Ivermectin

Clarissa Chan, PharmD

In community pharmacies across the United States, ivermectin prescriptions averaged 3,600 prescriptions per week pre-pandemic to 88,000 per week during the pandemic in August 2021. This represents a 24-fold increase from the pre-pandemic baseline, according to CDC Health Alert Network.

As pharmacists know, ivermectin is not FDA-approved for the treatment and prevention of COVID-19 and has been shown to be harmful when topical formulations like creams and large animal veterinary formulations are ingested. A September 2021 press release from APhA and others said that poison control centers received calls related to ivermectin misuse and overdose toxicity at a fivefold increase compared to pre-pandemic times. Veterinary formulations of ivermectin for large animals are especially potent and pose an increased risk to humans.

APhA, the American Medical Association, the American Society of Health-System Pharmacists (ASHP), CDC, and FDA have all discouraged the ordering, prescribing, and dispensing of ivermectin to prevent or treat COVID-19 outside of clinical trials.

Pharmacists should carefully evaluate their decision to dispense ivermectin.

“You need to evaluate whether that’s something you’re willing to risk with all of the evidence and information on ivermectin and alerts of abuse, if you’re going against these major groups’ alerts and recommendations,” said Elizabeth Skoy, PharmD, an associate professor of pharmacy practice at North Dakota State University and staff pharmacist at Thrifty White Pharmacy in Fargo, ND. “We have to do our due diligence for patient care and safety, even if the prescribed doses are within normal dosing limits for approved indications.”

This decision is up to individual pharmacist’s professional judgment to determine whether or not they decide to dispense ivermectin to patients on a case-by-case basis, keeping in mind increased liability and responsibility.

Pharmacists’ right to refuse to fill

Pharmacists have the right to refuse to fill medications—especially ivermectin-containing products—if they believe that it is not being used for a legitimate medical purpose, even if the dosing is appropriate for another FDA-approved indication.

“It’s hard to determine if a patient has a valid patient-provider relationship if you get something online, so it’s up to the pharmacist to verify if there is a legitimate relationship or not between the provider and patient, and whether or not they feel comfortable filling the prescription,” said Skoy.

Skoy has only heard of one prescriber, who often prescribes medications off-label, writing ivermectin prescriptions for COVID-19 where she practices. Other patients who have presented with ivermectin prescriptions obtained them online, said Skoy. “In reports across North Dakota, we are seeing it prescribed a little more from local physicians in more rural areas.”

One way in which Skoy has seen pharmacists evaluate their decision to fill ivermectin is to call and verify the prescription with the prescriber to make sure it’s prescribed within their scope of practice for a legitimate medical reason. Another option, according to Skoy, is for pharmacists to verify the patient’s diagnosis for the prescription. This can be done by calling the provider’s office for a diagnosis code and using professional judgment to determine if the prescription is valid or not.

Since ivermectin isn’t commonly used, some pharmacists choose not to stock it. “If [patients] want you to order it, let them know that you do not regularly dispense it and studies do not support the use of ivermectin in COVID-19,” said Skoy.

Among the North Dakota pharmacists with whom Skoy has spoken, none have experienced push-back from prescribers and patients.

In contrast, Anne Burns, RPh, vice president of professional affairs at APhA, said that other health care providers have expressed to pharmacists to “stay in your lane” and dispense the medication as prescribed without interfering with patients’ access to medications.

Dangers of misinformation

While the majority of evidence from clinical trials shows that ivermectin is not safe or effective for preventing or treating COVID-19, not all studies are well-designed or come to the same conclusions.

“There have been some studies that do not have a well-represented patient population, have small sample sizes, and confounding variables,” said Skoy. “The general public doesn’t understand what is considered a well-designed study,” said Skoy. “They want to know the outcome, which is what sells.” What sells is often a misguided news headline. “At first, the conclusion is that ivermectin may be effective. Then the headline is ‘ivermectin is potentially effective,’ ” said Skoy. “Once someone has an idea in their head, changing that idea is very hard. And when they believe something, information that doesn’t agree with their notion is filtered out.”

Pharmacists should counsel patients against use of ivermectin as a treatment for COVID-19, emphasizing the potential toxicity that could occur, including nausea, vomiting, and diarrhea. “Overdoses are associated with hypotension and neurologic effects such as decreased consciousness, confusion, hallucinations, seizures, coma, and death,” said a CDC Health Alert Network Advisory. Although misinformation has been prevalent, information overload has also been an issue.

“There has been so much evidence from many studies that have come out, resulting in information overload,” said Skoy. ”I think that it’s been hard for health care providers sometimes to decipher all of it; even for people like myself and my colleagues who are in the literature daily, working closely with the Center for Immunization Research and Education, it still feels like drinking out of a firehose.”

Pharmacists are important in the fight against misinformation and keeping patients safe and healthy; it is vital to remain educated about updates in health care from reliable sources to best care for patients.

Takeaway points

• Ivermectin-containing products are not currently authorized or approved by FDA for the prevention or treatment of COVID-19.
• Ivermectin-containing topical products indicated for external or for veterinary use are not appropriate for human consumption.
• Encourage people to get fully vaccinated against COVID-19, wear face masks, socially distance by staying at least 6 feet away from others in public places, wash hands frequently, and avoid large crowds of people or poorly ventilated places to limit the spread of COVID-19.
• Stay informed and educate people on the studies and how to understand them.
• Counsel patients against the use of ivermectin as a treatment for COVID-19, emphasizing the potential  of nausea, vomiting, and diarrhea. “Overdoses are associated with hypotension and neurologic effects such as decreased consciousness, confusion, hallucinations, seizures, coma, and death,” a CDC Health Alert Network Advisory states. Call the poison control center hotline at 1-800-222-1222 for medical management advice.