Aaliah Nelson
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[post_content] => A blistering opening plenary session at the FIP Congress last week has challenged policymakers and health professionals alike to act to slow the advance of antimicrobial resistance (AMR).
Mr Michele Cecchini, Head of Public Health, Organisation for Economic Co-operation and Development (OECD), worked through startling data showing the cost of AMR globally – in dollars, and in years of life lost.
The high price of insufficient action on AMR
The OECD has crunched the numbers, and the statistics are startling.
AMR is currently shortening life expectancy by an average of 1.8 years globally – 1.7 years for people in high-income countries, or 2.5 years for people in low-income countries.
This is represented in 79,000 people dying due to resistant infections across 34 OECD, European Union and European Economic Area counties – corresponding to 2.4 times the number of deaths due to tuberculosis, influenza and HIV/AIDS combined in 2020.
The financial burden on the health system is similarly staggering, with global annual costs totalling $US 412 billion.
Once lost productivity and loss of income costs are added in, this cost balloons to $US 850 billion annually – about the same size of Poland’s economy.
Bold action is required
Modelling by the OECD has shown that meaningful action is achievable – albeit with a substantial price tag.
To reduce AMR-related deaths by 10%, six actions are required:
- All countries need to have national AMR action plans and 60% of countries commit a budget
- 90% of countries should meet WHO’s minimum infection prevention and control programs at a national level
- All countries need to report surveillance data on AMR and antimicrobial use
- Meaningful reduction in antimicrobial use is taken in agrifood systems
- Strengthened actions to prevent and address the discharge of antimicrobials into the environment
- Mechanisms to support research and development to address AMR should be promoted.
The cost of these initiatives globally is estimated to be $US 52 billion annually – equivalent to 0.5% of the global health budget.
‘The World Bank told us this is a rounding error [in the context of health spending]. This is not an amount of money which cannot be mobilised,’ Mr Cecchini said.
These sentiments were echoed by the Danish Minister for the Interior and Health Sophie Løhde.
‘To tackle [AMR], we need to work much closer together, and your role as pharmacists and life science professionals is key,’ said Minister Løhde at the first plenary session of the 2025 FIP world congress last week. ‘We need your expertise to develop new antimicrobials in the most prudent and effective manner, and to inform and educate our citizens when you meet them in pharmacies all over the world.’
The FIP Copenhagen Declaration on Antimicrobial Resistance, signed by 79 organisations – including The Pharmaceutical Society of Australia – took place on 1 September 2025.
The FIP Declaration outlines clear priorities to address AMR, including global partnership building, promoting vaccination and rational antimicrobial use, protecting medicine supply chains, and advancing evidence on stewardship and outcomes.
[post_title] => OECD sounds the alarm on antimicrobial resistance
[post_excerpt] => A blistering session at the FIP Congress challenged policymakers and health professionals to slow the advance of antimicrobial resistance.
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[title_attribute] => OECD sounds the alarm on antimicrobial resistance
[title] => OECD sounds the alarm on antimicrobial resistance
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[post_content] => A study led by Flinders University and the Southern Adelaide Local Health Network shows that the anti-rheumatic medicine methotrexate significantly reduces blood pressure in some patients compared with sulfasalazine – the first clear evidence of this effect in patients newly diagnosed with rheumatoid arthritis (RA).
The common autoimmune disease occurs in around one in 100 people, leading to inflammation and pain in the connective tissue of the joints.
The inflammation caused by RA contributes to high blood pressure by damaging blood vessels, prompting rheumatologists to realise that people with RA don't typically die because of their condition, said lead researcher Professor Arduino Mangoni, Head of Pharmacology at Flinders University College of Medicine and Public Health.
[caption id="attachment_30469" align="alignright" width="216"]
Professor Arduino Mangoni[/caption]
‘The main reason people with RA die is because they have a cardiovascular event, such as a myocardial infarction or stroke,’ he said. ‘And this is often because of an excess prevalence of hypertension in these individuals.’
High blood pressure can significantly shorten the life expectancy of people with RA.
‘An epidemiological study quantifying the burden of cardiovascular disease in people with RA concluded that the increased risk imparted by rheumatoid arthritis was similar to diabetes,’ Prof Mangoni added.
What impact did methotrexate have on blood pressure?
Methotrexate is not the only anti-rheumatic medicine that can reduce hypertension, with hydroxychloroquine also being shown to be potentially protective against atherosclerosis, Prof Mangoni said.
‘So we wanted to use the comparator, sulfasalazine, that was still an anti-inflammatory drug [to test in] people with RA, but with very neutral effects on blood pressure,’ he said.
Among patients with RA, the blood pressure of those taking methotrexate differed by an average of 7.4 mmHg compared with people taking sulfasalazine.
‘Most tablets for blood pressure, when given at a moderate to high dose, will have an effect on blood pressure of between 5–10 mmHg – which is normally, at the population level, associated with the reduction in cardiovascular risk of around 10–15%,’ Prof Mangoni said. ‘So by extrapolation, methotrexate compares very well to a traditional antihypertensive medication.’
In patients with RA who don’t have hypertension, methotrexate could also have a preventative effect.
‘That was very well shown in our study, with only a proportion of [participants] having hypertension,’ Prof Mangoni said.
The medicine can also be assumed to lower cardiovascular risk.
‘If there is a positive effect on blood pressure, consequently, you should have a reduced risk of myocardial infarction and stroke, as well as potentially heart failure,’ he said.
Although the impacts of methotrexate on these indications were not specifically tested in the research, the observational results are promising.
‘They are in line with increasing clinical evidence from epidemiological studies that the use of methotrexate is associated with a reduced risk of heart failure, heart attacks and strokes in people with RA,’ Prof Mangoni said.
Is there potential for a new indication?
In people who have both hypertension and RA, there’s a possibility that medicine regimens could change, Prof Mangoni said.
‘The future should address whether the use of methotrexate in this population can allow modification of antihypertensive medications to have a different treatment regimen,’ he said.
‘Methotrexate could also be an adjuvant, but this can only be tested in adequately designed prospective studies.’
Beyond patients with RA, it’s possible that methotrexate might also be indicated for patients with hypertension in the not-too-distant future. But Prof Mangoni concedes this is an ‘increasingly debated topic’.
‘There has only been one study, published 5 years ago, that looks at the effects of low-dose methotrexate on cardiovascular risk in people without RA,’ he said.
‘The idea was that by giving methotrexate to this population that already has a high pro-inflammatory burden, you would actually reduce the risk of atherosclerosis.’
While this study didn’t yield positive results, there are a few reasons behind this that warrant further exploration. The participants in both the intervention and placebo groups did not have particularly high inflammatory markers, and both groups also received folic acid.
‘Folic acid is given together with methotrexate because it has been shown to reduce the toxicity of [the medicine],’ Prof Mangoni said. ‘However, folic acid can also be protective against atherosclerosis. So the fact that it was also given to the placebo arm might have somewhat diluted the protective effects of methotrexate in this trial.’
To best assess the effects in future research, he suggests a trial design comprising three arms: methotrexate plus folic acid, folic acid alone and the placebo group.
‘I suspect that in the future, methotrexate might have value in people without autoimmune diseases, but with a high inflammatory burden,’ he said.
What role does genetics play in the success of therapy?
Another key finding from the research is that methotrexate may not be the right fit for everyone. The medicine has a complex pharmacology, with several mechanisms facilitating its uptake and storage in cells, Prof Mangoni said.
‘Sometimes it is excreted by the cell, so it [reaches] different targets, with each of these targets potentially having genetic variations,’ he said.
Research has shown that there are several genetic polymorphisms that render people more or less responsive to methotrexate in terms of blood pressure reduction.
‘Interestingly, the polymorphisms that we observed [in our research] are different from the polymorphisms that have been previously described,’ Prof Mangoni said.
‘So future research should look for personalised treatment strategies to identify whether these polymorphisms are similar or different to other polymorphisms responsible for blood pressure reduction – and potentially the reduced risk of atherosclerosis.’
In further research, Prof Mangoni is keen to confirm the role of polymorphisms in lowering blood pressure after treatment with methotrexate, with pharmacogenomics determining who is a suitable candidate for the medicine.
‘The idea is to have a comprehensive genetic panel in people who are considered for treatment for methotrexate to determine from the very beginning who is more or less likely to respond,’ he said.
‘The next step is determining whether these polymorphisms could be translated into a non-RA population to see whether this can be tailored to the treatment of methotrexate in these [people].’
[post_title] => Blood pressure benefits seen with methotrexate treatment
[post_excerpt] => New research links methotrexate to a fall in blood pressure. This expert thinks it could lower cardiovascular risk in the general population.
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[post_content] => Parents have reported persistent anxiety about asthma attacks while children miss out. Pharmacists can help to pivot care from treating flare-ups to stopping them.
Australian families are still living with the hidden emotional toll of childhood asthma – even when they believe control is ‘good enough’.
New research, released as part of the launch of Asthma Australia's new multi-year 'Attack Asthma' campaign found that most (60%) of the parents surveyed live with constant anxiety about the next asthma attack, while 57% worry about their child missing out on normal activities.
A reactive approach to asthma management appears to be driving these concerns, with more than half (58%) of parents revealing their child does not use a preventer daily. More than two-thirds (66%) who notice wheeze, cough or breathlessness dismiss these as symptoms of a lingering cold, virus or allergy, rather than asthma. And even when asthma is suspected, nearly a third (30%) still don’t pursue a diagnosis, assuming the symptoms aren’t severe enough.
This National Asthma Week (1–7 September), Australian Pharmacist sat down with Dr Chris Pearce – a Melbourne-based GP who’s on the board of Asthma Australia – about how pharmacists can help to flip the narrative from ‘asthma attack’ to ‘attack asthma’.
Shifting the perspective from reactive to proactive
The difference between asthma and many other chronic conditions is its variability.
So for many decades, asthma care typically began with a reliever (usually a short-acting beta-2 agonist (SABA) as the first step for symptom relief.
‘The asthma action plans in times past emphasised that if you get an [attack] use [salbutamol] Ventolin,’ Dr Pearce said. ‘But we've now moved on to encourage the increased use of preventers to stop the acute attacks.’
The purpose of this strategy is to lessen the impact of asthma on children, along with the parental anxiety that goes with it.
‘The classic example is sport where we used to say, “make sure you've got a blue puffer and use it if you get a bit wheezy”,’ he said.
Even without obvious symptoms such as coughing and shortness of breath, these children were likely experiencing mild symptoms such as tiredness, Dr Pearce said.
‘They weren't reaching their full potential because they had subclinical symptoms,’ he said.
When dispensing preventers and supplying salbutamol, pharmacists can help to transform the approach to asthma management from reactive to proactive.
‘What you do in the intervals between attacks, that’s more important than how you manage an actual attack,’ Dr Pearce said.
‘I say to people, “This is a disease that you have all the time, and we need to manage it all the time because we're trying to maximise your child's potential, rather than just treating attacks.”
Identifying undiagnosed or uncontrolled asthma
Pharmacists are often the first port of call when children experience a minor ailment, Dr Pearce said.
‘That’s when parents front up to the pharmacy and say, “my child has a cough” or “my child's a bit wheezy”,’ he said.
But if you dig a little deeper, you can often unearth the root cause.
‘If you ask a few questions rather than taking it at face value, it might be revealed that they haven't got a runny nose or a temperature, and it could actually be a manifestation of asthma,’ he said.
‘If a child tends to get a cough with every cold and they're coming in for the cough syrup each and every time, that's a bit of a red flag.’
When parents of children who do have confirmed asthma buy salbutamol over-the-counter, pharmacists should monitor how often they purchase it and recommend a formal assessment where appropriate.
‘It’s not about refusing people who want to buy Ventolin, but just planting the seed that a more formal assessment is a good thing,’ Dr Pearce said.
Another indicator can lie in My Health Record.
‘You might see that, unbeknownst to you, there's been a couple of scripts of oral prednisolone from the local hospital,’ he said.
Picking up on poor inhaler technique
Even when patients are using preventer medicines, the wrong inhaler technique can impact treatment outcomes.
This can include anything from not using a spacer when it’s deemed appropriate or not pointing the inhaler in the right direction.
‘I've seen inhalers held six inches away from the mouth,’ Dr Pearce said. ‘I've also seen people who use other devices such as Turbuhalers not click the dial, so they're just inhaling air,’ he said.
When a preventer is first prescribed, Dr Pearce advises pharmacists to demonstrate the correct technique.
‘Then there's a role, especially in children, to check their technique a couple of times a year,’ he said. ‘You can also get the parent to bring the spacer in to check if it’s cracked and broken.’
In children with mild and intermittent asthma, pharmacists can also check whether the preventer dose is appropriate.
‘They grow, but [sometimes] their dose doesn't,’ he said. ‘So you need to occasionally rethink whether they're getting the right dose, and suggest they should go to the GP to get it reviewed.’
Improving adherence and long-term management
Pharmacists can help to reinforce strategies to improve adherence, Dr Pearce said.
‘One of the things about regular maintenance is that it's regular, so it gets into the routine,’ he said. ‘So if you're going to use an inhaler and spacer in the morning and night, having it when you get up and when you go to bed is easier to remember than having to pack it in your school bag every day,’ he said.
Asthma patterns are individual and can vary seasonally. So in all asthma cases, reviewing the pattern of disease is key.
‘For some people, spring has no impact, whereas for others it’s a complete disaster,’ Dr Pearce said.
‘For those patients, my recommendation would be to double the preventer dose for the next couple of months so they continue to be well – regardless of what's going on with the weather.
‘We're keen on a review every 6 months, even in stable children, just to make sure that everyone's keeping on top of it.’
For parents who are concerned about the medication burden of daily preventer use, Dr Pearce said it’s important to emphasise the risks and benefits.
‘There are some side effects from taking inhaled corticosteroids on a regular basis, but they're unusual, and if they do occur they are mild – much less than what you would get from several courses of oral corticosteroids over a year when asthma is not controlled,’ he said.
It’s also important for parents to balance the potential adverse effects from long-term corticosteroid use in a child with mild and untreated asthma, who's not able to concentrate at school.
‘If they’re not able to concentrate at school or perform at their best in sport, in my view the benefits outweigh the risks,’ Dr Pearce said.
It’s also helpful to remind parents that the better controlled their child’s asthma is, the lower their dose of inhaled corticosteroids will need to be.
‘The old asthma action plans used to say, “use your Ventolin when you need it. And if you get sick, take a big dose of your inhaled corticosteroids”,’ Dr Pearce said. ‘But if we use a small dose regularly, it’s much better tolerated by the body.’
[post_title] => The hidden toll of ‘good enough’ asthma control
[post_excerpt] => Parents have reported persistent anxiety about asthma attacks. Pharmacists can help to pivot care from treating flare-ups to stopping them.
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[title_attribute] => The hidden toll of ‘good enough’ asthma control
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[post_content] => Australia is one of many countries pursuing evolution in pharmacist scope of practice through prescribing.
While pharmacists have long prescribed Pharmacy Medicines and Pharmacist Only Medicines, prescribing higher-risk medicines is relatively new.
On Monday (1 September), a panel of experts at the FIP World Congress explored the ethical issues which arise from this shift, and those which Australian pharmacists and governance systems will need to navigate.
UK: Put in place structures to navigate undue pressure
The UK has had a head start on pharmacist prescribing, with a third of registered pharmacists now endorsed as pharmacist prescribers – a number set to grow rapidly following its incorporation into undergraduate training.
Claire May, Senior Lecturer in Pharmacy Practice at the University of Brighton, highlighted that number of UK pharmacists feel pressured to prescribe outside of their accountability and scope – and that this will probably be one of the greatest ethical challenges.
‘The future of pharmacists prescribing, I believe, is shaped by three powerful forces: digitalisation, workforce pressures and regulatory reform,’ she said. ‘How do we make sure every prescribing decision is made with confidence, competence and care?’
In exploring the answers to this, Mrs May identified commitment to lifelong learning, professional culture and getting the regulations right.
The panel cautioned other countries following a proliferation of independent pharmacists supporting protocol-based online prescribing clinics. They also reflected on situations where pharmacist prescribers in general practice were pressured to sign (authorise) prescriptions outside their individual scope of practice to facilitate ongoing patient care.
Basic ethical principles ‘more important’ when prescribing
So what are the key messages for Australia? Associate Professor Betty Chaar from the University of Sydney highlighted the key ethical issues related to prescribing in her address:
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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"]
Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"]
Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
[post_title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[post_excerpt] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the TGA recording thousands of approvals each month.
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[title_attribute] => As medicinal cannabis prescriptions climb, does the evidence hold up?
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[post_content] => A blistering opening plenary session at the FIP Congress last week has challenged policymakers and health professionals alike to act to slow the advance of antimicrobial resistance (AMR).
Mr Michele Cecchini, Head of Public Health, Organisation for Economic Co-operation and Development (OECD), worked through startling data showing the cost of AMR globally – in dollars, and in years of life lost.
The high price of insufficient action on AMR
The OECD has crunched the numbers, and the statistics are startling.
AMR is currently shortening life expectancy by an average of 1.8 years globally – 1.7 years for people in high-income countries, or 2.5 years for people in low-income countries.
This is represented in 79,000 people dying due to resistant infections across 34 OECD, European Union and European Economic Area counties – corresponding to 2.4 times the number of deaths due to tuberculosis, influenza and HIV/AIDS combined in 2020.
The financial burden on the health system is similarly staggering, with global annual costs totalling $US 412 billion.
Once lost productivity and loss of income costs are added in, this cost balloons to $US 850 billion annually – about the same size of Poland’s economy.
Bold action is required
Modelling by the OECD has shown that meaningful action is achievable – albeit with a substantial price tag.
To reduce AMR-related deaths by 10%, six actions are required:
- All countries need to have national AMR action plans and 60% of countries commit a budget
- 90% of countries should meet WHO’s minimum infection prevention and control programs at a national level
- All countries need to report surveillance data on AMR and antimicrobial use
- Meaningful reduction in antimicrobial use is taken in agrifood systems
- Strengthened actions to prevent and address the discharge of antimicrobials into the environment
- Mechanisms to support research and development to address AMR should be promoted.
The cost of these initiatives globally is estimated to be $US 52 billion annually – equivalent to 0.5% of the global health budget.
‘The World Bank told us this is a rounding error [in the context of health spending]. This is not an amount of money which cannot be mobilised,’ Mr Cecchini said.
These sentiments were echoed by the Danish Minister for the Interior and Health Sophie Løhde.
‘To tackle [AMR], we need to work much closer together, and your role as pharmacists and life science professionals is key,’ said Minister Løhde at the first plenary session of the 2025 FIP world congress last week. ‘We need your expertise to develop new antimicrobials in the most prudent and effective manner, and to inform and educate our citizens when you meet them in pharmacies all over the world.’
The FIP Copenhagen Declaration on Antimicrobial Resistance, signed by 79 organisations – including The Pharmaceutical Society of Australia – took place on 1 September 2025.
The FIP Declaration outlines clear priorities to address AMR, including global partnership building, promoting vaccination and rational antimicrobial use, protecting medicine supply chains, and advancing evidence on stewardship and outcomes.
[post_title] => OECD sounds the alarm on antimicrobial resistance
[post_excerpt] => A blistering session at the FIP Congress challenged policymakers and health professionals to slow the advance of antimicrobial resistance.
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[post_content] => A study led by Flinders University and the Southern Adelaide Local Health Network shows that the anti-rheumatic medicine methotrexate significantly reduces blood pressure in some patients compared with sulfasalazine – the first clear evidence of this effect in patients newly diagnosed with rheumatoid arthritis (RA).
The common autoimmune disease occurs in around one in 100 people, leading to inflammation and pain in the connective tissue of the joints.
The inflammation caused by RA contributes to high blood pressure by damaging blood vessels, prompting rheumatologists to realise that people with RA don't typically die because of their condition, said lead researcher Professor Arduino Mangoni, Head of Pharmacology at Flinders University College of Medicine and Public Health.
[caption id="attachment_30469" align="alignright" width="216"] Professor Arduino Mangoni[/caption]
‘The main reason people with RA die is because they have a cardiovascular event, such as a myocardial infarction or stroke,’ he said. ‘And this is often because of an excess prevalence of hypertension in these individuals.’
High blood pressure can significantly shorten the life expectancy of people with RA.
‘An epidemiological study quantifying the burden of cardiovascular disease in people with RA concluded that the increased risk imparted by rheumatoid arthritis was similar to diabetes,’ Prof Mangoni added.
What impact did methotrexate have on blood pressure?
Methotrexate is not the only anti-rheumatic medicine that can reduce hypertension, with hydroxychloroquine also being shown to be potentially protective against atherosclerosis, Prof Mangoni said.
‘So we wanted to use the comparator, sulfasalazine, that was still an anti-inflammatory drug [to test in] people with RA, but with very neutral effects on blood pressure,’ he said.
Among patients with RA, the blood pressure of those taking methotrexate differed by an average of 7.4 mmHg compared with people taking sulfasalazine.
‘Most tablets for blood pressure, when given at a moderate to high dose, will have an effect on blood pressure of between 5–10 mmHg – which is normally, at the population level, associated with the reduction in cardiovascular risk of around 10–15%,’ Prof Mangoni said. ‘So by extrapolation, methotrexate compares very well to a traditional antihypertensive medication.’
In patients with RA who don’t have hypertension, methotrexate could also have a preventative effect.
‘That was very well shown in our study, with only a proportion of [participants] having hypertension,’ Prof Mangoni said.
The medicine can also be assumed to lower cardiovascular risk.
‘If there is a positive effect on blood pressure, consequently, you should have a reduced risk of myocardial infarction and stroke, as well as potentially heart failure,’ he said.
Although the impacts of methotrexate on these indications were not specifically tested in the research, the observational results are promising.
‘They are in line with increasing clinical evidence from epidemiological studies that the use of methotrexate is associated with a reduced risk of heart failure, heart attacks and strokes in people with RA,’ Prof Mangoni said.
Is there potential for a new indication?
In people who have both hypertension and RA, there’s a possibility that medicine regimens could change, Prof Mangoni said.
‘The future should address whether the use of methotrexate in this population can allow modification of antihypertensive medications to have a different treatment regimen,’ he said.
‘Methotrexate could also be an adjuvant, but this can only be tested in adequately designed prospective studies.’
Beyond patients with RA, it’s possible that methotrexate might also be indicated for patients with hypertension in the not-too-distant future. But Prof Mangoni concedes this is an ‘increasingly debated topic’.
‘There has only been one study, published 5 years ago, that looks at the effects of low-dose methotrexate on cardiovascular risk in people without RA,’ he said.
‘The idea was that by giving methotrexate to this population that already has a high pro-inflammatory burden, you would actually reduce the risk of atherosclerosis.’
While this study didn’t yield positive results, there are a few reasons behind this that warrant further exploration. The participants in both the intervention and placebo groups did not have particularly high inflammatory markers, and both groups also received folic acid.
‘Folic acid is given together with methotrexate because it has been shown to reduce the toxicity of [the medicine],’ Prof Mangoni said. ‘However, folic acid can also be protective against atherosclerosis. So the fact that it was also given to the placebo arm might have somewhat diluted the protective effects of methotrexate in this trial.’
To best assess the effects in future research, he suggests a trial design comprising three arms: methotrexate plus folic acid, folic acid alone and the placebo group.
‘I suspect that in the future, methotrexate might have value in people without autoimmune diseases, but with a high inflammatory burden,’ he said.
What role does genetics play in the success of therapy?
Another key finding from the research is that methotrexate may not be the right fit for everyone. The medicine has a complex pharmacology, with several mechanisms facilitating its uptake and storage in cells, Prof Mangoni said.
‘Sometimes it is excreted by the cell, so it [reaches] different targets, with each of these targets potentially having genetic variations,’ he said.
Research has shown that there are several genetic polymorphisms that render people more or less responsive to methotrexate in terms of blood pressure reduction.
‘Interestingly, the polymorphisms that we observed [in our research] are different from the polymorphisms that have been previously described,’ Prof Mangoni said.
‘So future research should look for personalised treatment strategies to identify whether these polymorphisms are similar or different to other polymorphisms responsible for blood pressure reduction – and potentially the reduced risk of atherosclerosis.’
In further research, Prof Mangoni is keen to confirm the role of polymorphisms in lowering blood pressure after treatment with methotrexate, with pharmacogenomics determining who is a suitable candidate for the medicine.
‘The idea is to have a comprehensive genetic panel in people who are considered for treatment for methotrexate to determine from the very beginning who is more or less likely to respond,’ he said.
‘The next step is determining whether these polymorphisms could be translated into a non-RA population to see whether this can be tailored to the treatment of methotrexate in these [people].’
[post_title] => Blood pressure benefits seen with methotrexate treatment
[post_excerpt] => New research links methotrexate to a fall in blood pressure. This expert thinks it could lower cardiovascular risk in the general population.
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[post_content] => Parents have reported persistent anxiety about asthma attacks while children miss out. Pharmacists can help to pivot care from treating flare-ups to stopping them.
Australian families are still living with the hidden emotional toll of childhood asthma – even when they believe control is ‘good enough’.
New research, released as part of the launch of Asthma Australia's new multi-year 'Attack Asthma' campaign found that most (60%) of the parents surveyed live with constant anxiety about the next asthma attack, while 57% worry about their child missing out on normal activities.
A reactive approach to asthma management appears to be driving these concerns, with more than half (58%) of parents revealing their child does not use a preventer daily. More than two-thirds (66%) who notice wheeze, cough or breathlessness dismiss these as symptoms of a lingering cold, virus or allergy, rather than asthma. And even when asthma is suspected, nearly a third (30%) still don’t pursue a diagnosis, assuming the symptoms aren’t severe enough.
This National Asthma Week (1–7 September), Australian Pharmacist sat down with Dr Chris Pearce – a Melbourne-based GP who’s on the board of Asthma Australia – about how pharmacists can help to flip the narrative from ‘asthma attack’ to ‘attack asthma’.
Shifting the perspective from reactive to proactive
The difference between asthma and many other chronic conditions is its variability.
So for many decades, asthma care typically began with a reliever (usually a short-acting beta-2 agonist (SABA) as the first step for symptom relief.
‘The asthma action plans in times past emphasised that if you get an [attack] use [salbutamol] Ventolin,’ Dr Pearce said. ‘But we've now moved on to encourage the increased use of preventers to stop the acute attacks.’
The purpose of this strategy is to lessen the impact of asthma on children, along with the parental anxiety that goes with it.
‘The classic example is sport where we used to say, “make sure you've got a blue puffer and use it if you get a bit wheezy”,’ he said.
Even without obvious symptoms such as coughing and shortness of breath, these children were likely experiencing mild symptoms such as tiredness, Dr Pearce said.
‘They weren't reaching their full potential because they had subclinical symptoms,’ he said.
When dispensing preventers and supplying salbutamol, pharmacists can help to transform the approach to asthma management from reactive to proactive.
‘What you do in the intervals between attacks, that’s more important than how you manage an actual attack,’ Dr Pearce said.
‘I say to people, “This is a disease that you have all the time, and we need to manage it all the time because we're trying to maximise your child's potential, rather than just treating attacks.”
Identifying undiagnosed or uncontrolled asthma
Pharmacists are often the first port of call when children experience a minor ailment, Dr Pearce said.
‘That’s when parents front up to the pharmacy and say, “my child has a cough” or “my child's a bit wheezy”,’ he said.
But if you dig a little deeper, you can often unearth the root cause.
‘If you ask a few questions rather than taking it at face value, it might be revealed that they haven't got a runny nose or a temperature, and it could actually be a manifestation of asthma,’ he said.
‘If a child tends to get a cough with every cold and they're coming in for the cough syrup each and every time, that's a bit of a red flag.’
When parents of children who do have confirmed asthma buy salbutamol over-the-counter, pharmacists should monitor how often they purchase it and recommend a formal assessment where appropriate.
‘It’s not about refusing people who want to buy Ventolin, but just planting the seed that a more formal assessment is a good thing,’ Dr Pearce said.
Another indicator can lie in My Health Record.
‘You might see that, unbeknownst to you, there's been a couple of scripts of oral prednisolone from the local hospital,’ he said.
Picking up on poor inhaler technique
Even when patients are using preventer medicines, the wrong inhaler technique can impact treatment outcomes.
This can include anything from not using a spacer when it’s deemed appropriate or not pointing the inhaler in the right direction.
‘I've seen inhalers held six inches away from the mouth,’ Dr Pearce said. ‘I've also seen people who use other devices such as Turbuhalers not click the dial, so they're just inhaling air,’ he said.
When a preventer is first prescribed, Dr Pearce advises pharmacists to demonstrate the correct technique.
‘Then there's a role, especially in children, to check their technique a couple of times a year,’ he said. ‘You can also get the parent to bring the spacer in to check if it’s cracked and broken.’
In children with mild and intermittent asthma, pharmacists can also check whether the preventer dose is appropriate.
‘They grow, but [sometimes] their dose doesn't,’ he said. ‘So you need to occasionally rethink whether they're getting the right dose, and suggest they should go to the GP to get it reviewed.’
Improving adherence and long-term management
Pharmacists can help to reinforce strategies to improve adherence, Dr Pearce said.
‘One of the things about regular maintenance is that it's regular, so it gets into the routine,’ he said. ‘So if you're going to use an inhaler and spacer in the morning and night, having it when you get up and when you go to bed is easier to remember than having to pack it in your school bag every day,’ he said.
Asthma patterns are individual and can vary seasonally. So in all asthma cases, reviewing the pattern of disease is key.
‘For some people, spring has no impact, whereas for others it’s a complete disaster,’ Dr Pearce said.
‘For those patients, my recommendation would be to double the preventer dose for the next couple of months so they continue to be well – regardless of what's going on with the weather.
‘We're keen on a review every 6 months, even in stable children, just to make sure that everyone's keeping on top of it.’
For parents who are concerned about the medication burden of daily preventer use, Dr Pearce said it’s important to emphasise the risks and benefits.
‘There are some side effects from taking inhaled corticosteroids on a regular basis, but they're unusual, and if they do occur they are mild – much less than what you would get from several courses of oral corticosteroids over a year when asthma is not controlled,’ he said.
It’s also important for parents to balance the potential adverse effects from long-term corticosteroid use in a child with mild and untreated asthma, who's not able to concentrate at school.
‘If they’re not able to concentrate at school or perform at their best in sport, in my view the benefits outweigh the risks,’ Dr Pearce said.
It’s also helpful to remind parents that the better controlled their child’s asthma is, the lower their dose of inhaled corticosteroids will need to be.
‘The old asthma action plans used to say, “use your Ventolin when you need it. And if you get sick, take a big dose of your inhaled corticosteroids”,’ Dr Pearce said. ‘But if we use a small dose regularly, it’s much better tolerated by the body.’
[post_title] => The hidden toll of ‘good enough’ asthma control
[post_excerpt] => Parents have reported persistent anxiety about asthma attacks. Pharmacists can help to pivot care from treating flare-ups to stopping them.
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[title_attribute] => The hidden toll of ‘good enough’ asthma control
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[post_content] => Australia is one of many countries pursuing evolution in pharmacist scope of practice through prescribing.
While pharmacists have long prescribed Pharmacy Medicines and Pharmacist Only Medicines, prescribing higher-risk medicines is relatively new.
On Monday (1 September), a panel of experts at the FIP World Congress explored the ethical issues which arise from this shift, and those which Australian pharmacists and governance systems will need to navigate.
UK: Put in place structures to navigate undue pressure
The UK has had a head start on pharmacist prescribing, with a third of registered pharmacists now endorsed as pharmacist prescribers – a number set to grow rapidly following its incorporation into undergraduate training.
Claire May, Senior Lecturer in Pharmacy Practice at the University of Brighton, highlighted that number of UK pharmacists feel pressured to prescribe outside of their accountability and scope – and that this will probably be one of the greatest ethical challenges.
‘The future of pharmacists prescribing, I believe, is shaped by three powerful forces: digitalisation, workforce pressures and regulatory reform,’ she said. ‘How do we make sure every prescribing decision is made with confidence, competence and care?’
In exploring the answers to this, Mrs May identified commitment to lifelong learning, professional culture and getting the regulations right.
The panel cautioned other countries following a proliferation of independent pharmacists supporting protocol-based online prescribing clinics. They also reflected on situations where pharmacist prescribers in general practice were pressured to sign (authorise) prescriptions outside their individual scope of practice to facilitate ongoing patient care.
Basic ethical principles ‘more important’ when prescribing
So what are the key messages for Australia? Associate Professor Betty Chaar from the University of Sydney highlighted the key ethical issues related to prescribing in her address:
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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"] Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"] Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
[post_title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[post_excerpt] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the TGA recording thousands of approvals each month.
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[title_attribute] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[href] => https://www.australianpharmacist.com.au/as-medicinal-cannabis-prescriptions-climb-does-the-evidence-hold-up/
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[post_content] => A blistering opening plenary session at the FIP Congress last week has challenged policymakers and health professionals alike to act to slow the advance of antimicrobial resistance (AMR).
Mr Michele Cecchini, Head of Public Health, Organisation for Economic Co-operation and Development (OECD), worked through startling data showing the cost of AMR globally – in dollars, and in years of life lost.
The high price of insufficient action on AMR
The OECD has crunched the numbers, and the statistics are startling.
AMR is currently shortening life expectancy by an average of 1.8 years globally – 1.7 years for people in high-income countries, or 2.5 years for people in low-income countries.
This is represented in 79,000 people dying due to resistant infections across 34 OECD, European Union and European Economic Area counties – corresponding to 2.4 times the number of deaths due to tuberculosis, influenza and HIV/AIDS combined in 2020.
The financial burden on the health system is similarly staggering, with global annual costs totalling $US 412 billion.
Once lost productivity and loss of income costs are added in, this cost balloons to $US 850 billion annually – about the same size of Poland’s economy.
Bold action is required
Modelling by the OECD has shown that meaningful action is achievable – albeit with a substantial price tag.
To reduce AMR-related deaths by 10%, six actions are required:
- All countries need to have national AMR action plans and 60% of countries commit a budget
- 90% of countries should meet WHO’s minimum infection prevention and control programs at a national level
- All countries need to report surveillance data on AMR and antimicrobial use
- Meaningful reduction in antimicrobial use is taken in agrifood systems
- Strengthened actions to prevent and address the discharge of antimicrobials into the environment
- Mechanisms to support research and development to address AMR should be promoted.
The cost of these initiatives globally is estimated to be $US 52 billion annually – equivalent to 0.5% of the global health budget.
‘The World Bank told us this is a rounding error [in the context of health spending]. This is not an amount of money which cannot be mobilised,’ Mr Cecchini said.
These sentiments were echoed by the Danish Minister for the Interior and Health Sophie Løhde.
‘To tackle [AMR], we need to work much closer together, and your role as pharmacists and life science professionals is key,’ said Minister Løhde at the first plenary session of the 2025 FIP world congress last week. ‘We need your expertise to develop new antimicrobials in the most prudent and effective manner, and to inform and educate our citizens when you meet them in pharmacies all over the world.’
The FIP Copenhagen Declaration on Antimicrobial Resistance, signed by 79 organisations – including The Pharmaceutical Society of Australia – took place on 1 September 2025.
The FIP Declaration outlines clear priorities to address AMR, including global partnership building, promoting vaccination and rational antimicrobial use, protecting medicine supply chains, and advancing evidence on stewardship and outcomes.
[post_title] => OECD sounds the alarm on antimicrobial resistance
[post_excerpt] => A blistering session at the FIP Congress challenged policymakers and health professionals to slow the advance of antimicrobial resistance.
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[title_attribute] => OECD sounds the alarm on antimicrobial resistance
[title] => OECD sounds the alarm on antimicrobial resistance
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[post_content] => A study led by Flinders University and the Southern Adelaide Local Health Network shows that the anti-rheumatic medicine methotrexate significantly reduces blood pressure in some patients compared with sulfasalazine – the first clear evidence of this effect in patients newly diagnosed with rheumatoid arthritis (RA).
The common autoimmune disease occurs in around one in 100 people, leading to inflammation and pain in the connective tissue of the joints.
The inflammation caused by RA contributes to high blood pressure by damaging blood vessels, prompting rheumatologists to realise that people with RA don't typically die because of their condition, said lead researcher Professor Arduino Mangoni, Head of Pharmacology at Flinders University College of Medicine and Public Health.
[caption id="attachment_30469" align="alignright" width="216"] Professor Arduino Mangoni[/caption]
‘The main reason people with RA die is because they have a cardiovascular event, such as a myocardial infarction or stroke,’ he said. ‘And this is often because of an excess prevalence of hypertension in these individuals.’
High blood pressure can significantly shorten the life expectancy of people with RA.
‘An epidemiological study quantifying the burden of cardiovascular disease in people with RA concluded that the increased risk imparted by rheumatoid arthritis was similar to diabetes,’ Prof Mangoni added.
What impact did methotrexate have on blood pressure?
Methotrexate is not the only anti-rheumatic medicine that can reduce hypertension, with hydroxychloroquine also being shown to be potentially protective against atherosclerosis, Prof Mangoni said.
‘So we wanted to use the comparator, sulfasalazine, that was still an anti-inflammatory drug [to test in] people with RA, but with very neutral effects on blood pressure,’ he said.
Among patients with RA, the blood pressure of those taking methotrexate differed by an average of 7.4 mmHg compared with people taking sulfasalazine.
‘Most tablets for blood pressure, when given at a moderate to high dose, will have an effect on blood pressure of between 5–10 mmHg – which is normally, at the population level, associated with the reduction in cardiovascular risk of around 10–15%,’ Prof Mangoni said. ‘So by extrapolation, methotrexate compares very well to a traditional antihypertensive medication.’
In patients with RA who don’t have hypertension, methotrexate could also have a preventative effect.
‘That was very well shown in our study, with only a proportion of [participants] having hypertension,’ Prof Mangoni said.
The medicine can also be assumed to lower cardiovascular risk.
‘If there is a positive effect on blood pressure, consequently, you should have a reduced risk of myocardial infarction and stroke, as well as potentially heart failure,’ he said.
Although the impacts of methotrexate on these indications were not specifically tested in the research, the observational results are promising.
‘They are in line with increasing clinical evidence from epidemiological studies that the use of methotrexate is associated with a reduced risk of heart failure, heart attacks and strokes in people with RA,’ Prof Mangoni said.
Is there potential for a new indication?
In people who have both hypertension and RA, there’s a possibility that medicine regimens could change, Prof Mangoni said.
‘The future should address whether the use of methotrexate in this population can allow modification of antihypertensive medications to have a different treatment regimen,’ he said.
‘Methotrexate could also be an adjuvant, but this can only be tested in adequately designed prospective studies.’
Beyond patients with RA, it’s possible that methotrexate might also be indicated for patients with hypertension in the not-too-distant future. But Prof Mangoni concedes this is an ‘increasingly debated topic’.
‘There has only been one study, published 5 years ago, that looks at the effects of low-dose methotrexate on cardiovascular risk in people without RA,’ he said.
‘The idea was that by giving methotrexate to this population that already has a high pro-inflammatory burden, you would actually reduce the risk of atherosclerosis.’
While this study didn’t yield positive results, there are a few reasons behind this that warrant further exploration. The participants in both the intervention and placebo groups did not have particularly high inflammatory markers, and both groups also received folic acid.
‘Folic acid is given together with methotrexate because it has been shown to reduce the toxicity of [the medicine],’ Prof Mangoni said. ‘However, folic acid can also be protective against atherosclerosis. So the fact that it was also given to the placebo arm might have somewhat diluted the protective effects of methotrexate in this trial.’
To best assess the effects in future research, he suggests a trial design comprising three arms: methotrexate plus folic acid, folic acid alone and the placebo group.
‘I suspect that in the future, methotrexate might have value in people without autoimmune diseases, but with a high inflammatory burden,’ he said.
What role does genetics play in the success of therapy?
Another key finding from the research is that methotrexate may not be the right fit for everyone. The medicine has a complex pharmacology, with several mechanisms facilitating its uptake and storage in cells, Prof Mangoni said.
‘Sometimes it is excreted by the cell, so it [reaches] different targets, with each of these targets potentially having genetic variations,’ he said.
Research has shown that there are several genetic polymorphisms that render people more or less responsive to methotrexate in terms of blood pressure reduction.
‘Interestingly, the polymorphisms that we observed [in our research] are different from the polymorphisms that have been previously described,’ Prof Mangoni said.
‘So future research should look for personalised treatment strategies to identify whether these polymorphisms are similar or different to other polymorphisms responsible for blood pressure reduction – and potentially the reduced risk of atherosclerosis.’
In further research, Prof Mangoni is keen to confirm the role of polymorphisms in lowering blood pressure after treatment with methotrexate, with pharmacogenomics determining who is a suitable candidate for the medicine.
‘The idea is to have a comprehensive genetic panel in people who are considered for treatment for methotrexate to determine from the very beginning who is more or less likely to respond,’ he said.
‘The next step is determining whether these polymorphisms could be translated into a non-RA population to see whether this can be tailored to the treatment of methotrexate in these [people].’
[post_title] => Blood pressure benefits seen with methotrexate treatment
[post_excerpt] => New research links methotrexate to a fall in blood pressure. This expert thinks it could lower cardiovascular risk in the general population.
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[title_attribute] => Blood pressure benefits seen with methotrexate treatment
[title] => Blood pressure benefits seen with methotrexate treatment
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[post_content] => Parents have reported persistent anxiety about asthma attacks while children miss out. Pharmacists can help to pivot care from treating flare-ups to stopping them.
Australian families are still living with the hidden emotional toll of childhood asthma – even when they believe control is ‘good enough’.
New research, released as part of the launch of Asthma Australia's new multi-year 'Attack Asthma' campaign found that most (60%) of the parents surveyed live with constant anxiety about the next asthma attack, while 57% worry about their child missing out on normal activities.
A reactive approach to asthma management appears to be driving these concerns, with more than half (58%) of parents revealing their child does not use a preventer daily. More than two-thirds (66%) who notice wheeze, cough or breathlessness dismiss these as symptoms of a lingering cold, virus or allergy, rather than asthma. And even when asthma is suspected, nearly a third (30%) still don’t pursue a diagnosis, assuming the symptoms aren’t severe enough.
This National Asthma Week (1–7 September), Australian Pharmacist sat down with Dr Chris Pearce – a Melbourne-based GP who’s on the board of Asthma Australia – about how pharmacists can help to flip the narrative from ‘asthma attack’ to ‘attack asthma’.
Shifting the perspective from reactive to proactive
The difference between asthma and many other chronic conditions is its variability.
So for many decades, asthma care typically began with a reliever (usually a short-acting beta-2 agonist (SABA) as the first step for symptom relief.
‘The asthma action plans in times past emphasised that if you get an [attack] use [salbutamol] Ventolin,’ Dr Pearce said. ‘But we've now moved on to encourage the increased use of preventers to stop the acute attacks.’
The purpose of this strategy is to lessen the impact of asthma on children, along with the parental anxiety that goes with it.
‘The classic example is sport where we used to say, “make sure you've got a blue puffer and use it if you get a bit wheezy”,’ he said.
Even without obvious symptoms such as coughing and shortness of breath, these children were likely experiencing mild symptoms such as tiredness, Dr Pearce said.
‘They weren't reaching their full potential because they had subclinical symptoms,’ he said.
When dispensing preventers and supplying salbutamol, pharmacists can help to transform the approach to asthma management from reactive to proactive.
‘What you do in the intervals between attacks, that’s more important than how you manage an actual attack,’ Dr Pearce said.
‘I say to people, “This is a disease that you have all the time, and we need to manage it all the time because we're trying to maximise your child's potential, rather than just treating attacks.”
Identifying undiagnosed or uncontrolled asthma
Pharmacists are often the first port of call when children experience a minor ailment, Dr Pearce said.
‘That’s when parents front up to the pharmacy and say, “my child has a cough” or “my child's a bit wheezy”,’ he said.
But if you dig a little deeper, you can often unearth the root cause.
‘If you ask a few questions rather than taking it at face value, it might be revealed that they haven't got a runny nose or a temperature, and it could actually be a manifestation of asthma,’ he said.
‘If a child tends to get a cough with every cold and they're coming in for the cough syrup each and every time, that's a bit of a red flag.’
When parents of children who do have confirmed asthma buy salbutamol over-the-counter, pharmacists should monitor how often they purchase it and recommend a formal assessment where appropriate.
‘It’s not about refusing people who want to buy Ventolin, but just planting the seed that a more formal assessment is a good thing,’ Dr Pearce said.
Another indicator can lie in My Health Record.
‘You might see that, unbeknownst to you, there's been a couple of scripts of oral prednisolone from the local hospital,’ he said.
Picking up on poor inhaler technique
Even when patients are using preventer medicines, the wrong inhaler technique can impact treatment outcomes.
This can include anything from not using a spacer when it’s deemed appropriate or not pointing the inhaler in the right direction.
‘I've seen inhalers held six inches away from the mouth,’ Dr Pearce said. ‘I've also seen people who use other devices such as Turbuhalers not click the dial, so they're just inhaling air,’ he said.
When a preventer is first prescribed, Dr Pearce advises pharmacists to demonstrate the correct technique.
‘Then there's a role, especially in children, to check their technique a couple of times a year,’ he said. ‘You can also get the parent to bring the spacer in to check if it’s cracked and broken.’
In children with mild and intermittent asthma, pharmacists can also check whether the preventer dose is appropriate.
‘They grow, but [sometimes] their dose doesn't,’ he said. ‘So you need to occasionally rethink whether they're getting the right dose, and suggest they should go to the GP to get it reviewed.’
Improving adherence and long-term management
Pharmacists can help to reinforce strategies to improve adherence, Dr Pearce said.
‘One of the things about regular maintenance is that it's regular, so it gets into the routine,’ he said. ‘So if you're going to use an inhaler and spacer in the morning and night, having it when you get up and when you go to bed is easier to remember than having to pack it in your school bag every day,’ he said.
Asthma patterns are individual and can vary seasonally. So in all asthma cases, reviewing the pattern of disease is key.
‘For some people, spring has no impact, whereas for others it’s a complete disaster,’ Dr Pearce said.
‘For those patients, my recommendation would be to double the preventer dose for the next couple of months so they continue to be well – regardless of what's going on with the weather.
‘We're keen on a review every 6 months, even in stable children, just to make sure that everyone's keeping on top of it.’
For parents who are concerned about the medication burden of daily preventer use, Dr Pearce said it’s important to emphasise the risks and benefits.
‘There are some side effects from taking inhaled corticosteroids on a regular basis, but they're unusual, and if they do occur they are mild – much less than what you would get from several courses of oral corticosteroids over a year when asthma is not controlled,’ he said.
It’s also important for parents to balance the potential adverse effects from long-term corticosteroid use in a child with mild and untreated asthma, who's not able to concentrate at school.
‘If they’re not able to concentrate at school or perform at their best in sport, in my view the benefits outweigh the risks,’ Dr Pearce said.
It’s also helpful to remind parents that the better controlled their child’s asthma is, the lower their dose of inhaled corticosteroids will need to be.
‘The old asthma action plans used to say, “use your Ventolin when you need it. And if you get sick, take a big dose of your inhaled corticosteroids”,’ Dr Pearce said. ‘But if we use a small dose regularly, it’s much better tolerated by the body.’
[post_title] => The hidden toll of ‘good enough’ asthma control
[post_excerpt] => Parents have reported persistent anxiety about asthma attacks. Pharmacists can help to pivot care from treating flare-ups to stopping them.
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[title_attribute] => The hidden toll of ‘good enough’ asthma control
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[post_content] => Australia is one of many countries pursuing evolution in pharmacist scope of practice through prescribing.
While pharmacists have long prescribed Pharmacy Medicines and Pharmacist Only Medicines, prescribing higher-risk medicines is relatively new.
On Monday (1 September), a panel of experts at the FIP World Congress explored the ethical issues which arise from this shift, and those which Australian pharmacists and governance systems will need to navigate.
UK: Put in place structures to navigate undue pressure
The UK has had a head start on pharmacist prescribing, with a third of registered pharmacists now endorsed as pharmacist prescribers – a number set to grow rapidly following its incorporation into undergraduate training.
Claire May, Senior Lecturer in Pharmacy Practice at the University of Brighton, highlighted that number of UK pharmacists feel pressured to prescribe outside of their accountability and scope – and that this will probably be one of the greatest ethical challenges.
‘The future of pharmacists prescribing, I believe, is shaped by three powerful forces: digitalisation, workforce pressures and regulatory reform,’ she said. ‘How do we make sure every prescribing decision is made with confidence, competence and care?’
In exploring the answers to this, Mrs May identified commitment to lifelong learning, professional culture and getting the regulations right.
The panel cautioned other countries following a proliferation of independent pharmacists supporting protocol-based online prescribing clinics. They also reflected on situations where pharmacist prescribers in general practice were pressured to sign (authorise) prescriptions outside their individual scope of practice to facilitate ongoing patient care.
Basic ethical principles ‘more important’ when prescribing
So what are the key messages for Australia? Associate Professor Betty Chaar from the University of Sydney highlighted the key ethical issues related to prescribing in her address:
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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"] Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"] Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
[post_title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[post_excerpt] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the TGA recording thousands of approvals each month.
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[title_attribute] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[href] => https://www.australianpharmacist.com.au/as-medicinal-cannabis-prescriptions-climb-does-the-evidence-hold-up/
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[post_content] => A blistering opening plenary session at the FIP Congress last week has challenged policymakers and health professionals alike to act to slow the advance of antimicrobial resistance (AMR).
Mr Michele Cecchini, Head of Public Health, Organisation for Economic Co-operation and Development (OECD), worked through startling data showing the cost of AMR globally – in dollars, and in years of life lost.
The high price of insufficient action on AMR
The OECD has crunched the numbers, and the statistics are startling.
AMR is currently shortening life expectancy by an average of 1.8 years globally – 1.7 years for people in high-income countries, or 2.5 years for people in low-income countries.
This is represented in 79,000 people dying due to resistant infections across 34 OECD, European Union and European Economic Area counties – corresponding to 2.4 times the number of deaths due to tuberculosis, influenza and HIV/AIDS combined in 2020.
The financial burden on the health system is similarly staggering, with global annual costs totalling $US 412 billion.
Once lost productivity and loss of income costs are added in, this cost balloons to $US 850 billion annually – about the same size of Poland’s economy.
Bold action is required
Modelling by the OECD has shown that meaningful action is achievable – albeit with a substantial price tag.
To reduce AMR-related deaths by 10%, six actions are required:
- All countries need to have national AMR action plans and 60% of countries commit a budget
- 90% of countries should meet WHO’s minimum infection prevention and control programs at a national level
- All countries need to report surveillance data on AMR and antimicrobial use
- Meaningful reduction in antimicrobial use is taken in agrifood systems
- Strengthened actions to prevent and address the discharge of antimicrobials into the environment
- Mechanisms to support research and development to address AMR should be promoted.
The cost of these initiatives globally is estimated to be $US 52 billion annually – equivalent to 0.5% of the global health budget.
‘The World Bank told us this is a rounding error [in the context of health spending]. This is not an amount of money which cannot be mobilised,’ Mr Cecchini said.
These sentiments were echoed by the Danish Minister for the Interior and Health Sophie Løhde.
‘To tackle [AMR], we need to work much closer together, and your role as pharmacists and life science professionals is key,’ said Minister Løhde at the first plenary session of the 2025 FIP world congress last week. ‘We need your expertise to develop new antimicrobials in the most prudent and effective manner, and to inform and educate our citizens when you meet them in pharmacies all over the world.’
The FIP Copenhagen Declaration on Antimicrobial Resistance, signed by 79 organisations – including The Pharmaceutical Society of Australia – took place on 1 September 2025.
The FIP Declaration outlines clear priorities to address AMR, including global partnership building, promoting vaccination and rational antimicrobial use, protecting medicine supply chains, and advancing evidence on stewardship and outcomes.
[post_title] => OECD sounds the alarm on antimicrobial resistance
[post_excerpt] => A blistering session at the FIP Congress challenged policymakers and health professionals to slow the advance of antimicrobial resistance.
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[title_attribute] => OECD sounds the alarm on antimicrobial resistance
[title] => OECD sounds the alarm on antimicrobial resistance
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[post_content] => A study led by Flinders University and the Southern Adelaide Local Health Network shows that the anti-rheumatic medicine methotrexate significantly reduces blood pressure in some patients compared with sulfasalazine – the first clear evidence of this effect in patients newly diagnosed with rheumatoid arthritis (RA).
The common autoimmune disease occurs in around one in 100 people, leading to inflammation and pain in the connective tissue of the joints.
The inflammation caused by RA contributes to high blood pressure by damaging blood vessels, prompting rheumatologists to realise that people with RA don't typically die because of their condition, said lead researcher Professor Arduino Mangoni, Head of Pharmacology at Flinders University College of Medicine and Public Health.
[caption id="attachment_30469" align="alignright" width="216"] Professor Arduino Mangoni[/caption]
‘The main reason people with RA die is because they have a cardiovascular event, such as a myocardial infarction or stroke,’ he said. ‘And this is often because of an excess prevalence of hypertension in these individuals.’
High blood pressure can significantly shorten the life expectancy of people with RA.
‘An epidemiological study quantifying the burden of cardiovascular disease in people with RA concluded that the increased risk imparted by rheumatoid arthritis was similar to diabetes,’ Prof Mangoni added.
What impact did methotrexate have on blood pressure?
Methotrexate is not the only anti-rheumatic medicine that can reduce hypertension, with hydroxychloroquine also being shown to be potentially protective against atherosclerosis, Prof Mangoni said.
‘So we wanted to use the comparator, sulfasalazine, that was still an anti-inflammatory drug [to test in] people with RA, but with very neutral effects on blood pressure,’ he said.
Among patients with RA, the blood pressure of those taking methotrexate differed by an average of 7.4 mmHg compared with people taking sulfasalazine.
‘Most tablets for blood pressure, when given at a moderate to high dose, will have an effect on blood pressure of between 5–10 mmHg – which is normally, at the population level, associated with the reduction in cardiovascular risk of around 10–15%,’ Prof Mangoni said. ‘So by extrapolation, methotrexate compares very well to a traditional antihypertensive medication.’
In patients with RA who don’t have hypertension, methotrexate could also have a preventative effect.
‘That was very well shown in our study, with only a proportion of [participants] having hypertension,’ Prof Mangoni said.
The medicine can also be assumed to lower cardiovascular risk.
‘If there is a positive effect on blood pressure, consequently, you should have a reduced risk of myocardial infarction and stroke, as well as potentially heart failure,’ he said.
Although the impacts of methotrexate on these indications were not specifically tested in the research, the observational results are promising.
‘They are in line with increasing clinical evidence from epidemiological studies that the use of methotrexate is associated with a reduced risk of heart failure, heart attacks and strokes in people with RA,’ Prof Mangoni said.
Is there potential for a new indication?
In people who have both hypertension and RA, there’s a possibility that medicine regimens could change, Prof Mangoni said.
‘The future should address whether the use of methotrexate in this population can allow modification of antihypertensive medications to have a different treatment regimen,’ he said.
‘Methotrexate could also be an adjuvant, but this can only be tested in adequately designed prospective studies.’
Beyond patients with RA, it’s possible that methotrexate might also be indicated for patients with hypertension in the not-too-distant future. But Prof Mangoni concedes this is an ‘increasingly debated topic’.
‘There has only been one study, published 5 years ago, that looks at the effects of low-dose methotrexate on cardiovascular risk in people without RA,’ he said.
‘The idea was that by giving methotrexate to this population that already has a high pro-inflammatory burden, you would actually reduce the risk of atherosclerosis.’
While this study didn’t yield positive results, there are a few reasons behind this that warrant further exploration. The participants in both the intervention and placebo groups did not have particularly high inflammatory markers, and both groups also received folic acid.
‘Folic acid is given together with methotrexate because it has been shown to reduce the toxicity of [the medicine],’ Prof Mangoni said. ‘However, folic acid can also be protective against atherosclerosis. So the fact that it was also given to the placebo arm might have somewhat diluted the protective effects of methotrexate in this trial.’
To best assess the effects in future research, he suggests a trial design comprising three arms: methotrexate plus folic acid, folic acid alone and the placebo group.
‘I suspect that in the future, methotrexate might have value in people without autoimmune diseases, but with a high inflammatory burden,’ he said.
What role does genetics play in the success of therapy?
Another key finding from the research is that methotrexate may not be the right fit for everyone. The medicine has a complex pharmacology, with several mechanisms facilitating its uptake and storage in cells, Prof Mangoni said.
‘Sometimes it is excreted by the cell, so it [reaches] different targets, with each of these targets potentially having genetic variations,’ he said.
Research has shown that there are several genetic polymorphisms that render people more or less responsive to methotrexate in terms of blood pressure reduction.
‘Interestingly, the polymorphisms that we observed [in our research] are different from the polymorphisms that have been previously described,’ Prof Mangoni said.
‘So future research should look for personalised treatment strategies to identify whether these polymorphisms are similar or different to other polymorphisms responsible for blood pressure reduction – and potentially the reduced risk of atherosclerosis.’
In further research, Prof Mangoni is keen to confirm the role of polymorphisms in lowering blood pressure after treatment with methotrexate, with pharmacogenomics determining who is a suitable candidate for the medicine.
‘The idea is to have a comprehensive genetic panel in people who are considered for treatment for methotrexate to determine from the very beginning who is more or less likely to respond,’ he said.
‘The next step is determining whether these polymorphisms could be translated into a non-RA population to see whether this can be tailored to the treatment of methotrexate in these [people].’
[post_title] => Blood pressure benefits seen with methotrexate treatment
[post_excerpt] => New research links methotrexate to a fall in blood pressure. This expert thinks it could lower cardiovascular risk in the general population.
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[title_attribute] => Blood pressure benefits seen with methotrexate treatment
[title] => Blood pressure benefits seen with methotrexate treatment
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[post_content] => Parents have reported persistent anxiety about asthma attacks while children miss out. Pharmacists can help to pivot care from treating flare-ups to stopping them.
Australian families are still living with the hidden emotional toll of childhood asthma – even when they believe control is ‘good enough’.
New research, released as part of the launch of Asthma Australia's new multi-year 'Attack Asthma' campaign found that most (60%) of the parents surveyed live with constant anxiety about the next asthma attack, while 57% worry about their child missing out on normal activities.
A reactive approach to asthma management appears to be driving these concerns, with more than half (58%) of parents revealing their child does not use a preventer daily. More than two-thirds (66%) who notice wheeze, cough or breathlessness dismiss these as symptoms of a lingering cold, virus or allergy, rather than asthma. And even when asthma is suspected, nearly a third (30%) still don’t pursue a diagnosis, assuming the symptoms aren’t severe enough.
This National Asthma Week (1–7 September), Australian Pharmacist sat down with Dr Chris Pearce – a Melbourne-based GP who’s on the board of Asthma Australia – about how pharmacists can help to flip the narrative from ‘asthma attack’ to ‘attack asthma’.
Shifting the perspective from reactive to proactive
The difference between asthma and many other chronic conditions is its variability.
So for many decades, asthma care typically began with a reliever (usually a short-acting beta-2 agonist (SABA) as the first step for symptom relief.
‘The asthma action plans in times past emphasised that if you get an [attack] use [salbutamol] Ventolin,’ Dr Pearce said. ‘But we've now moved on to encourage the increased use of preventers to stop the acute attacks.’
The purpose of this strategy is to lessen the impact of asthma on children, along with the parental anxiety that goes with it.
‘The classic example is sport where we used to say, “make sure you've got a blue puffer and use it if you get a bit wheezy”,’ he said.
Even without obvious symptoms such as coughing and shortness of breath, these children were likely experiencing mild symptoms such as tiredness, Dr Pearce said.
‘They weren't reaching their full potential because they had subclinical symptoms,’ he said.
When dispensing preventers and supplying salbutamol, pharmacists can help to transform the approach to asthma management from reactive to proactive.
‘What you do in the intervals between attacks, that’s more important than how you manage an actual attack,’ Dr Pearce said.
‘I say to people, “This is a disease that you have all the time, and we need to manage it all the time because we're trying to maximise your child's potential, rather than just treating attacks.”
Identifying undiagnosed or uncontrolled asthma
Pharmacists are often the first port of call when children experience a minor ailment, Dr Pearce said.
‘That’s when parents front up to the pharmacy and say, “my child has a cough” or “my child's a bit wheezy”,’ he said.
But if you dig a little deeper, you can often unearth the root cause.
‘If you ask a few questions rather than taking it at face value, it might be revealed that they haven't got a runny nose or a temperature, and it could actually be a manifestation of asthma,’ he said.
‘If a child tends to get a cough with every cold and they're coming in for the cough syrup each and every time, that's a bit of a red flag.’
When parents of children who do have confirmed asthma buy salbutamol over-the-counter, pharmacists should monitor how often they purchase it and recommend a formal assessment where appropriate.
‘It’s not about refusing people who want to buy Ventolin, but just planting the seed that a more formal assessment is a good thing,’ Dr Pearce said.
Another indicator can lie in My Health Record.
‘You might see that, unbeknownst to you, there's been a couple of scripts of oral prednisolone from the local hospital,’ he said.
Picking up on poor inhaler technique
Even when patients are using preventer medicines, the wrong inhaler technique can impact treatment outcomes.
This can include anything from not using a spacer when it’s deemed appropriate or not pointing the inhaler in the right direction.
‘I've seen inhalers held six inches away from the mouth,’ Dr Pearce said. ‘I've also seen people who use other devices such as Turbuhalers not click the dial, so they're just inhaling air,’ he said.
When a preventer is first prescribed, Dr Pearce advises pharmacists to demonstrate the correct technique.
‘Then there's a role, especially in children, to check their technique a couple of times a year,’ he said. ‘You can also get the parent to bring the spacer in to check if it’s cracked and broken.’
In children with mild and intermittent asthma, pharmacists can also check whether the preventer dose is appropriate.
‘They grow, but [sometimes] their dose doesn't,’ he said. ‘So you need to occasionally rethink whether they're getting the right dose, and suggest they should go to the GP to get it reviewed.’
Improving adherence and long-term management
Pharmacists can help to reinforce strategies to improve adherence, Dr Pearce said.
‘One of the things about regular maintenance is that it's regular, so it gets into the routine,’ he said. ‘So if you're going to use an inhaler and spacer in the morning and night, having it when you get up and when you go to bed is easier to remember than having to pack it in your school bag every day,’ he said.
Asthma patterns are individual and can vary seasonally. So in all asthma cases, reviewing the pattern of disease is key.
‘For some people, spring has no impact, whereas for others it’s a complete disaster,’ Dr Pearce said.
‘For those patients, my recommendation would be to double the preventer dose for the next couple of months so they continue to be well – regardless of what's going on with the weather.
‘We're keen on a review every 6 months, even in stable children, just to make sure that everyone's keeping on top of it.’
For parents who are concerned about the medication burden of daily preventer use, Dr Pearce said it’s important to emphasise the risks and benefits.
‘There are some side effects from taking inhaled corticosteroids on a regular basis, but they're unusual, and if they do occur they are mild – much less than what you would get from several courses of oral corticosteroids over a year when asthma is not controlled,’ he said.
It’s also important for parents to balance the potential adverse effects from long-term corticosteroid use in a child with mild and untreated asthma, who's not able to concentrate at school.
‘If they’re not able to concentrate at school or perform at their best in sport, in my view the benefits outweigh the risks,’ Dr Pearce said.
It’s also helpful to remind parents that the better controlled their child’s asthma is, the lower their dose of inhaled corticosteroids will need to be.
‘The old asthma action plans used to say, “use your Ventolin when you need it. And if you get sick, take a big dose of your inhaled corticosteroids”,’ Dr Pearce said. ‘But if we use a small dose regularly, it’s much better tolerated by the body.’
[post_title] => The hidden toll of ‘good enough’ asthma control
[post_excerpt] => Parents have reported persistent anxiety about asthma attacks. Pharmacists can help to pivot care from treating flare-ups to stopping them.
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[title_attribute] => The hidden toll of ‘good enough’ asthma control
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[post_content] => Australia is one of many countries pursuing evolution in pharmacist scope of practice through prescribing.
While pharmacists have long prescribed Pharmacy Medicines and Pharmacist Only Medicines, prescribing higher-risk medicines is relatively new.
On Monday (1 September), a panel of experts at the FIP World Congress explored the ethical issues which arise from this shift, and those which Australian pharmacists and governance systems will need to navigate.
UK: Put in place structures to navigate undue pressure
The UK has had a head start on pharmacist prescribing, with a third of registered pharmacists now endorsed as pharmacist prescribers – a number set to grow rapidly following its incorporation into undergraduate training.
Claire May, Senior Lecturer in Pharmacy Practice at the University of Brighton, highlighted that number of UK pharmacists feel pressured to prescribe outside of their accountability and scope – and that this will probably be one of the greatest ethical challenges.
‘The future of pharmacists prescribing, I believe, is shaped by three powerful forces: digitalisation, workforce pressures and regulatory reform,’ she said. ‘How do we make sure every prescribing decision is made with confidence, competence and care?’
In exploring the answers to this, Mrs May identified commitment to lifelong learning, professional culture and getting the regulations right.
The panel cautioned other countries following a proliferation of independent pharmacists supporting protocol-based online prescribing clinics. They also reflected on situations where pharmacist prescribers in general practice were pressured to sign (authorise) prescriptions outside their individual scope of practice to facilitate ongoing patient care.
Basic ethical principles ‘more important’ when prescribing
So what are the key messages for Australia? Associate Professor Betty Chaar from the University of Sydney highlighted the key ethical issues related to prescribing in her address:
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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"] Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"] Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
[post_title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[post_excerpt] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the TGA recording thousands of approvals each month.
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[title_attribute] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[href] => https://www.australianpharmacist.com.au/as-medicinal-cannabis-prescriptions-climb-does-the-evidence-hold-up/
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
