Ask VACEP: Pharmacists Prescribing Paxlovid
This week, we received an inquiry via our Ask VACEP online resource. We did some research, then dug a bit deeper to offer some Virginia perspective and context to emergency physicians.
Q: Can pharmacists prescribe Paxlovid for adults and children at risk for severe COVID-19?
A: Yes, with limitations.
On July 6, the U.S. Food and Drug Administration authorized state-licensed pharmacists to prescribe Paxlovid to eligible patients, with certain limitations to ensure appropriate patient assessment and prescribing. Paxlovid (nirmatrelvir and ritonavir) is authorized for the treatment of mild-to-moderate COVID-19 in adults and children at high risk for severe COVID-19, including hospitalization or death. The FDA issued the order under an Emergency Use Authorization (EUA).
Among the limitations is the need to refer patients for clinical evaluation with a physician or advanced practice provider if sufficient information is unavailable to assess:
the patient’s renal and hepatic function
potential interactions with other drugs the patient may be using
To receive a Paxlovid prescription from a pharmacist, the patient need only provide an electronic or printed health record less than 12 months old, including the most recent reports of laboratory blood work, to review for kidney or liver problems. Pharmacists can also consult with the patient’s health care provider.
The pharmacist must also review a list of medications the patient is taking, including over-the-counter medications, to screen for drugs with potentially serious interactions.
The Medical Society of Virginia confirmed with the Virginia Board of Pharmacy that state-licensed pharmacists can prescribe Paxlovid if they meet the FDA’s EUA requirements.
However, as our friends at MSV explain, the lack of reimbursement for the clinical requirements appear to have a chilling effect on how much prescribing is taking place. For example, FDA regulations pay pharmacists for dispensing ($6.89), but not the time to consult with the patient or the patient’s provider to determine if medication is appropriate. We are awaiting further guidance from the Board.
In Virginia, pharmacists have prescriptive authority for a number of medications and other products. VACEP, under the lead of MSV, opposed such authority, but over the years legislators have allowed pharmacists to expand their scope of practice. Today, Virginia pharmacists may practice and initiate treatment and administer medications, including:
Naloxone
Epinephrine
Self-administered hormonal contraceptives
Pre-natal vitamins
Dietary fluoride supplements
Covered medications when the out-of-pocket cost is lower than the over-the-counter equivalent
Drugs, devices, paraphernalia, supplies, and equipment
Vaccines on the CDC Immunization schedule, including for children 3 and older
TB testing (with corresponding, strict Board of Pharmacy regulations and guidelines)
Controlled substances for the prevention of HIV known as PrEP and PEP* (with corresponding, strict Board of Pharmacy regulations and guidelines)
Nicotine replacement and other tobacco cessation therapies
Tests for COVID-19 and other coronaviruses
More information on Paxlovid, including dosage, contraindications, and warnings, can be found at the FDA’s website.
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