this marketing research is correct but it is sad if this is the case. I wonder where the various authorities such as the TGA stands on the marketing of these potentially harmful products.


So how to deal with simple wounds at home.

Settle the distress

Clean up the blood and the wound with just boring tap water

Consider using an old fashioned (cheap) non medicated bandaid for pain relief (until it needs to be removed), to keep the sheets clean; and deal with infection if it arises.

Did you hear this is World Antimicrobial Awareness Week? Let’s keep antibiotics use under control to reduce the pressure on antibiotics resistance. It’s a bit like climate change we all have to do our bit.

Should pharmacist be able to sell antibiotics for a UTI?

Covenience vs Rsik

As a doctor and pharmacist. I have learnt since becoming a doctor, that not every woman with dysuria have a bladder infection. I work in North Queensland and have first-hand knowledge of the challenges with expanded scope of pharmacy practice. 

In Queensland, women may be able to buy trimethoprim over the counter for dysuria, however they are at risk of misdiagnosis. A pharmacist is not able to take a comprehensive history nor be in the position to perform an examination. Firstly, few pharmacies have an area where this can take place confidentially. Across a counter is certainly not the correct place. Secondly, if I prescribe antibiotics, I will also examine the woman, and test urine to exclude an early pregnancy if necessary and use a dipstick to guide my diagnosis.  I have treated women who believe they have a simple UTI instead have pyelonephritis, chlamydia or herpes as the cause of their symptoms. These requires treatments other than trimethoprim. In fact, a study found women who present with 1 or more symptoms of UTI, the probability of infection is approximately 50%, ie., no better than tossing a coin. https://jamanetwork.com/journals/jama/article-abstract/194952

Men are specifically excluded from this protocol in Queensland, as the cause of male UTI’s may well be more complicated, and is certainly less common.

There is pressure on a pharmacist to maximise profit, and the only way to do this is through sales. As a doctor, if I write a prescription, I do not get a financial reward for doing so. This study found that when physicians were permitted to dispense medication, costs went up. https://pubmed.ncbi.nlm.nih.gov/25393362/

A concerning example of down scheduling is the sale of chloramphenicol eye drops has markedly increased since this antibiotic was made available over the counter. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784527/  https://pubmed.ncbi.nlm.nih.gov/20840682/

The use of trimethoprim would be expected to follow the same trajectory.

“A UTI is commonly caused by bacteria in the urethra, bladder and/or kidneys and is often difficult to predict or prevent.” Your media release lumps a number of different illnesses together which requires different management. Not all UTI’s a bacterial, ergo not all UTIs need antibiotics. Management of a cystitis (bladder infection) is different well to pyelonephritis (kidney infection).

This study showed that delaying use of antibiotic was not detrimental to a patient’s health. A simple bladder infection may well resolve within a few days, and symptomatic relief with ibuprofen can be useful.  https://www.bmj.com/content/340/bmj.c199

WHO and many other organisations are calling for better antibiotic stewardship. November 18 to 24 is a week set aside to increase the awareness of antibiotic resistance. https://www.who.int/campaigns/world-antimicrobial-awareness-week/2022

Antibiotics resistance is a massive challenge worldwide. Already countries such as the UK and New Zealand where trimethoprim can be sold over the counter for a bladder infection are having to deal with increased trimethoprim resistance. https://www.nice.org.uk/news/article/antibiotic-resistance-is-now-common-in-urinary-tract-infectionshttps://journal.nzma.org.nz/journal-articles/appropriateness-of-trimethoprim-as-empiric-treatment-for-cystitis-in-15-55-year-old-women-an-audit

Moves to improve convenience, will result in the same situation in Australia. I strongly believe that women do need appropriate and timely treatment for a UTI, but there are hazards associated with this planned overreach of pharmacy scope of practice.

Who is at greater risk?

Next time you hear, Aboriginal and Torres Strait Islander people [insert alternate racial group] are at greater risk [insert disease] think about what is really been stated.

What is really putting that person in front of you at greater risk?

Is it their home environment, family history, where they grew up, lifestyle choices. Is it truly their racial origins?

This enlightening podcast from Nature discusses the issue of racism in medicine. How medical technology neglect real differences (pulse oximetry) or add imagined differences (spirometry) as well as highlighting that there sometimes is a real genetic difference.( HLA-B*1502 and SJS syndrome)


“I’ve been coughing up green sputum, I need antibiotics”

This is a common question all primary care doctor face. There is a preconceived notion that having thick, yellow or green globs of sputum indicates a bacterial infection and antibiotics are vital. Discoloured sputum colour may have a variety of causes.

The yellow-green colour in sputum is caused by heme containing myeloperoxidase. These enzyme is released by white cells that are part of the immune response to infection or inflammation. The enzyme produced hypochlorous acid which can directly kill bacteria. Here oxidation is a good thing! The shade of yellowness or greenness and its thickness depends up how much respiratory mucus is mixed in with the respiratory debris and the presence of blood.

This elegant 2009 German study included otherwise healthy patients from a general practice setting with an onset of acute cough. So it doesn’t include patients with bronchiectasis, chronic bronchitis, cystic fibrosis or other lung problems.

The authors found the colour of the sputum

  • cannot be used to differentiate between viral and bacterial infections in otherwise healthy adults
  • should not be used to make a decision on whether to prescribe an antibiotic within this group of patients.

In only 12% of patients with coloured sputum a bacterial infection was proven. In only 5% of clear samples, bacteria was found.

Thus, you have to treat eight patients with yellow-green sputum antibiotics to help one. So seven patients were exposed to the risk of antibiotics side effects (for example, skin rash, diarrhoea, thrush), financial cost and the increased pressure on developing bacterial resistance.

This is not new knowledge. A 1976 UK randomised controlled trial of antibiotics in 212 GP patients with typical URTI symptoms with cough and purulent sputum showed that using doyxcycline was as good as a placebo when it came to resolving symptoms.

It is also not surprising that the same myth surrounds rhinorrhea or nasal secretions. In uncomplicated viral nasopharyngitis or rhinitis, nasal discharge is initially clear but can become white, yellow, or green. Recommendations to distinguish between a viral and a bacterial source based on purulent rhinorrhea are not supported by evidence, and the decision to prescribe antibiotic treatment should not depend on its presence, advises this systematic review. Even after 10 days of snot the chances of a having a bacterial infection is only slightly better than tossing a coin, ie., 60%,

I think this also goes a way to answering the next question which commonly comes up , “I need antibiotics before it goes to my chest”.

The colour of the sputum has been shown not differ between specific bacteria cultured in this microbiological study. The authors found even the dogma that pseudomonas givens your lime green sputum did not hold up to be true in the petri dish.

The situation may be different for those patients who have underlying lung problems like chronic obstructive airways disease. In this case, an increase in coloured sputum can be a sign of infection and antibiotic amongst other measures, may be necessary. There is still a preference to assessing the sputum colour rather than accepting a patients description. Thankfully, I can look at sputum without feeling queasy.

Ultimately, the key is to not just look at what the patient spits up into a tissue, but to look at holistically.

Need to read more about respiratory secretions?

Current medication shortages in Australia

Sourced from Therapeutic Goods Administration 5 November 2022

I count 421 medications. By way on comparison the FDA lists 145 medication on their shortage list.

The most common reason seems to be “manufacturing” whatever that means?

acetylcholine chloride acetylcysteine activated charcoal~sorbitol adefovir dipivoxil adenosine adrenaline (epinephrine) acid tartrate adrenaline (epinephrine) acid tartrate~bupivacaine hydrochloride monohydrate adrenaline (epinephrine) acid tartrate~lidocaine (lignocaine) hydrochloride adrenaline (epinephrine) hydrochloride~articaine hydrochloride aggregated albumin~stannous chloride~Albumin agomelatine Albumin alendronate sodium~colecalciferol allopurinol alprazolam Alteplase amifostine amikacin amisulpride amitriptyline hydrochloride amlodipine besilate amlodipine besilate~hydrochlorothiazide~olmesartan medoxomil amlodipine besilate~olmesartan medoxomil amlodipine besilate~olmesartan medoxomil~hydrochlorothiazide amoxicillin trihydrate~potassium clavulanate anastrozole antimony trisulfide aripiprazole articaine hydrochloride~adrenaline (epinephrine) hydrochloride asenapine maleate aspirin~clopidogrel hydrogen sulfate aspirin~codeine phosphate hemihydrate atazanavir sulfate atenolol atomoxetine hydrochloride atorvastatin calcium atorvastatin calcium trihydrate~ezetimibe atracurium besilate atropine sulfate monohydrate azacitidine azathioprine azithromycin azithromycin dihydrate barium sulfate benralizumab benzylpenicillin sodium betiatide Bevacizumab bicisate dihydrochloride bimatoprost bisoprolol fumarate bleomycin sulfate bosentan monohydrate brigatinib bromazepam budesonide bupivacaine hydrochloride bupivacaine hydrochloride monohydrate~adrenaline (epinephrine) acid tartrate buprenorphine cabazitaxel acetone solvate calcipotriol~betamethasone dipropionate calcitriol calcium chloride dihydrate~fytic acid~potassium hydrogen phthalate calcium folinate candesartan cilexetil captopril carbetocin carbidopa monohydrate~levodopa~entacapone carboplatin carvedilol cefalexin monohydrate cefotaxime sodium celecoxib cetrimide~chlorhexidine gluconate chloramphenicol chlorhexidine gluconate chlorhexidine gluconate~cetrimide chlorpromazine hydrochloride ciclesonide ciclosporin cidofovir ciprofloxacin ciprofloxacin hydrochloride cisatracurium besilate cisplatin citalopram hydrobromide clindamycin hydrochloride clindamycin phosphate clioquinol~flumetasone pivalate clonazepam clopidogrel besilate clozapine codeine phosphate hemihydrate~ibuprofen colecalciferol~alendronate sodium cyproterone acetate dalteparin sodium dantrolene sodium hemiheptahydrate dasatinib propylene glycol deferasirox deferiprone desmopressin acetate desogestrel~ethinylestradiol dexamethasone sodium phosphate dexmedetomidine hydrochloride diazepam diclofenac sodium diltiazem hydrochloride dipyridamole disopyramide docetaxel donepezil hydrochloride dosulepin (dothiepin) hydrochloride doxepin hydrochloride doxorubicin hydrochloride doxycycline hyclate (hydrochloride) doxycycline monohydrate dulaglutide eletriptan hydrobromide elotuzumab enalapril maleate entacapone~carbidopa monohydrate~levodopa entacapone~levodopa~carbidopa monohydrate entecavir ephedrine hydrochloride ephedrine sulfate eprosartan mesilate eptifibatide eptifibatide Equine antithymocyte immunoglobulin erlotinib hydrochloride ertapenem sodium ertugliflozin pyroglutamic acid ertugliflozin pyroglutamic acid~metformin hydrochloride ertugliflozin pyroglutamic acid~sitagliptin phosphate monohydrate erythromycin erythromycin ethyl succinate erythromycin lactobionate escitalopram oxalate esomeprazole magnesium dihydrate estradiol~norethisterone acetate~estradiol ethanol~chlorhexidine gluconate ethinylestradiol~gestodene ethinylestradiol~levonorgestrel ethinylestradiol~norethisterone ethosuximide etoposide evolocumab exenatide ezetimibe~atorvastatin calcium trihydrate ezetimibe~rosuvastatin calcium famciclovir felodipine~ramipril fenofibrate fentanyl citrate Fibrinogen~Factor XIII~human thrombin finasteride flecainide acetate flucloxacillin flucloxacillin sodium monohydrate flumazenil fluorouracil fluoxetine hydrochloride fomepizole fosinopril sodium fulvestrant Funnelweb spider antivenom furosemide (frusemide) gabapentin galantamine hydrobromide gallium (67Ga) citrate gemtuzumab ozogamicin gentamicin sulfate gliclazide glimepiride heparin sodium Hepatitis a virus antigen honey bee venom human menopausal gonadotrophin human thrombin~Factor XIII~Fibrinogen hydralazine hydrochloride hydrochlorothiazide~candesartan cilexetil hydrochlorothiazide~enalapril maleate hydrochlorothiazide~eprosartan mesilate hydrochlorothiazide~olmesartan medoxomil hydrochlorothiazide~olmesartan medoxomil~amlodipine besilate hydrochlorothiazide~quinapril hydrochloride hydrochlorothiazide~valsartan hydrocortisone hydrocortisone acetate hydrocortisone sodium succinate hydrogen peroxide hydromorphone hydrochloride hydroxocobalamin chloride hydroxychloroquine sulfate hyoscine hydrobromide ibandronate sodium ibuprofen idarubicin hydrochloride imatinib mesilate imipramine hydrochloride indapamide hemihydrate indometacin Influenza virus haemagglutinin iobenguane (123I) sulfate iodixanol iohexol iopromide ioversol ipratropium bromide monohydrate irbesartan irinotecan hydrochloride trihydrate isavuconazonium sulfate isosorbide mononitrate itraconazole ivabradine hydrochloride Japanese encephalitis virus ketorolac trometamol labetalol hydrochloride lacosamide lamotrigine lansoprazole latanoprost leflunomide lercanidipine hydrochloride letermovir letrozole levetiracetam levobupivacaine hydrochloride levobupivacaine hydrochloride~levobupivacine levodopa~carbidopa monohydrate levonorgestrel~ethinylestradiol lidocaine (lignocaine) lidocaine (lignocaine) hydrochloride monohydrate lidocaine (lignocaine)~chlorhexidine gluconate lincomycin hydrochloride monohydrate lisdexamfetamine dimesilate lisinopril dihydrate live varicella vaccine lomustine lorazepam losartan potassium lurasidone hydrochloride medroxyprogesterone acetate memantine hydrochloride mercaptopurine monohydrate meropenem trihydrate mesalazine mestranol~norethisterone metaraminol tartrate metformin hydrochloride metformin hydrochloride~ertugliflozin pyroglutamic acid methotrexate methylene blue methylphenidate hydrochloride metoclopramide hydrochloride monohydrate metronidazole metronidazole benzoate midazolam minocycline hydrochloride dihydrate minoxidil mirtazapine mirtazapine mivacurium chloride moclobemide modafinil morphine sulfate pentahydrate moxifloxacin hydrochloride Mycobacterium bovis (Bacillus Calmette and Guerin (BCG) strain) mycophenolate mofetil naloxone hydrochloride dihydrate naproxen sodium nebivolol hydrochloride nepafenac nicorandil nifedipine nitrofurantoin noradrenaline (norepinephrine) acid tartrate monohydrate norethisterone nortriptyline hydrochloride octreotide olanzapine olmesartan medoxomil~amlodipine besilate olmesartan medoxomil~amlodipine besilate~hydrochlorothiazide olmesartan medoxomil~hydrochlorothiazide olopatadine hydrochloride olsalazine sodium omeprazole magnesium omeprazole sodium ondansetron ondansetron hydrochloride dihydrate oseltamivir phosphate oxazepam oxcarbazepine oxybutynin hydrochloride oxycodone hydrochloride~naloxone hydrochloride dihydrate paclitaxel pamidronate disodium Pancreatic extract Pancrelipase pantoprazole sodium pantoprazole sodium sesquihydrate papaverine hydrochloride Paper wasp venom paracetamol paracetamol~tramadol hydrochloride Pegfilgrastim pemetrexed disodium hemipentahydrate perindopril erbumine phenoxybenzamine hydrochloride phenoxymethylpenicillin phenoxymethylpenicillin benzathine phenoxymethylpenicillin potassium phentermine hydrochloride phenytoin sodium pilocarpine hydrochloride pioglitazone hydrochloride piroxicam potassium clavulanate~amoxicillin sodium povidoneiodine pramipexole dihydrochloride monohydrate prasugrel prazosin hydrochloride pregabalin prilocaine hydrochloride procaine benzylpenicillin (procaine penicillin) prochlorperazine maleate prochlorperazine mesilate propofol pyridostigmine bromide quetiapine fumarate quinapril hydrochloride rabies immunoglobulin Rabies virus ramipril ranitidine hydrochloride ravulizumab reboxetine mesilate remifentanil hydrochloride rifampicin rifaximin riociguat risperidone rituximab rizatriptan benzoate rocuronium bromide ropivacaine hydrochloride ropivacaine hydrochloride monohydrate rosuvastatin calcium rosuvastatin calcium~ezetimibe roxithromycin Rubella virus~live varicella vaccine~Measles virus~Mumps virus Salmonella typhi samarium (153Sm) saquinavir mesilate Semaglutide sertraline hydrochloride simvastatin simvastatin~ezetimibe sitagliptin phosphate monohydrate~ertugliflozin pyroglutamic acid sodium chloride sodium citrate dihydrate~sodium lauryl sulfoacetate~sorbitol solution (70 per cent) (noncrystallising) sodium cromoglycate sodium iodide(131I) sodium nitroprusside sodium oxidronate sodium pertechnetate(99mTc) sodium valproate solifenacin succinate sotalol hydrochloride spironolactone stannous chloride dihydrate~sodium chloride~Albumin~aggregated albumin Sterculia Sterculia~Rhamnus frangula stiripentol succimer sulfamethoxazole~trimethoprim sunitinib malate tadalafil tafluprost tamoxifen citrate tamsulosin hydrochloride telmisartan~hydrochlorothiazide temazepam Tenecteplase terbinafine hydrochloride teriflunomide tetracosactide (tetracosactrin) tetrakis(2methoxyisobutylisonitrile) copper(1) tetrafluoroborate thallous(201Tl) chloride thiopental sodium Thyrotropin alfa ticagrelor timolol maleate~latanoprost tobramycin trandolapril tranexamic acid Trastuzumab travoprost tretinoin trimethoprim trimethoprim~sulfamethoxazole valaciclovir valsartan valsartan~hydrochlorothiazide vancomycin vardenafil hydrochloride trihydrate varenicline tartrate varenicline tartrate~varenicline tartrate vecuronium bromide venetoclax venlafaxine hydrochloride Vespula spp venom Vibrio cholerae~Vibrio cholerae vincristine sulfate voriconazole warfarin sodium water for injections water for injections~cetrorelix ziprasidone hydrochloride zoledronic acid monohydrate zolmitriptan