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[post_content] => Yesterday (19 August), it was announced that Ozempic (semaglutide 1.0 mg) has received approval from the Therapeutic Goods Administration (TGA) for an expansion of indication to reduce the risk of kidney disease progression in patients with type 2 diabetes and chronic kidney disease (CKD).
It’s estimated that around 2.7 million Australians are living with indicators of CKD, including both diagnosed and undiagnosed cases.
Of these, diabetes is the leading cause of end stage kidney disease (ESKD) – accounting for over a third (38%) of new cases. Of an estimated 333,000 Australians living with both CKD and diabetes, approximately 10,000 are expected to progress to kidney failure.
If not managed appropriately and in serious cases, CKD may also lead to kidney failure, heart disease and stroke, and in some cases, premature death, said Professor Vlado Perkovic, nephrologist and Provost at the University of New South Wales.
‘Early intervention can help with slowing disease progression,’ he said.
‘This approval represents a step forward in addressing the multifaceted needs of individuals living with type 2 diabetes and CKD,’ added Dr Ana Svensson, Vice President of Clinical, Medical and Regulatory at Novo Nordisk Oceania.
What does the evidence say?
The FLOW (Evaluate Renal Function with Semaglutide Once Weekly) trial is a large multinational study that assessed the effects of once-weekly semaglutide 1.0 mg in adults with type 2 diabetes and CKD.
Participants who received semaglutide had a 24% reduction in risk of major kidney events, slower decline in estimated glomerular filtration rate, and decreased albuminuria – compared to placebo. They also experienced improvements in cardiovascular outcomes and all-cause mortality – with the safety profile consistent with previous studies.
To date, the TGA has not released specific dosing guidance related to the new CKD indication.
Will Ozempic be PBS listed for CKD?
Semaglutide (Ozempic) for CKD is currently not subsidised under the Pharmaceutical Benefits Scheme (PBS).
That means the out-of-pocket costs will not be subsidised, compared to around $31.60 for general patients using the medicine under existing PBS criteria.
‘While it is not specifically reimbursed for kidney disease risk reduction, Novo Nordisk continues to engage with government stakeholders to explore opportunities for broader access to our medicines for Australians living with chronic conditions,’ a spokesperson for Novo Nordisk told Australian Pharmacist.
With Ozempic no longer in shortage, will access open up?
Last month (18 July), the TGA officially removed Ozempic from its medicine shortages list, with previous supply restrictions now lifted. Now that Ozempic stocks have returned to a sufficient level, new patients can be initiated on the medicine. But Ozempic prescribed for weight loss is still off-label, with no update to the indication for weight loss. So the PBS criteria on this front also remain unchanged, and it’s uncertain if this will change any time soon.
‘We have semaglutide 2.4 mg (Wegovy) available – it is indicated for the treatment of patients with obesity or overweight and established cardiovascular disease,’ the Novo Nordisk spokesperson said.
But experts hope that subsidy and accessibility will improve over time as demand and evidence grow.
‘There’s no doubt that both cost and availability present a barrier to the more widespread use of semaglutide at the moment,’ Prof Perkovic said. ‘But I’m sure that over time that situation will change and the drugs will become more widely available.’
[post_title] => Ozempic now indicated to prevent CKD progression
[post_excerpt] => Ozempic is the first medicine in Australia approved to slow kidney disease progression in patients with both type 2 diabetes and CKD.
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[post_content] => This national resource supports frontline assessment, management and prompt referral of burn injuries.
Community pharmacists are often the first point of contact for health concerns and public health initiatives, including burns, said Rebecca Schrale, Burns Nurse Practitioner at the Royal Hobart Hospital’s Burns Unit and Australian and New Zealand Burn Association (ANZBA) Burns Prevention Representative for Tasmania.
‘[So] community pharmacists are in a unique position to provide education on initial first aid, referral and wound care,’ she said. ‘They also have an important role in prevention of burn injuries, educating the community and reducing risk.’
To that end, ANZBA, PSA and the National Australian Pharmacy Students’ Association (NAPSA) collaborated to develop guidelines specifically for pharmacists to assist with the assessment and management of burns.
Australian Pharmacist investigates what pharmacists should look out for and how to manage and refer burns appropriately.
What burns do community pharmacists typically encounter?
The full spectrum – from minor to severe, said PSA Tasmania State Manager Dr Ella van Tienen FPS.
‘A lot of it is advice for minor sunburn or small burns,’ she said. ‘But you do get some more serious burns when people aren’t sure what to do with them, or whether they’re serious enough to [require further attention].’
Burns are more likely to occur out of hours, such as on weekends and public holidays – particularly among children – when general practices are typically closed.
‘That’s when kids are home,’ Dr van Tienen added.
Common causes of burns in children include hot water scalds due to access to kettles or stove tops.
‘Teenagers who are newly independent and off at the beach on their own, also present with blistering sunburn,’ she said.
What impact do burns have on the community?
It’s important to remember that even minor burns can have long-term effects on the patient in regard to range of movement, function and the look and feel of the scar, Ms Schrale said.
‘All burn injuries – whether large or small can have a psychological effect on the individual and their family,’ she said. ‘And it’s imperative that patients are referred to burns clinicians in a timely manner.’
Deep burn injuries will result in scarring and could restrict the function of the area that is affected.
‘Pharmacies are often open after hours and on weekends so again they provide clients and their families with timely advice, education and support,’ Ms Schrale said.
What does the burns resource involve?
The new Pharmacists Advisory Card and A3 Poster are new iterations of an old resource, Dr van Tienen said.
‘The original resource had been around for many years, and it needed to be updated,’ she said.
The refreshed burns advisory resource provides pharmacists with up-to-date information on Burns First Aid, and assessment – including burn depth, assessment and minor burn wound care, Ms Schrale said.
‘With this knowledge they are equipped to then follow the ANZBA referral guidelines, highlighting who requires discussion or referral to primary [care] or the local emergency department (ED),’ she said. ‘The updated card ensures the messaging is consistent across pharmacies, community health, primary care and EDs nationally.’
What new information is included?
The new version of the card focuses on information that will assist in early assessment, management and referral of minor burns, Ms Schrale said.
‘It also provides simple and consistent messaging on wound care and medical emergencies – such as large surface area burns, airway burns, circumferential burns and infection,’ she said.
‘The other new addition is the inclusion of information on burns scar management based on evidence-based practice and encouraging referral for any patient who sustains a scar from a burn injury.’
How can the burns resource be used in practice?
Let’s say a parent presents to the pharmacy with a child who has sustained a burn after accidentally knocking over a pot of boiling water while cooking pasta on the stove.
‘If the child has a small [dermal] burn that’s not significantly blistered, the pharmacist could appropriately treat it in the community by providing first aid and dressing advice,’ Dr van Tienen said.
‘The pharmacist should advise the parent to watch out for [significant] blistering, the blisters breaking, any signs of infection or excessive [levels] of pain.’
Indicators that should prompt further action include if the child:
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[post_content] => Too many people are taking way too much Vitamin B6. Here are the risks of high doses and how the Therapeutic Goods Administration (TGA) is responding.
What is the concern about Vitamin B6?
High doses and/or prolonged use of Vitamin B6 above the recommended daily intake (RDI) have been linked to peripheral neuropathy. Most cases have been reported at doses exceeding 500 mg/day, although cases at lower doses have been reported.1
The TGA’s adverse events notification database contains 174 reports1 of peripheral neuropathy, peripheral sensory neuropathy, small fibre neuropathy or chronic polyneuropathy for products containing Vitamin B6.1
The primary concern is the risk of overconsumption of Vitamin B6 from a variety of sources, particularly in individuals using multiple multivitamin and supplement products.1
How many products have Vitamin B6 in them?
Lots! There are over 1,500 products listed on the Australian Register of Therapeutic Goods (ARTG) which contain Vitamin B6. Approximately 100 of these products have more than 50 mg of Vitamin B6 as the single active ingredient.
The inclusion of Vitamin B6 in these products is rarely prominently displayed. And labelling of Vitamin B6 is often not visible to or understood by consumers, instead being referenced as pyridoxine, pyridoxine hydrochloride, pyridoxal 5-phosphate and pyridoxal 5-phosphate monohydrate.1
What is the TGA doing?
The TGA Delegate has made an interim decision to amend the scheduling of medicines containing more than 50 mg of Vitamin B6 but less than 200 mg (per recommended daily dose) to classify them as Pharmacist Only Medicines (Schedule 3).
If the TGA Delegate’s interim decision is confirmed, the schedule changes will take effect on 1 February 2027.
What should pharmacists do differently?
Ensure all consumers are asked if they are taking multiple vitamin or mineral supplements every time a Vitamin B6-containing product is requested or supplied. Where this is the case, it’s important to consider total Vitamin B6 dose, including dietary sources, and ensure it does not exceed 200 mg daily.
Pharmacists should also warn of early signs of neuropathy, such as tingling, burning or numbness – and advise they cease the medicine and seek medical review if this occurs.
Should pharmacists still supply Vitamin B6 for use in pregnancy?
There are a couple of different treatment regimens for pyridoxine (Vitamin B6) tablets for nausea and vomiting of pregnancy which involve divided doses.2–4 Some references caution against quality of evidence and modest benefit.
The maximum daily dose should not exceed 200 mg. This upper dose is generally considered to be safe for the duration of pregnancy.
References
- Australian Government Department of Health, Disability and Ageing. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard in relation to pyridoxine, pyridoxal or pyridoxamine (vitamin B6). 2025. At: www.tga.gov.au/sites/default/files/2025-06/notice-interim-decision-amend-or-not-amend-current-poisons-standard-pyridoxine-pyridoxal-pyridoxamine-vitaminb6.pdf
- Therapeutic Guidelines: Nausea and vomiting during pregnancy. 2025. At: www.tg.org.au
- Government of Western Australia. North Metropolitan Health Service Women and Newborn Health Service. Pyridoxine (Vitamin B6). 2024. At: www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-MPs/Pyridoxine---Vitamin-B6.pdf?thn=0
- Safer Care Victoria. Medications to treat hyperemesis. 2025. At: www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/maternity/nausea-and-vomiting#goto-table1.-medications-to-treat-hyperemesis
[post_title] => How pharmacists should address rising B6 overuse
[post_excerpt] => Too many people are taking way too much Vitamin B6. A senior pharmacist explains the risks of high doses, and how the TGA is responding.
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[post_content] => Pharmacist prescribing is emerging as a powerful extension of primary care in Australia – one that has the potential to improve access, enhance patient outcomes and reshape the profession.
For patients, it means timely, evidence-based treatment without the long waits often associated with GP appointments. For pharmacists, it represents an opportunity to practise to full scope, strengthen professional relationships and deliver care with immediacy and depth.
But becoming a prescriber is not just a new credential – it’s a mindset shift, demanding confidence, competence and a willingness to explore every aspect of a patient’s life to inform safe and effective decisions.
Kate Gunthorpe MPS, a Queensland-based pharmacist prescriber who recently presented at PSA25 and received special commendation in the PSA Symbion Early Career Pharmacist of the Year award category, explained to Australian Pharmacist what budding pharmacist prescribers should expect.
Pharmacist prescribing to become standard practice
According to Ms Gunthorpe, it is no longer a question of if, but when, pharmacist prescribing will become a normal part of primary care in Australia – as it already is in other countries.
‘Our scope will continue to expand. It’s not about replacing anyone, it’s about using every healthcare professional’s skills to their fullest,’ she said. ‘Pharmacist prescribing will also bring more students into the profession, and improve job satisfaction and retention.’
For Ms Gunthorpe, becoming a prescriber was a quest to close the gap between what patients needed and what she could offer.
‘I was often the first health professional someone would see, but without the ability to diagnose and treat within my scope, I sometimes felt like I was sending them away with half the solution,’ she said. ‘Prescribing gives me the ability to act in that moment, keep care local, and make a real difference straight away.’
Patients can often wait weeks to see a GP – or avoid care altogether because it feels too hard. Pharmacist prescribing gives them another safe, qualified option, and helps to ease pressure on other parts of the health system.
‘I’ve seen people walk in with something that’s been bothering them for months, and walk out with a treatment plan in under half an hour,’ Ms Gunthorpe said. ‘For some, it’s the difference between getting treated and just living with the problem.’
From a patient perspective, the feedback on the service has been overwhelmingly positive.
‘People are often surprised that pharmacists can now prescribe, but once they experience it, they appreciate the convenience and thoroughness,’ she said. ‘Many have told me they wish this had been available years ago and I’ve already had several patients come back for other prescribing services because they trust the process.’
Evolving your practice mindset
Becoming a pharmacist prescriber is not a box-ticking exercise – it’s a mindset shift.
Pharmacists are already great at taking medication histories. Asking, ‘Do you have any allergies? Have you had this before? What medications are you taking? Have you had any adverse effects?’ is par for the course.
But effectively growing into full scope requires pharmacists to push the envelope further. Take acne management for example.
As part of standard pharmacist care, acne consultations are mainly about over-the-counter options and suggesting a GP review for more severe cases.
‘Now, [as a pharmacist prescriber], I take a full patient history – incorporating their biopsychosocial factors – to assess the severity and check for underlying causes,’ she said. ‘I can [also] initiate prescription-only treatments when appropriate. It means I can manage the condition from start to finish, rather than just being a stepping stone.’
Sometimes it can be a matter of life or death. Ms Gunthorpe recalled a case where a patient presented with nausea and vomiting. After reviewing his symptoms and social history, a diagnosis of viral or bacterial gastroenteritis didn’t quite fit. So, she probed further:
Q: ‘What do you do for work?’
A: ‘I'm an electrician.’
Q: ‘So did you work today?’
A: ‘Yeah.’
Q: ‘How was work? Anything a bit unusual happen today? Did you bump your head or anything like that?’
A: ‘I stood up in a room today and hit the back of my head so hard I've had a raging headache ever since and I feel dizzy.’
Following this interaction, Ms Gunthorpe sent the patient to the emergency department straight away.
‘If I had just provided him with some ondansetron, he could have not woken up that night,’ she said. ‘So think about how that impacted his treatment plan, just because I asked him what his occupation is.’
Encouraging patients to open up
It’s not always easy getting the right information out of patients – particularly in a pharmacy environment. So Ms Gunthorpe takes a structured approach to these interactions.
‘I say, “I'm going to ask you a few questions about your life and your lifestyle, just to let me get to know you a little bit more so we can create a unique and shared management plan for you”,’ she said.
This helps patients understand that she’s not just prying – and that each question has a purpose.
‘Then they are more than willing,’ she said. ‘Nothing actually surprises me now about what patients say to me – whether it's recreational drugs or the sexual activity they get up to on the weekend.’
Post-consultation, documentation is an equally important part of the process.
‘Everything you asked, the answers to these questions and what the patient tells you has to be documented,’ Ms Gunthorpe said. ‘If it's not documented, then it didn't happen. That's just a flat out rule.’
In other words, you will not be covered medicolegally if you provide advice and there is no paper trail.
‘I encourage you to start documenting – even if it doesn't feel like it's too important,’ she said. ‘That’s something we as a whole industry need to start doing better.’
Redesigning workflows and upskilling staff
While embracing a prescribing mindset is crucial, so is maintaining the dispensary – allowing for uninterrupted patient consultations.
‘We need to ensure our dispensary keeps running while we are off the floor,’ Ms Gunthorpe said. ‘I’ve never worried that someone will burst into the room [when I'm seeing a] GP mid-consult – so we need to create that same protected environment in pharmacy.’
Upskilling pharmacy assistants and dispensary technicians has been key to making this possible. Staff now take patient details before the consultation, manage the consult rooms, and triage patients when Ms Gunthorpe is unavailable – a role they have embraced with enthusiasm.
‘When I’m not there, they need to make appointments, explain our services, and direct patients to me when I am in consults,’ she said. ‘It’s been really satisfying for them to step into expanded roles.’
Reframing relationships with general practice
Pharmacist prescribing is not intended to replace GPs, but to create more accessible, collaborative and timely care – relying on strong relationships, shared responsibility and open communication.
‘Think of prescribing as stepping into a shared space, not taking over someone else’s. Let’s do it together, with confidence, compassion, and clinical excellence,’ Ms Gunthorpe said.
In some cases referral to a GP is necessary, particularly when additional diagnostics are required. This can cause frustration if patients pay for a consultation but leave without medicines. So strengthening GP-pharmacist relationships is essential to making the model work.
‘We want this to be a shared space where we both feel safe and respected when referring either way,’ she said. ‘If a GP is booked out for 2 weeks and a child has otitis media, we want the receptionist to be able to say, “Kate down the road has consults available this afternoon”. That’s the collaboration we’re aiming for.’
Queensland Government funding for pharmacists to undertake prescribing training remains open. For more information and to check eligibility visit Pharmacist Prescribing Scope of Practice Training Program.
[post_title] => The mindset shift that’s key to prescribing success
[post_excerpt] => Pharmacist prescribing is emerging as a powerful extension of primary care, with potential to improve access and enhance patient outcomes.
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[post_content] => Case scenario
Mrs Nguyen, a 68-year-old woman, consults you about over-the-counter treatments for light-headedness, particularly when getting out of bed. She denies a spinning sensation, nausea or hearing issues. Her symptoms began 2 weeks ago, shortly after starting perindopril for hypertension.
After reading this article, pharmacists should be able to:
|
Dizziness is a non-specific term patients use to describe various sensations that can be categorised into light-headedness, vertigo, imbalance, or the feeling of fainting.1 Vertigo, as a subtype of dizziness, is typically caused by an imbalance in the vestibular system,2 which includes inner ear balance organs responsible for spatial orientation and coordination.3
The most common causes of vertigo are vestibular neuritis and benign paroxysmal positional vertigo (BPPV), which can be triggered by changes in the head’s position, particularly when rolling over in bed or looking upward.2,4 Although less common, central causes of vertigo other than vestibular migraine exist and will be briefly discussed in this article.5 Dizziness or vertigo can be burdensome to the extent that it significantly impacts quality of life.6 In older people, this symptom alone may increase the risk of falls.7
Pharmacists can guide appropriate management for the acute presentation of vertigo or refer to healthcare providers when necessary for further evaluation.
It is important to note that vertigo is a symptom rather than a diagnosis.8 Symptoms of dizziness or vertigo account for up to 16% of all primary care visits globally, with the most common cause related to the vestibular system.9 A 2009 Australian cohort study that included 2,751 community-dwelling adults revealed that 36% (n = 995) of people over the age of 50 years self-reported symptoms of dizziness or vertigo.10 Additionally, vestibular vertigo and non-vestibular vertigo were reported by 10% (276) and 14% (391) of the cohort respectively.10 In the study, the prevalence of dizziness and vestibular vertigo were reported to be significantly higher in women than men. A 10-year follow-up study in 2024 further re-examined the participants (aged 55 years and older) available for follow-up.6 The incidence of symptoms of dizziness or vertigo, vestibular vertigo and non-vestibular vertigo were 40%, 27% and 12% respectively.6
Dizziness and imbalance are especially common in older people, with the prevalence increasing with age.11 While the causes are multifactorial (complex interplay of neurological, cardiovascular, visual, vestibular or psychological issues), these symptoms are more commonly due to an age-related decline of vestibular function.11
The underlying aetiology associated with vertigo can be categorised as either peripheral or central causes.
Peripheral causes of vertigo are related to pathology in the inner ear and are more common than central causes. Peripheral vertigo is caused by an imbalance in the vestibular system.2 For instance, in BPPV, the sudden onset of spinning sensation is caused by a displacement of otoliths (calcium debris) located in the posterior semicircular canal following a rapid head movement.8 Other common peripheral causes include Ménière’s disease and vestibular neuritis.8 See Table 1 for more information on the various causes of vertigo.
[caption id="attachment_30304" align="aligncenter" width="1035"]
Table 1 – Types of vertigo (non-exhaustive list)[/caption]
Central causes of vertigo, on the other hand, are related to a pathology that affects vestibular pathways in the central nervous system, specifically the brain stem, cerebellum and cortex.5 Central causes are uncommon with the exception of vestibular migraine.12 A report from Migraine Australia in 2021 indicated that vestibular migraine is one of the many subtypes of migraine that may be largely undiagnosed.13 A cohort study found that age and migraine are significantly associated with an increased risk of dizziness or vertigo symptoms.6
Vertigo is most often described as a spinning sensation, which is typically a rotatory illusion of motion, but could also be linear with a sensation of falling.5 Other autonomic symptoms commonly accompanied by vertigo include nausea and/or vomiting, sweating or pallor.5,14 Symptoms of vertigo are typically acute and tend to improve over hours to days as central vestibular compensation occurs, or once the contributing factor has been removed.2
The clinical presentation of vertigo can be useful in differentiating whether the cause is peripheral or central. Peripheral features include auditory symptoms such as hearing loss, tinnitus, the feeling of blockage in the ear, or a positive head impulse test.5 The head impulse test is a manoeuvre test conducted by a clinician to test the patient’s vestibulo-ocular reflex function and subsequently identify peripheral vestibular dysfunctions.15 On the other hand, central features of vertigo include movement abnormalities (e.g. gait ataxia out of proportion to the extent of vertigo, limb weakness and ataxia), vision abnormalities (e.g. direction-changing nystagmus, skew deviation, visual field loss, diplopia), slurred speech, difficulty swallowing or hemisensory loss.16
Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
As discussed in Table 1, the treatment approach for vertigo is tailored to the underlying cause and generally involves reassurance and management of symptoms.17
When required for acute vertigo, symptomatic treatment of nausea and vomiting should only be for a short period of time (<48 hours). This is because prolonged treatment can increase the risk of neurological adverse effects (See Precautions and adverse effects).20 Treatment options are listed below.
Nausea (without vomiting)
For nausea (without vomiting), oral prochlorperazine or promethazine may be used for up to 2 days.20 If not effective or tolerated, diazepam or ondansetron may be considered for up to 2 days.20
Vomiting
If the patient is vomiting, other routes of administration are used, including20:
Prochlorperazine is a dopamine antagonist that blocks dopamine type 2 (D2) receptors centrally in the chemoreceptor trigger zone of the brainstem and peripherally in the gastrointestinal tract.21 At high doses, blockage at other receptors (serotonin, histamine, adrenergic and muscarinic receptors) may be seen.21 Prochlorperazine can cause anticholinergic adverse effects (e.g. constipation, dry mouth, blurred vision) and other adverse effects including sedation and extrapyramidal adverse effects (e.g. akathisia, parkinsonism).22 Long-term use of prochlorperazine should be avoided due to the acute and episodic nature of the condition.20 The risk of tardive dyskinesia increases with prolonged treatment duration and higher cumulative doses.22 In older people, these adverse effects may be severe and lead to cognitive impairment, falls, fractures and increased all-cause mortality.21,23
Promethazine is a sedating antihistamine that acts by blocking H1 receptors, muscarinic receptors and dopamine D2 receptors.21 Promethazine is commonly associated with anticholinergic adverse effects (including confusion, dry mouth, constipation), dizziness and sedation.24 Similar to prochlorperazine, it may have some antidopaminergic activity, thus causing extrapyramidal adverse effects.21,24
Appropriate management of ongoing falls risk is especially important in older people when using antiemetics, as some adverse effects can increase the risk of falls.17 Antiemetic medicines, if used, should be at the lowest effective dose for the shortest period possible with close monitoring for adverse effects. The harms of long-term prochlorperazine use are likely to outweigh the benefits in most cases. Guidelines suggest offering deprescribing to older people taking long-term prochlorperazine when originally prescribed for a short-term indication (e.g. acute vertigo).25 Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
It is crucial to note that isolated vertigo can be a symptom of transient ischaemic attacks, which require emergency care.19 This is particularly relevant to pharmacists practising in a primary care setting to be able to identify and recognise initial symptoms indicative of a stroke at first medical contact. In general, patients presenting with the following symptoms should be immediately referred to the emergency department26:
In addition to these diseases, many medicines can also cause symptoms of dizziness and/or vertigo, including but not limited to medicines associated with vestibulotoxicity.27 In particular, cardiovascular medicines (e.g. antihypertensives) and antidepressants are commonly associated with dizziness and/or vertigo as an adverse effect. An inappropriate prescribing cascade may occur when a new medicine is being prescribed to manage an adverse reaction to another drug.28 For instance, if prochlorperazine is prescribed to treat dizziness from antihypertensive use.28
In older people, dizziness significantly increases the risk of falls.7 Implementing appropriate interventions to address modifiable risk factors such as dizziness is of paramount importance. In cases of drug-induced dizziness, deprescribing can be considered if the medicine can be safely reduced, discontinued or substituted to prevent inappropriate prescribing cascades of potentially inappropriate medicines (PIM), especially in the context of older people.29
When patients present with dizziness, it can often indicate a broad range of underlying conditions, including vestibular disorders, making it essential for pharmacists to carefully assess the patient’s health history and medicines.
Pharmacists have the knowledge to determine when referral to other healthcare providers is warranted. Through medicine reviews, pharmacists can identify medicines (such as antihypertensives, sedatives and anticholinergics) that may contribute to symptoms resembling vertigo. They can then collaborate with healthcare providers to adjust medicines as needed. Additionally, pharmacists have a crucial role in providing patient education to ensure patients understand the proper use of antiemetics and provide guidance on safety precautions during episodes of dizziness. They also play a key role in monitoring medicine use and managing any adverse effects that arise.
Pharmacists can promote the quality use of medicines by offering deprescribing recommendations to patients and their prescribers when there is an unclear, unknown or lack of persistent indication for a medicine. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
The treatment of vertigo largely depends on its underlying cause. Targeted non-pharmacological treatments like repositioning manoeuvres and physical therapy are effective in managing motion-induced vertigo. With appropriate treatment and patient education, most patients can experience significant symptom improvement and a reduced impact on daily life. Pharmacists are integral to achieving these positive outcomes. Through timely interventions, medicine optimisation, patient education, and collaboration with other healthcare providers, pharmacists can help ensure the effective management of vertigo.
Case scenario continuedRecognising dizziness as a common adverse effect of perindopril, you explain the possibility of drug-induced dizziness and recommend that Mrs Nguyen see her doctor for a review. You also provide advice on managing dizziness in the meantime, such as avoiding sudden movements and standing up slowly to minimise the risk of falls. Two weeks later, Mrs Nguyen returns to the pharmacy with a new prescription to trial a different antihypertensive. Within a week, Mrs Nguyen reports significant improvement in her dizziness, which allows her to resume her daily activities with greater confidence. She also sees a noticeable improvement in her overall quality of life, and she thanks you for your help. |
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and the director of the Centre for Optimisation of Medicines at UWA’s School of Allied Health.
Hana Numan (she/her) BPharm, PGCertClinPharm, PGDipClinPharm
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) Scholarship at the University of Western Australia.
Amy Page is supported by the Western Australian Future Health Research and Innovation Fund/Western Australian Department of Health, Grant ID WANMA/EL2022/1. She is an employee of the University of Western Australia and a practitioner member of the Pharmacy Board of Australia.
[post_title] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [post_excerpt] => Dizziness or vertigo can be burdensome to the extent that it significantly impacts quality of life, and in older people, this symptom alone may increase the risk of falls. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => beyond-the-spin-diagnosis-symptoms-and-treatment-options-for-vertigo [to_ping] => [pinged] => [post_modified] => 2025-08-13 17:37:31 [post_modified_gmt] => 2025-08-13 07:37:31 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=29857 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [title] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [href] => https://www.australianpharmacist.com.au/beyond-the-spin-diagnosis-symptoms-and-treatment-options-for-vertigo/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 30298 [authorType] => )td_module_mega_menu Object
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[post_content] => Yesterday (19 August), it was announced that Ozempic (semaglutide 1.0 mg) has received approval from the Therapeutic Goods Administration (TGA) for an expansion of indication to reduce the risk of kidney disease progression in patients with type 2 diabetes and chronic kidney disease (CKD).
It’s estimated that around 2.7 million Australians are living with indicators of CKD, including both diagnosed and undiagnosed cases.
Of these, diabetes is the leading cause of end stage kidney disease (ESKD) – accounting for over a third (38%) of new cases. Of an estimated 333,000 Australians living with both CKD and diabetes, approximately 10,000 are expected to progress to kidney failure.
If not managed appropriately and in serious cases, CKD may also lead to kidney failure, heart disease and stroke, and in some cases, premature death, said Professor Vlado Perkovic, nephrologist and Provost at the University of New South Wales.
‘Early intervention can help with slowing disease progression,’ he said.
‘This approval represents a step forward in addressing the multifaceted needs of individuals living with type 2 diabetes and CKD,’ added Dr Ana Svensson, Vice President of Clinical, Medical and Regulatory at Novo Nordisk Oceania.
What does the evidence say?
The FLOW (Evaluate Renal Function with Semaglutide Once Weekly) trial is a large multinational study that assessed the effects of once-weekly semaglutide 1.0 mg in adults with type 2 diabetes and CKD.
Participants who received semaglutide had a 24% reduction in risk of major kidney events, slower decline in estimated glomerular filtration rate, and decreased albuminuria – compared to placebo. They also experienced improvements in cardiovascular outcomes and all-cause mortality – with the safety profile consistent with previous studies.
To date, the TGA has not released specific dosing guidance related to the new CKD indication.
Will Ozempic be PBS listed for CKD?
Semaglutide (Ozempic) for CKD is currently not subsidised under the Pharmaceutical Benefits Scheme (PBS).
That means the out-of-pocket costs will not be subsidised, compared to around $31.60 for general patients using the medicine under existing PBS criteria.
‘While it is not specifically reimbursed for kidney disease risk reduction, Novo Nordisk continues to engage with government stakeholders to explore opportunities for broader access to our medicines for Australians living with chronic conditions,’ a spokesperson for Novo Nordisk told Australian Pharmacist.
With Ozempic no longer in shortage, will access open up?
Last month (18 July), the TGA officially removed Ozempic from its medicine shortages list, with previous supply restrictions now lifted. Now that Ozempic stocks have returned to a sufficient level, new patients can be initiated on the medicine. But Ozempic prescribed for weight loss is still off-label, with no update to the indication for weight loss. So the PBS criteria on this front also remain unchanged, and it’s uncertain if this will change any time soon.
‘We have semaglutide 2.4 mg (Wegovy) available – it is indicated for the treatment of patients with obesity or overweight and established cardiovascular disease,’ the Novo Nordisk spokesperson said.
But experts hope that subsidy and accessibility will improve over time as demand and evidence grow.
‘There’s no doubt that both cost and availability present a barrier to the more widespread use of semaglutide at the moment,’ Prof Perkovic said. ‘But I’m sure that over time that situation will change and the drugs will become more widely available.’
[post_title] => Ozempic now indicated to prevent CKD progression
[post_excerpt] => Ozempic is the first medicine in Australia approved to slow kidney disease progression in patients with both type 2 diabetes and CKD.
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[post_content] => This national resource supports frontline assessment, management and prompt referral of burn injuries.
Community pharmacists are often the first point of contact for health concerns and public health initiatives, including burns, said Rebecca Schrale, Burns Nurse Practitioner at the Royal Hobart Hospital’s Burns Unit and Australian and New Zealand Burn Association (ANZBA) Burns Prevention Representative for Tasmania.
‘[So] community pharmacists are in a unique position to provide education on initial first aid, referral and wound care,’ she said. ‘They also have an important role in prevention of burn injuries, educating the community and reducing risk.’
To that end, ANZBA, PSA and the National Australian Pharmacy Students’ Association (NAPSA) collaborated to develop guidelines specifically for pharmacists to assist with the assessment and management of burns.
Australian Pharmacist investigates what pharmacists should look out for and how to manage and refer burns appropriately.
What burns do community pharmacists typically encounter?
The full spectrum – from minor to severe, said PSA Tasmania State Manager Dr Ella van Tienen FPS.
‘A lot of it is advice for minor sunburn or small burns,’ she said. ‘But you do get some more serious burns when people aren’t sure what to do with them, or whether they’re serious enough to [require further attention].’
Burns are more likely to occur out of hours, such as on weekends and public holidays – particularly among children – when general practices are typically closed.
‘That’s when kids are home,’ Dr van Tienen added.
Common causes of burns in children include hot water scalds due to access to kettles or stove tops.
‘Teenagers who are newly independent and off at the beach on their own, also present with blistering sunburn,’ she said.
What impact do burns have on the community?
It’s important to remember that even minor burns can have long-term effects on the patient in regard to range of movement, function and the look and feel of the scar, Ms Schrale said.
‘All burn injuries – whether large or small can have a psychological effect on the individual and their family,’ she said. ‘And it’s imperative that patients are referred to burns clinicians in a timely manner.’
Deep burn injuries will result in scarring and could restrict the function of the area that is affected.
‘Pharmacies are often open after hours and on weekends so again they provide clients and their families with timely advice, education and support,’ Ms Schrale said.
What does the burns resource involve?
The new Pharmacists Advisory Card and A3 Poster are new iterations of an old resource, Dr van Tienen said.
‘The original resource had been around for many years, and it needed to be updated,’ she said.
The refreshed burns advisory resource provides pharmacists with up-to-date information on Burns First Aid, and assessment – including burn depth, assessment and minor burn wound care, Ms Schrale said.
‘With this knowledge they are equipped to then follow the ANZBA referral guidelines, highlighting who requires discussion or referral to primary [care] or the local emergency department (ED),’ she said. ‘The updated card ensures the messaging is consistent across pharmacies, community health, primary care and EDs nationally.’
What new information is included?
The new version of the card focuses on information that will assist in early assessment, management and referral of minor burns, Ms Schrale said.
‘It also provides simple and consistent messaging on wound care and medical emergencies – such as large surface area burns, airway burns, circumferential burns and infection,’ she said.
‘The other new addition is the inclusion of information on burns scar management based on evidence-based practice and encouraging referral for any patient who sustains a scar from a burn injury.’
How can the burns resource be used in practice?
Let’s say a parent presents to the pharmacy with a child who has sustained a burn after accidentally knocking over a pot of boiling water while cooking pasta on the stove.
‘If the child has a small [dermal] burn that’s not significantly blistered, the pharmacist could appropriately treat it in the community by providing first aid and dressing advice,’ Dr van Tienen said.
‘The pharmacist should advise the parent to watch out for [significant] blistering, the blisters breaking, any signs of infection or excessive [levels] of pain.’
Indicators that should prompt further action include if the child:
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[post_content] => Too many people are taking way too much Vitamin B6. Here are the risks of high doses and how the Therapeutic Goods Administration (TGA) is responding.
What is the concern about Vitamin B6?
High doses and/or prolonged use of Vitamin B6 above the recommended daily intake (RDI) have been linked to peripheral neuropathy. Most cases have been reported at doses exceeding 500 mg/day, although cases at lower doses have been reported.1
The TGA’s adverse events notification database contains 174 reports1 of peripheral neuropathy, peripheral sensory neuropathy, small fibre neuropathy or chronic polyneuropathy for products containing Vitamin B6.1
The primary concern is the risk of overconsumption of Vitamin B6 from a variety of sources, particularly in individuals using multiple multivitamin and supplement products.1
How many products have Vitamin B6 in them?
Lots! There are over 1,500 products listed on the Australian Register of Therapeutic Goods (ARTG) which contain Vitamin B6. Approximately 100 of these products have more than 50 mg of Vitamin B6 as the single active ingredient.
The inclusion of Vitamin B6 in these products is rarely prominently displayed. And labelling of Vitamin B6 is often not visible to or understood by consumers, instead being referenced as pyridoxine, pyridoxine hydrochloride, pyridoxal 5-phosphate and pyridoxal 5-phosphate monohydrate.1
What is the TGA doing?
The TGA Delegate has made an interim decision to amend the scheduling of medicines containing more than 50 mg of Vitamin B6 but less than 200 mg (per recommended daily dose) to classify them as Pharmacist Only Medicines (Schedule 3).
If the TGA Delegate’s interim decision is confirmed, the schedule changes will take effect on 1 February 2027.
What should pharmacists do differently?
Ensure all consumers are asked if they are taking multiple vitamin or mineral supplements every time a Vitamin B6-containing product is requested or supplied. Where this is the case, it’s important to consider total Vitamin B6 dose, including dietary sources, and ensure it does not exceed 200 mg daily.
Pharmacists should also warn of early signs of neuropathy, such as tingling, burning or numbness – and advise they cease the medicine and seek medical review if this occurs.
Should pharmacists still supply Vitamin B6 for use in pregnancy?
There are a couple of different treatment regimens for pyridoxine (Vitamin B6) tablets for nausea and vomiting of pregnancy which involve divided doses.2–4 Some references caution against quality of evidence and modest benefit.
The maximum daily dose should not exceed 200 mg. This upper dose is generally considered to be safe for the duration of pregnancy.
References
- Australian Government Department of Health, Disability and Ageing. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard in relation to pyridoxine, pyridoxal or pyridoxamine (vitamin B6). 2025. At: www.tga.gov.au/sites/default/files/2025-06/notice-interim-decision-amend-or-not-amend-current-poisons-standard-pyridoxine-pyridoxal-pyridoxamine-vitaminb6.pdf
- Therapeutic Guidelines: Nausea and vomiting during pregnancy. 2025. At: www.tg.org.au
- Government of Western Australia. North Metropolitan Health Service Women and Newborn Health Service. Pyridoxine (Vitamin B6). 2024. At: www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-MPs/Pyridoxine---Vitamin-B6.pdf?thn=0
- Safer Care Victoria. Medications to treat hyperemesis. 2025. At: www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/maternity/nausea-and-vomiting#goto-table1.-medications-to-treat-hyperemesis
[post_title] => How pharmacists should address rising B6 overuse
[post_excerpt] => Too many people are taking way too much Vitamin B6. A senior pharmacist explains the risks of high doses, and how the TGA is responding.
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[post_content] => Pharmacist prescribing is emerging as a powerful extension of primary care in Australia – one that has the potential to improve access, enhance patient outcomes and reshape the profession.
For patients, it means timely, evidence-based treatment without the long waits often associated with GP appointments. For pharmacists, it represents an opportunity to practise to full scope, strengthen professional relationships and deliver care with immediacy and depth.
But becoming a prescriber is not just a new credential – it’s a mindset shift, demanding confidence, competence and a willingness to explore every aspect of a patient’s life to inform safe and effective decisions.
Kate Gunthorpe MPS, a Queensland-based pharmacist prescriber who recently presented at PSA25 and received special commendation in the PSA Symbion Early Career Pharmacist of the Year award category, explained to Australian Pharmacist what budding pharmacist prescribers should expect.
Pharmacist prescribing to become standard practice
According to Ms Gunthorpe, it is no longer a question of if, but when, pharmacist prescribing will become a normal part of primary care in Australia – as it already is in other countries.
‘Our scope will continue to expand. It’s not about replacing anyone, it’s about using every healthcare professional’s skills to their fullest,’ she said. ‘Pharmacist prescribing will also bring more students into the profession, and improve job satisfaction and retention.’
For Ms Gunthorpe, becoming a prescriber was a quest to close the gap between what patients needed and what she could offer.
‘I was often the first health professional someone would see, but without the ability to diagnose and treat within my scope, I sometimes felt like I was sending them away with half the solution,’ she said. ‘Prescribing gives me the ability to act in that moment, keep care local, and make a real difference straight away.’
Patients can often wait weeks to see a GP – or avoid care altogether because it feels too hard. Pharmacist prescribing gives them another safe, qualified option, and helps to ease pressure on other parts of the health system.
‘I’ve seen people walk in with something that’s been bothering them for months, and walk out with a treatment plan in under half an hour,’ Ms Gunthorpe said. ‘For some, it’s the difference between getting treated and just living with the problem.’
From a patient perspective, the feedback on the service has been overwhelmingly positive.
‘People are often surprised that pharmacists can now prescribe, but once they experience it, they appreciate the convenience and thoroughness,’ she said. ‘Many have told me they wish this had been available years ago and I’ve already had several patients come back for other prescribing services because they trust the process.’
Evolving your practice mindset
Becoming a pharmacist prescriber is not a box-ticking exercise – it’s a mindset shift.
Pharmacists are already great at taking medication histories. Asking, ‘Do you have any allergies? Have you had this before? What medications are you taking? Have you had any adverse effects?’ is par for the course.
But effectively growing into full scope requires pharmacists to push the envelope further. Take acne management for example.
As part of standard pharmacist care, acne consultations are mainly about over-the-counter options and suggesting a GP review for more severe cases.
‘Now, [as a pharmacist prescriber], I take a full patient history – incorporating their biopsychosocial factors – to assess the severity and check for underlying causes,’ she said. ‘I can [also] initiate prescription-only treatments when appropriate. It means I can manage the condition from start to finish, rather than just being a stepping stone.’
Sometimes it can be a matter of life or death. Ms Gunthorpe recalled a case where a patient presented with nausea and vomiting. After reviewing his symptoms and social history, a diagnosis of viral or bacterial gastroenteritis didn’t quite fit. So, she probed further:
Q: ‘What do you do for work?’
A: ‘I'm an electrician.’
Q: ‘So did you work today?’
A: ‘Yeah.’
Q: ‘How was work? Anything a bit unusual happen today? Did you bump your head or anything like that?’
A: ‘I stood up in a room today and hit the back of my head so hard I've had a raging headache ever since and I feel dizzy.’
Following this interaction, Ms Gunthorpe sent the patient to the emergency department straight away.
‘If I had just provided him with some ondansetron, he could have not woken up that night,’ she said. ‘So think about how that impacted his treatment plan, just because I asked him what his occupation is.’
Encouraging patients to open up
It’s not always easy getting the right information out of patients – particularly in a pharmacy environment. So Ms Gunthorpe takes a structured approach to these interactions.
‘I say, “I'm going to ask you a few questions about your life and your lifestyle, just to let me get to know you a little bit more so we can create a unique and shared management plan for you”,’ she said.
This helps patients understand that she’s not just prying – and that each question has a purpose.
‘Then they are more than willing,’ she said. ‘Nothing actually surprises me now about what patients say to me – whether it's recreational drugs or the sexual activity they get up to on the weekend.’
Post-consultation, documentation is an equally important part of the process.
‘Everything you asked, the answers to these questions and what the patient tells you has to be documented,’ Ms Gunthorpe said. ‘If it's not documented, then it didn't happen. That's just a flat out rule.’
In other words, you will not be covered medicolegally if you provide advice and there is no paper trail.
‘I encourage you to start documenting – even if it doesn't feel like it's too important,’ she said. ‘That’s something we as a whole industry need to start doing better.’
Redesigning workflows and upskilling staff
While embracing a prescribing mindset is crucial, so is maintaining the dispensary – allowing for uninterrupted patient consultations.
‘We need to ensure our dispensary keeps running while we are off the floor,’ Ms Gunthorpe said. ‘I’ve never worried that someone will burst into the room [when I'm seeing a] GP mid-consult – so we need to create that same protected environment in pharmacy.’
Upskilling pharmacy assistants and dispensary technicians has been key to making this possible. Staff now take patient details before the consultation, manage the consult rooms, and triage patients when Ms Gunthorpe is unavailable – a role they have embraced with enthusiasm.
‘When I’m not there, they need to make appointments, explain our services, and direct patients to me when I am in consults,’ she said. ‘It’s been really satisfying for them to step into expanded roles.’
Reframing relationships with general practice
Pharmacist prescribing is not intended to replace GPs, but to create more accessible, collaborative and timely care – relying on strong relationships, shared responsibility and open communication.
‘Think of prescribing as stepping into a shared space, not taking over someone else’s. Let’s do it together, with confidence, compassion, and clinical excellence,’ Ms Gunthorpe said.
In some cases referral to a GP is necessary, particularly when additional diagnostics are required. This can cause frustration if patients pay for a consultation but leave without medicines. So strengthening GP-pharmacist relationships is essential to making the model work.
‘We want this to be a shared space where we both feel safe and respected when referring either way,’ she said. ‘If a GP is booked out for 2 weeks and a child has otitis media, we want the receptionist to be able to say, “Kate down the road has consults available this afternoon”. That’s the collaboration we’re aiming for.’
Queensland Government funding for pharmacists to undertake prescribing training remains open. For more information and to check eligibility visit Pharmacist Prescribing Scope of Practice Training Program.
[post_title] => The mindset shift that’s key to prescribing success
[post_excerpt] => Pharmacist prescribing is emerging as a powerful extension of primary care, with potential to improve access and enhance patient outcomes.
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[post_content] => Case scenario
Mrs Nguyen, a 68-year-old woman, consults you about over-the-counter treatments for light-headedness, particularly when getting out of bed. She denies a spinning sensation, nausea or hearing issues. Her symptoms began 2 weeks ago, shortly after starting perindopril for hypertension.
After reading this article, pharmacists should be able to:
|
Dizziness is a non-specific term patients use to describe various sensations that can be categorised into light-headedness, vertigo, imbalance, or the feeling of fainting.1 Vertigo, as a subtype of dizziness, is typically caused by an imbalance in the vestibular system,2 which includes inner ear balance organs responsible for spatial orientation and coordination.3
The most common causes of vertigo are vestibular neuritis and benign paroxysmal positional vertigo (BPPV), which can be triggered by changes in the head’s position, particularly when rolling over in bed or looking upward.2,4 Although less common, central causes of vertigo other than vestibular migraine exist and will be briefly discussed in this article.5 Dizziness or vertigo can be burdensome to the extent that it significantly impacts quality of life.6 In older people, this symptom alone may increase the risk of falls.7
Pharmacists can guide appropriate management for the acute presentation of vertigo or refer to healthcare providers when necessary for further evaluation.
It is important to note that vertigo is a symptom rather than a diagnosis.8 Symptoms of dizziness or vertigo account for up to 16% of all primary care visits globally, with the most common cause related to the vestibular system.9 A 2009 Australian cohort study that included 2,751 community-dwelling adults revealed that 36% (n = 995) of people over the age of 50 years self-reported symptoms of dizziness or vertigo.10 Additionally, vestibular vertigo and non-vestibular vertigo were reported by 10% (276) and 14% (391) of the cohort respectively.10 In the study, the prevalence of dizziness and vestibular vertigo were reported to be significantly higher in women than men. A 10-year follow-up study in 2024 further re-examined the participants (aged 55 years and older) available for follow-up.6 The incidence of symptoms of dizziness or vertigo, vestibular vertigo and non-vestibular vertigo were 40%, 27% and 12% respectively.6
Dizziness and imbalance are especially common in older people, with the prevalence increasing with age.11 While the causes are multifactorial (complex interplay of neurological, cardiovascular, visual, vestibular or psychological issues), these symptoms are more commonly due to an age-related decline of vestibular function.11
The underlying aetiology associated with vertigo can be categorised as either peripheral or central causes.
Peripheral causes of vertigo are related to pathology in the inner ear and are more common than central causes. Peripheral vertigo is caused by an imbalance in the vestibular system.2 For instance, in BPPV, the sudden onset of spinning sensation is caused by a displacement of otoliths (calcium debris) located in the posterior semicircular canal following a rapid head movement.8 Other common peripheral causes include Ménière’s disease and vestibular neuritis.8 See Table 1 for more information on the various causes of vertigo.
[caption id="attachment_30304" align="aligncenter" width="1035"] Table 1 – Types of vertigo (non-exhaustive list)[/caption]
Central causes of vertigo, on the other hand, are related to a pathology that affects vestibular pathways in the central nervous system, specifically the brain stem, cerebellum and cortex.5 Central causes are uncommon with the exception of vestibular migraine.12 A report from Migraine Australia in 2021 indicated that vestibular migraine is one of the many subtypes of migraine that may be largely undiagnosed.13 A cohort study found that age and migraine are significantly associated with an increased risk of dizziness or vertigo symptoms.6
Vertigo is most often described as a spinning sensation, which is typically a rotatory illusion of motion, but could also be linear with a sensation of falling.5 Other autonomic symptoms commonly accompanied by vertigo include nausea and/or vomiting, sweating or pallor.5,14 Symptoms of vertigo are typically acute and tend to improve over hours to days as central vestibular compensation occurs, or once the contributing factor has been removed.2
The clinical presentation of vertigo can be useful in differentiating whether the cause is peripheral or central. Peripheral features include auditory symptoms such as hearing loss, tinnitus, the feeling of blockage in the ear, or a positive head impulse test.5 The head impulse test is a manoeuvre test conducted by a clinician to test the patient’s vestibulo-ocular reflex function and subsequently identify peripheral vestibular dysfunctions.15 On the other hand, central features of vertigo include movement abnormalities (e.g. gait ataxia out of proportion to the extent of vertigo, limb weakness and ataxia), vision abnormalities (e.g. direction-changing nystagmus, skew deviation, visual field loss, diplopia), slurred speech, difficulty swallowing or hemisensory loss.16
Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
As discussed in Table 1, the treatment approach for vertigo is tailored to the underlying cause and generally involves reassurance and management of symptoms.17
When required for acute vertigo, symptomatic treatment of nausea and vomiting should only be for a short period of time (<48 hours). This is because prolonged treatment can increase the risk of neurological adverse effects (See Precautions and adverse effects).20 Treatment options are listed below.
Nausea (without vomiting)
For nausea (without vomiting), oral prochlorperazine or promethazine may be used for up to 2 days.20 If not effective or tolerated, diazepam or ondansetron may be considered for up to 2 days.20
Vomiting
If the patient is vomiting, other routes of administration are used, including20:
Prochlorperazine is a dopamine antagonist that blocks dopamine type 2 (D2) receptors centrally in the chemoreceptor trigger zone of the brainstem and peripherally in the gastrointestinal tract.21 At high doses, blockage at other receptors (serotonin, histamine, adrenergic and muscarinic receptors) may be seen.21 Prochlorperazine can cause anticholinergic adverse effects (e.g. constipation, dry mouth, blurred vision) and other adverse effects including sedation and extrapyramidal adverse effects (e.g. akathisia, parkinsonism).22 Long-term use of prochlorperazine should be avoided due to the acute and episodic nature of the condition.20 The risk of tardive dyskinesia increases with prolonged treatment duration and higher cumulative doses.22 In older people, these adverse effects may be severe and lead to cognitive impairment, falls, fractures and increased all-cause mortality.21,23
Promethazine is a sedating antihistamine that acts by blocking H1 receptors, muscarinic receptors and dopamine D2 receptors.21 Promethazine is commonly associated with anticholinergic adverse effects (including confusion, dry mouth, constipation), dizziness and sedation.24 Similar to prochlorperazine, it may have some antidopaminergic activity, thus causing extrapyramidal adverse effects.21,24
Appropriate management of ongoing falls risk is especially important in older people when using antiemetics, as some adverse effects can increase the risk of falls.17 Antiemetic medicines, if used, should be at the lowest effective dose for the shortest period possible with close monitoring for adverse effects. The harms of long-term prochlorperazine use are likely to outweigh the benefits in most cases. Guidelines suggest offering deprescribing to older people taking long-term prochlorperazine when originally prescribed for a short-term indication (e.g. acute vertigo).25 Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
It is crucial to note that isolated vertigo can be a symptom of transient ischaemic attacks, which require emergency care.19 This is particularly relevant to pharmacists practising in a primary care setting to be able to identify and recognise initial symptoms indicative of a stroke at first medical contact. In general, patients presenting with the following symptoms should be immediately referred to the emergency department26:
In addition to these diseases, many medicines can also cause symptoms of dizziness and/or vertigo, including but not limited to medicines associated with vestibulotoxicity.27 In particular, cardiovascular medicines (e.g. antihypertensives) and antidepressants are commonly associated with dizziness and/or vertigo as an adverse effect. An inappropriate prescribing cascade may occur when a new medicine is being prescribed to manage an adverse reaction to another drug.28 For instance, if prochlorperazine is prescribed to treat dizziness from antihypertensive use.28
In older people, dizziness significantly increases the risk of falls.7 Implementing appropriate interventions to address modifiable risk factors such as dizziness is of paramount importance. In cases of drug-induced dizziness, deprescribing can be considered if the medicine can be safely reduced, discontinued or substituted to prevent inappropriate prescribing cascades of potentially inappropriate medicines (PIM), especially in the context of older people.29
When patients present with dizziness, it can often indicate a broad range of underlying conditions, including vestibular disorders, making it essential for pharmacists to carefully assess the patient’s health history and medicines.
Pharmacists have the knowledge to determine when referral to other healthcare providers is warranted. Through medicine reviews, pharmacists can identify medicines (such as antihypertensives, sedatives and anticholinergics) that may contribute to symptoms resembling vertigo. They can then collaborate with healthcare providers to adjust medicines as needed. Additionally, pharmacists have a crucial role in providing patient education to ensure patients understand the proper use of antiemetics and provide guidance on safety precautions during episodes of dizziness. They also play a key role in monitoring medicine use and managing any adverse effects that arise.
Pharmacists can promote the quality use of medicines by offering deprescribing recommendations to patients and their prescribers when there is an unclear, unknown or lack of persistent indication for a medicine. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
The treatment of vertigo largely depends on its underlying cause. Targeted non-pharmacological treatments like repositioning manoeuvres and physical therapy are effective in managing motion-induced vertigo. With appropriate treatment and patient education, most patients can experience significant symptom improvement and a reduced impact on daily life. Pharmacists are integral to achieving these positive outcomes. Through timely interventions, medicine optimisation, patient education, and collaboration with other healthcare providers, pharmacists can help ensure the effective management of vertigo.
Case scenario continuedRecognising dizziness as a common adverse effect of perindopril, you explain the possibility of drug-induced dizziness and recommend that Mrs Nguyen see her doctor for a review. You also provide advice on managing dizziness in the meantime, such as avoiding sudden movements and standing up slowly to minimise the risk of falls. Two weeks later, Mrs Nguyen returns to the pharmacy with a new prescription to trial a different antihypertensive. Within a week, Mrs Nguyen reports significant improvement in her dizziness, which allows her to resume her daily activities with greater confidence. She also sees a noticeable improvement in her overall quality of life, and she thanks you for your help. |
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and the director of the Centre for Optimisation of Medicines at UWA’s School of Allied Health.
Hana Numan (she/her) BPharm, PGCertClinPharm, PGDipClinPharm
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) Scholarship at the University of Western Australia.
Amy Page is supported by the Western Australian Future Health Research and Innovation Fund/Western Australian Department of Health, Grant ID WANMA/EL2022/1. She is an employee of the University of Western Australia and a practitioner member of the Pharmacy Board of Australia.
[post_title] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [post_excerpt] => Dizziness or vertigo can be burdensome to the extent that it significantly impacts quality of life, and in older people, this symptom alone may increase the risk of falls. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => beyond-the-spin-diagnosis-symptoms-and-treatment-options-for-vertigo [to_ping] => [pinged] => [post_modified] => 2025-08-13 17:37:31 [post_modified_gmt] => 2025-08-13 07:37:31 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=29857 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [title] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [href] => https://www.australianpharmacist.com.au/beyond-the-spin-diagnosis-symptoms-and-treatment-options-for-vertigo/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 30298 [authorType] => )td_module_mega_menu Object
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[post_content] => Yesterday (19 August), it was announced that Ozempic (semaglutide 1.0 mg) has received approval from the Therapeutic Goods Administration (TGA) for an expansion of indication to reduce the risk of kidney disease progression in patients with type 2 diabetes and chronic kidney disease (CKD).
It’s estimated that around 2.7 million Australians are living with indicators of CKD, including both diagnosed and undiagnosed cases.
Of these, diabetes is the leading cause of end stage kidney disease (ESKD) – accounting for over a third (38%) of new cases. Of an estimated 333,000 Australians living with both CKD and diabetes, approximately 10,000 are expected to progress to kidney failure.
If not managed appropriately and in serious cases, CKD may also lead to kidney failure, heart disease and stroke, and in some cases, premature death, said Professor Vlado Perkovic, nephrologist and Provost at the University of New South Wales.
‘Early intervention can help with slowing disease progression,’ he said.
‘This approval represents a step forward in addressing the multifaceted needs of individuals living with type 2 diabetes and CKD,’ added Dr Ana Svensson, Vice President of Clinical, Medical and Regulatory at Novo Nordisk Oceania.
What does the evidence say?
The FLOW (Evaluate Renal Function with Semaglutide Once Weekly) trial is a large multinational study that assessed the effects of once-weekly semaglutide 1.0 mg in adults with type 2 diabetes and CKD.
Participants who received semaglutide had a 24% reduction in risk of major kidney events, slower decline in estimated glomerular filtration rate, and decreased albuminuria – compared to placebo. They also experienced improvements in cardiovascular outcomes and all-cause mortality – with the safety profile consistent with previous studies.
To date, the TGA has not released specific dosing guidance related to the new CKD indication.
Will Ozempic be PBS listed for CKD?
Semaglutide (Ozempic) for CKD is currently not subsidised under the Pharmaceutical Benefits Scheme (PBS).
That means the out-of-pocket costs will not be subsidised, compared to around $31.60 for general patients using the medicine under existing PBS criteria.
‘While it is not specifically reimbursed for kidney disease risk reduction, Novo Nordisk continues to engage with government stakeholders to explore opportunities for broader access to our medicines for Australians living with chronic conditions,’ a spokesperson for Novo Nordisk told Australian Pharmacist.
With Ozempic no longer in shortage, will access open up?
Last month (18 July), the TGA officially removed Ozempic from its medicine shortages list, with previous supply restrictions now lifted. Now that Ozempic stocks have returned to a sufficient level, new patients can be initiated on the medicine. But Ozempic prescribed for weight loss is still off-label, with no update to the indication for weight loss. So the PBS criteria on this front also remain unchanged, and it’s uncertain if this will change any time soon.
‘We have semaglutide 2.4 mg (Wegovy) available – it is indicated for the treatment of patients with obesity or overweight and established cardiovascular disease,’ the Novo Nordisk spokesperson said.
But experts hope that subsidy and accessibility will improve over time as demand and evidence grow.
‘There’s no doubt that both cost and availability present a barrier to the more widespread use of semaglutide at the moment,’ Prof Perkovic said. ‘But I’m sure that over time that situation will change and the drugs will become more widely available.’
[post_title] => Ozempic now indicated to prevent CKD progression
[post_excerpt] => Ozempic is the first medicine in Australia approved to slow kidney disease progression in patients with both type 2 diabetes and CKD.
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[post_content] => This national resource supports frontline assessment, management and prompt referral of burn injuries.
Community pharmacists are often the first point of contact for health concerns and public health initiatives, including burns, said Rebecca Schrale, Burns Nurse Practitioner at the Royal Hobart Hospital’s Burns Unit and Australian and New Zealand Burn Association (ANZBA) Burns Prevention Representative for Tasmania.
‘[So] community pharmacists are in a unique position to provide education on initial first aid, referral and wound care,’ she said. ‘They also have an important role in prevention of burn injuries, educating the community and reducing risk.’
To that end, ANZBA, PSA and the National Australian Pharmacy Students’ Association (NAPSA) collaborated to develop guidelines specifically for pharmacists to assist with the assessment and management of burns.
Australian Pharmacist investigates what pharmacists should look out for and how to manage and refer burns appropriately.
What burns do community pharmacists typically encounter?
The full spectrum – from minor to severe, said PSA Tasmania State Manager Dr Ella van Tienen FPS.
‘A lot of it is advice for minor sunburn or small burns,’ she said. ‘But you do get some more serious burns when people aren’t sure what to do with them, or whether they’re serious enough to [require further attention].’
Burns are more likely to occur out of hours, such as on weekends and public holidays – particularly among children – when general practices are typically closed.
‘That’s when kids are home,’ Dr van Tienen added.
Common causes of burns in children include hot water scalds due to access to kettles or stove tops.
‘Teenagers who are newly independent and off at the beach on their own, also present with blistering sunburn,’ she said.
What impact do burns have on the community?
It’s important to remember that even minor burns can have long-term effects on the patient in regard to range of movement, function and the look and feel of the scar, Ms Schrale said.
‘All burn injuries – whether large or small can have a psychological effect on the individual and their family,’ she said. ‘And it’s imperative that patients are referred to burns clinicians in a timely manner.’
Deep burn injuries will result in scarring and could restrict the function of the area that is affected.
‘Pharmacies are often open after hours and on weekends so again they provide clients and their families with timely advice, education and support,’ Ms Schrale said.
What does the burns resource involve?
The new Pharmacists Advisory Card and A3 Poster are new iterations of an old resource, Dr van Tienen said.
‘The original resource had been around for many years, and it needed to be updated,’ she said.
The refreshed burns advisory resource provides pharmacists with up-to-date information on Burns First Aid, and assessment – including burn depth, assessment and minor burn wound care, Ms Schrale said.
‘With this knowledge they are equipped to then follow the ANZBA referral guidelines, highlighting who requires discussion or referral to primary [care] or the local emergency department (ED),’ she said. ‘The updated card ensures the messaging is consistent across pharmacies, community health, primary care and EDs nationally.’
What new information is included?
The new version of the card focuses on information that will assist in early assessment, management and referral of minor burns, Ms Schrale said.
‘It also provides simple and consistent messaging on wound care and medical emergencies – such as large surface area burns, airway burns, circumferential burns and infection,’ she said.
‘The other new addition is the inclusion of information on burns scar management based on evidence-based practice and encouraging referral for any patient who sustains a scar from a burn injury.’
How can the burns resource be used in practice?
Let’s say a parent presents to the pharmacy with a child who has sustained a burn after accidentally knocking over a pot of boiling water while cooking pasta on the stove.
‘If the child has a small [dermal] burn that’s not significantly blistered, the pharmacist could appropriately treat it in the community by providing first aid and dressing advice,’ Dr van Tienen said.
‘The pharmacist should advise the parent to watch out for [significant] blistering, the blisters breaking, any signs of infection or excessive [levels] of pain.’
Indicators that should prompt further action include if the child:
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[post_content] => Too many people are taking way too much Vitamin B6. Here are the risks of high doses and how the Therapeutic Goods Administration (TGA) is responding.
What is the concern about Vitamin B6?
High doses and/or prolonged use of Vitamin B6 above the recommended daily intake (RDI) have been linked to peripheral neuropathy. Most cases have been reported at doses exceeding 500 mg/day, although cases at lower doses have been reported.1
The TGA’s adverse events notification database contains 174 reports1 of peripheral neuropathy, peripheral sensory neuropathy, small fibre neuropathy or chronic polyneuropathy for products containing Vitamin B6.1
The primary concern is the risk of overconsumption of Vitamin B6 from a variety of sources, particularly in individuals using multiple multivitamin and supplement products.1
How many products have Vitamin B6 in them?
Lots! There are over 1,500 products listed on the Australian Register of Therapeutic Goods (ARTG) which contain Vitamin B6. Approximately 100 of these products have more than 50 mg of Vitamin B6 as the single active ingredient.
The inclusion of Vitamin B6 in these products is rarely prominently displayed. And labelling of Vitamin B6 is often not visible to or understood by consumers, instead being referenced as pyridoxine, pyridoxine hydrochloride, pyridoxal 5-phosphate and pyridoxal 5-phosphate monohydrate.1
What is the TGA doing?
The TGA Delegate has made an interim decision to amend the scheduling of medicines containing more than 50 mg of Vitamin B6 but less than 200 mg (per recommended daily dose) to classify them as Pharmacist Only Medicines (Schedule 3).
If the TGA Delegate’s interim decision is confirmed, the schedule changes will take effect on 1 February 2027.
What should pharmacists do differently?
Ensure all consumers are asked if they are taking multiple vitamin or mineral supplements every time a Vitamin B6-containing product is requested or supplied. Where this is the case, it’s important to consider total Vitamin B6 dose, including dietary sources, and ensure it does not exceed 200 mg daily.
Pharmacists should also warn of early signs of neuropathy, such as tingling, burning or numbness – and advise they cease the medicine and seek medical review if this occurs.
Should pharmacists still supply Vitamin B6 for use in pregnancy?
There are a couple of different treatment regimens for pyridoxine (Vitamin B6) tablets for nausea and vomiting of pregnancy which involve divided doses.2–4 Some references caution against quality of evidence and modest benefit.
The maximum daily dose should not exceed 200 mg. This upper dose is generally considered to be safe for the duration of pregnancy.
References
- Australian Government Department of Health, Disability and Ageing. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard in relation to pyridoxine, pyridoxal or pyridoxamine (vitamin B6). 2025. At: www.tga.gov.au/sites/default/files/2025-06/notice-interim-decision-amend-or-not-amend-current-poisons-standard-pyridoxine-pyridoxal-pyridoxamine-vitaminb6.pdf
- Therapeutic Guidelines: Nausea and vomiting during pregnancy. 2025. At: www.tg.org.au
- Government of Western Australia. North Metropolitan Health Service Women and Newborn Health Service. Pyridoxine (Vitamin B6). 2024. At: www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-MPs/Pyridoxine---Vitamin-B6.pdf?thn=0
- Safer Care Victoria. Medications to treat hyperemesis. 2025. At: www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/maternity/nausea-and-vomiting#goto-table1.-medications-to-treat-hyperemesis
[post_title] => How pharmacists should address rising B6 overuse
[post_excerpt] => Too many people are taking way too much Vitamin B6. A senior pharmacist explains the risks of high doses, and how the TGA is responding.
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[post_content] => Pharmacist prescribing is emerging as a powerful extension of primary care in Australia – one that has the potential to improve access, enhance patient outcomes and reshape the profession.
For patients, it means timely, evidence-based treatment without the long waits often associated with GP appointments. For pharmacists, it represents an opportunity to practise to full scope, strengthen professional relationships and deliver care with immediacy and depth.
But becoming a prescriber is not just a new credential – it’s a mindset shift, demanding confidence, competence and a willingness to explore every aspect of a patient’s life to inform safe and effective decisions.
Kate Gunthorpe MPS, a Queensland-based pharmacist prescriber who recently presented at PSA25 and received special commendation in the PSA Symbion Early Career Pharmacist of the Year award category, explained to Australian Pharmacist what budding pharmacist prescribers should expect.
Pharmacist prescribing to become standard practice
According to Ms Gunthorpe, it is no longer a question of if, but when, pharmacist prescribing will become a normal part of primary care in Australia – as it already is in other countries.
‘Our scope will continue to expand. It’s not about replacing anyone, it’s about using every healthcare professional’s skills to their fullest,’ she said. ‘Pharmacist prescribing will also bring more students into the profession, and improve job satisfaction and retention.’
For Ms Gunthorpe, becoming a prescriber was a quest to close the gap between what patients needed and what she could offer.
‘I was often the first health professional someone would see, but without the ability to diagnose and treat within my scope, I sometimes felt like I was sending them away with half the solution,’ she said. ‘Prescribing gives me the ability to act in that moment, keep care local, and make a real difference straight away.’
Patients can often wait weeks to see a GP – or avoid care altogether because it feels too hard. Pharmacist prescribing gives them another safe, qualified option, and helps to ease pressure on other parts of the health system.
‘I’ve seen people walk in with something that’s been bothering them for months, and walk out with a treatment plan in under half an hour,’ Ms Gunthorpe said. ‘For some, it’s the difference between getting treated and just living with the problem.’
From a patient perspective, the feedback on the service has been overwhelmingly positive.
‘People are often surprised that pharmacists can now prescribe, but once they experience it, they appreciate the convenience and thoroughness,’ she said. ‘Many have told me they wish this had been available years ago and I’ve already had several patients come back for other prescribing services because they trust the process.’
Evolving your practice mindset
Becoming a pharmacist prescriber is not a box-ticking exercise – it’s a mindset shift.
Pharmacists are already great at taking medication histories. Asking, ‘Do you have any allergies? Have you had this before? What medications are you taking? Have you had any adverse effects?’ is par for the course.
But effectively growing into full scope requires pharmacists to push the envelope further. Take acne management for example.
As part of standard pharmacist care, acne consultations are mainly about over-the-counter options and suggesting a GP review for more severe cases.
‘Now, [as a pharmacist prescriber], I take a full patient history – incorporating their biopsychosocial factors – to assess the severity and check for underlying causes,’ she said. ‘I can [also] initiate prescription-only treatments when appropriate. It means I can manage the condition from start to finish, rather than just being a stepping stone.’
Sometimes it can be a matter of life or death. Ms Gunthorpe recalled a case where a patient presented with nausea and vomiting. After reviewing his symptoms and social history, a diagnosis of viral or bacterial gastroenteritis didn’t quite fit. So, she probed further:
Q: ‘What do you do for work?’
A: ‘I'm an electrician.’
Q: ‘So did you work today?’
A: ‘Yeah.’
Q: ‘How was work? Anything a bit unusual happen today? Did you bump your head or anything like that?’
A: ‘I stood up in a room today and hit the back of my head so hard I've had a raging headache ever since and I feel dizzy.’
Following this interaction, Ms Gunthorpe sent the patient to the emergency department straight away.
‘If I had just provided him with some ondansetron, he could have not woken up that night,’ she said. ‘So think about how that impacted his treatment plan, just because I asked him what his occupation is.’
Encouraging patients to open up
It’s not always easy getting the right information out of patients – particularly in a pharmacy environment. So Ms Gunthorpe takes a structured approach to these interactions.
‘I say, “I'm going to ask you a few questions about your life and your lifestyle, just to let me get to know you a little bit more so we can create a unique and shared management plan for you”,’ she said.
This helps patients understand that she’s not just prying – and that each question has a purpose.
‘Then they are more than willing,’ she said. ‘Nothing actually surprises me now about what patients say to me – whether it's recreational drugs or the sexual activity they get up to on the weekend.’
Post-consultation, documentation is an equally important part of the process.
‘Everything you asked, the answers to these questions and what the patient tells you has to be documented,’ Ms Gunthorpe said. ‘If it's not documented, then it didn't happen. That's just a flat out rule.’
In other words, you will not be covered medicolegally if you provide advice and there is no paper trail.
‘I encourage you to start documenting – even if it doesn't feel like it's too important,’ she said. ‘That’s something we as a whole industry need to start doing better.’
Redesigning workflows and upskilling staff
While embracing a prescribing mindset is crucial, so is maintaining the dispensary – allowing for uninterrupted patient consultations.
‘We need to ensure our dispensary keeps running while we are off the floor,’ Ms Gunthorpe said. ‘I’ve never worried that someone will burst into the room [when I'm seeing a] GP mid-consult – so we need to create that same protected environment in pharmacy.’
Upskilling pharmacy assistants and dispensary technicians has been key to making this possible. Staff now take patient details before the consultation, manage the consult rooms, and triage patients when Ms Gunthorpe is unavailable – a role they have embraced with enthusiasm.
‘When I’m not there, they need to make appointments, explain our services, and direct patients to me when I am in consults,’ she said. ‘It’s been really satisfying for them to step into expanded roles.’
Reframing relationships with general practice
Pharmacist prescribing is not intended to replace GPs, but to create more accessible, collaborative and timely care – relying on strong relationships, shared responsibility and open communication.
‘Think of prescribing as stepping into a shared space, not taking over someone else’s. Let’s do it together, with confidence, compassion, and clinical excellence,’ Ms Gunthorpe said.
In some cases referral to a GP is necessary, particularly when additional diagnostics are required. This can cause frustration if patients pay for a consultation but leave without medicines. So strengthening GP-pharmacist relationships is essential to making the model work.
‘We want this to be a shared space where we both feel safe and respected when referring either way,’ she said. ‘If a GP is booked out for 2 weeks and a child has otitis media, we want the receptionist to be able to say, “Kate down the road has consults available this afternoon”. That’s the collaboration we’re aiming for.’
Queensland Government funding for pharmacists to undertake prescribing training remains open. For more information and to check eligibility visit Pharmacist Prescribing Scope of Practice Training Program.
[post_title] => The mindset shift that’s key to prescribing success
[post_excerpt] => Pharmacist prescribing is emerging as a powerful extension of primary care, with potential to improve access and enhance patient outcomes.
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[post_content] => Case scenario
Mrs Nguyen, a 68-year-old woman, consults you about over-the-counter treatments for light-headedness, particularly when getting out of bed. She denies a spinning sensation, nausea or hearing issues. Her symptoms began 2 weeks ago, shortly after starting perindopril for hypertension.
After reading this article, pharmacists should be able to:
|
Dizziness is a non-specific term patients use to describe various sensations that can be categorised into light-headedness, vertigo, imbalance, or the feeling of fainting.1 Vertigo, as a subtype of dizziness, is typically caused by an imbalance in the vestibular system,2 which includes inner ear balance organs responsible for spatial orientation and coordination.3
The most common causes of vertigo are vestibular neuritis and benign paroxysmal positional vertigo (BPPV), which can be triggered by changes in the head’s position, particularly when rolling over in bed or looking upward.2,4 Although less common, central causes of vertigo other than vestibular migraine exist and will be briefly discussed in this article.5 Dizziness or vertigo can be burdensome to the extent that it significantly impacts quality of life.6 In older people, this symptom alone may increase the risk of falls.7
Pharmacists can guide appropriate management for the acute presentation of vertigo or refer to healthcare providers when necessary for further evaluation.
It is important to note that vertigo is a symptom rather than a diagnosis.8 Symptoms of dizziness or vertigo account for up to 16% of all primary care visits globally, with the most common cause related to the vestibular system.9 A 2009 Australian cohort study that included 2,751 community-dwelling adults revealed that 36% (n = 995) of people over the age of 50 years self-reported symptoms of dizziness or vertigo.10 Additionally, vestibular vertigo and non-vestibular vertigo were reported by 10% (276) and 14% (391) of the cohort respectively.10 In the study, the prevalence of dizziness and vestibular vertigo were reported to be significantly higher in women than men. A 10-year follow-up study in 2024 further re-examined the participants (aged 55 years and older) available for follow-up.6 The incidence of symptoms of dizziness or vertigo, vestibular vertigo and non-vestibular vertigo were 40%, 27% and 12% respectively.6
Dizziness and imbalance are especially common in older people, with the prevalence increasing with age.11 While the causes are multifactorial (complex interplay of neurological, cardiovascular, visual, vestibular or psychological issues), these symptoms are more commonly due to an age-related decline of vestibular function.11
The underlying aetiology associated with vertigo can be categorised as either peripheral or central causes.
Peripheral causes of vertigo are related to pathology in the inner ear and are more common than central causes. Peripheral vertigo is caused by an imbalance in the vestibular system.2 For instance, in BPPV, the sudden onset of spinning sensation is caused by a displacement of otoliths (calcium debris) located in the posterior semicircular canal following a rapid head movement.8 Other common peripheral causes include Ménière’s disease and vestibular neuritis.8 See Table 1 for more information on the various causes of vertigo.
[caption id="attachment_30304" align="aligncenter" width="1035"] Table 1 – Types of vertigo (non-exhaustive list)[/caption]
Central causes of vertigo, on the other hand, are related to a pathology that affects vestibular pathways in the central nervous system, specifically the brain stem, cerebellum and cortex.5 Central causes are uncommon with the exception of vestibular migraine.12 A report from Migraine Australia in 2021 indicated that vestibular migraine is one of the many subtypes of migraine that may be largely undiagnosed.13 A cohort study found that age and migraine are significantly associated with an increased risk of dizziness or vertigo symptoms.6
Vertigo is most often described as a spinning sensation, which is typically a rotatory illusion of motion, but could also be linear with a sensation of falling.5 Other autonomic symptoms commonly accompanied by vertigo include nausea and/or vomiting, sweating or pallor.5,14 Symptoms of vertigo are typically acute and tend to improve over hours to days as central vestibular compensation occurs, or once the contributing factor has been removed.2
The clinical presentation of vertigo can be useful in differentiating whether the cause is peripheral or central. Peripheral features include auditory symptoms such as hearing loss, tinnitus, the feeling of blockage in the ear, or a positive head impulse test.5 The head impulse test is a manoeuvre test conducted by a clinician to test the patient’s vestibulo-ocular reflex function and subsequently identify peripheral vestibular dysfunctions.15 On the other hand, central features of vertigo include movement abnormalities (e.g. gait ataxia out of proportion to the extent of vertigo, limb weakness and ataxia), vision abnormalities (e.g. direction-changing nystagmus, skew deviation, visual field loss, diplopia), slurred speech, difficulty swallowing or hemisensory loss.16
Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
As discussed in Table 1, the treatment approach for vertigo is tailored to the underlying cause and generally involves reassurance and management of symptoms.17
When required for acute vertigo, symptomatic treatment of nausea and vomiting should only be for a short period of time (<48 hours). This is because prolonged treatment can increase the risk of neurological adverse effects (See Precautions and adverse effects).20 Treatment options are listed below.
Nausea (without vomiting)
For nausea (without vomiting), oral prochlorperazine or promethazine may be used for up to 2 days.20 If not effective or tolerated, diazepam or ondansetron may be considered for up to 2 days.20
Vomiting
If the patient is vomiting, other routes of administration are used, including20:
Prochlorperazine is a dopamine antagonist that blocks dopamine type 2 (D2) receptors centrally in the chemoreceptor trigger zone of the brainstem and peripherally in the gastrointestinal tract.21 At high doses, blockage at other receptors (serotonin, histamine, adrenergic and muscarinic receptors) may be seen.21 Prochlorperazine can cause anticholinergic adverse effects (e.g. constipation, dry mouth, blurred vision) and other adverse effects including sedation and extrapyramidal adverse effects (e.g. akathisia, parkinsonism).22 Long-term use of prochlorperazine should be avoided due to the acute and episodic nature of the condition.20 The risk of tardive dyskinesia increases with prolonged treatment duration and higher cumulative doses.22 In older people, these adverse effects may be severe and lead to cognitive impairment, falls, fractures and increased all-cause mortality.21,23
Promethazine is a sedating antihistamine that acts by blocking H1 receptors, muscarinic receptors and dopamine D2 receptors.21 Promethazine is commonly associated with anticholinergic adverse effects (including confusion, dry mouth, constipation), dizziness and sedation.24 Similar to prochlorperazine, it may have some antidopaminergic activity, thus causing extrapyramidal adverse effects.21,24
Appropriate management of ongoing falls risk is especially important in older people when using antiemetics, as some adverse effects can increase the risk of falls.17 Antiemetic medicines, if used, should be at the lowest effective dose for the shortest period possible with close monitoring for adverse effects. The harms of long-term prochlorperazine use are likely to outweigh the benefits in most cases. Guidelines suggest offering deprescribing to older people taking long-term prochlorperazine when originally prescribed for a short-term indication (e.g. acute vertigo).25 Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
It is crucial to note that isolated vertigo can be a symptom of transient ischaemic attacks, which require emergency care.19 This is particularly relevant to pharmacists practising in a primary care setting to be able to identify and recognise initial symptoms indicative of a stroke at first medical contact. In general, patients presenting with the following symptoms should be immediately referred to the emergency department26:
In addition to these diseases, many medicines can also cause symptoms of dizziness and/or vertigo, including but not limited to medicines associated with vestibulotoxicity.27 In particular, cardiovascular medicines (e.g. antihypertensives) and antidepressants are commonly associated with dizziness and/or vertigo as an adverse effect. An inappropriate prescribing cascade may occur when a new medicine is being prescribed to manage an adverse reaction to another drug.28 For instance, if prochlorperazine is prescribed to treat dizziness from antihypertensive use.28
In older people, dizziness significantly increases the risk of falls.7 Implementing appropriate interventions to address modifiable risk factors such as dizziness is of paramount importance. In cases of drug-induced dizziness, deprescribing can be considered if the medicine can be safely reduced, discontinued or substituted to prevent inappropriate prescribing cascades of potentially inappropriate medicines (PIM), especially in the context of older people.29
When patients present with dizziness, it can often indicate a broad range of underlying conditions, including vestibular disorders, making it essential for pharmacists to carefully assess the patient’s health history and medicines.
Pharmacists have the knowledge to determine when referral to other healthcare providers is warranted. Through medicine reviews, pharmacists can identify medicines (such as antihypertensives, sedatives and anticholinergics) that may contribute to symptoms resembling vertigo. They can then collaborate with healthcare providers to adjust medicines as needed. Additionally, pharmacists have a crucial role in providing patient education to ensure patients understand the proper use of antiemetics and provide guidance on safety precautions during episodes of dizziness. They also play a key role in monitoring medicine use and managing any adverse effects that arise.
Pharmacists can promote the quality use of medicines by offering deprescribing recommendations to patients and their prescribers when there is an unclear, unknown or lack of persistent indication for a medicine. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
The treatment of vertigo largely depends on its underlying cause. Targeted non-pharmacological treatments like repositioning manoeuvres and physical therapy are effective in managing motion-induced vertigo. With appropriate treatment and patient education, most patients can experience significant symptom improvement and a reduced impact on daily life. Pharmacists are integral to achieving these positive outcomes. Through timely interventions, medicine optimisation, patient education, and collaboration with other healthcare providers, pharmacists can help ensure the effective management of vertigo.
Case scenario continuedRecognising dizziness as a common adverse effect of perindopril, you explain the possibility of drug-induced dizziness and recommend that Mrs Nguyen see her doctor for a review. You also provide advice on managing dizziness in the meantime, such as avoiding sudden movements and standing up slowly to minimise the risk of falls. Two weeks later, Mrs Nguyen returns to the pharmacy with a new prescription to trial a different antihypertensive. Within a week, Mrs Nguyen reports significant improvement in her dizziness, which allows her to resume her daily activities with greater confidence. She also sees a noticeable improvement in her overall quality of life, and she thanks you for your help. |
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and the director of the Centre for Optimisation of Medicines at UWA’s School of Allied Health.
Hana Numan (she/her) BPharm, PGCertClinPharm, PGDipClinPharm
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) Scholarship at the University of Western Australia.
Amy Page is supported by the Western Australian Future Health Research and Innovation Fund/Western Australian Department of Health, Grant ID WANMA/EL2022/1. She is an employee of the University of Western Australia and a practitioner member of the Pharmacy Board of Australia.
[post_title] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [post_excerpt] => Dizziness or vertigo can be burdensome to the extent that it significantly impacts quality of life, and in older people, this symptom alone may increase the risk of falls. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => beyond-the-spin-diagnosis-symptoms-and-treatment-options-for-vertigo [to_ping] => [pinged] => [post_modified] => 2025-08-13 17:37:31 [post_modified_gmt] => 2025-08-13 07:37:31 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=29857 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [title] => Beyond the spin: diagnosis, symptoms and treatment options for vertigo [href] => https://www.australianpharmacist.com.au/beyond-the-spin-diagnosis-symptoms-and-treatment-options-for-vertigo/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 30298 [authorType] => )td_module_mega_menu Object
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[post_content] => Yesterday (19 August), it was announced that Ozempic (semaglutide 1.0 mg) has received approval from the Therapeutic Goods Administration (TGA) for an expansion of indication to reduce the risk of kidney disease progression in patients with type 2 diabetes and chronic kidney disease (CKD).
It’s estimated that around 2.7 million Australians are living with indicators of CKD, including both diagnosed and undiagnosed cases.
Of these, diabetes is the leading cause of end stage kidney disease (ESKD) – accounting for over a third (38%) of new cases. Of an estimated 333,000 Australians living with both CKD and diabetes, approximately 10,000 are expected to progress to kidney failure.
If not managed appropriately and in serious cases, CKD may also lead to kidney failure, heart disease and stroke, and in some cases, premature death, said Professor Vlado Perkovic, nephrologist and Provost at the University of New South Wales.
‘Early intervention can help with slowing disease progression,’ he said.
‘This approval represents a step forward in addressing the multifaceted needs of individuals living with type 2 diabetes and CKD,’ added Dr Ana Svensson, Vice President of Clinical, Medical and Regulatory at Novo Nordisk Oceania.
What does the evidence say?
The FLOW (Evaluate Renal Function with Semaglutide Once Weekly) trial is a large multinational study that assessed the effects of once-weekly semaglutide 1.0 mg in adults with type 2 diabetes and CKD.
Participants who received semaglutide had a 24% reduction in risk of major kidney events, slower decline in estimated glomerular filtration rate, and decreased albuminuria – compared to placebo. They also experienced improvements in cardiovascular outcomes and all-cause mortality – with the safety profile consistent with previous studies.
To date, the TGA has not released specific dosing guidance related to the new CKD indication.
Will Ozempic be PBS listed for CKD?
Semaglutide (Ozempic) for CKD is currently not subsidised under the Pharmaceutical Benefits Scheme (PBS).
That means the out-of-pocket costs will not be subsidised, compared to around $31.60 for general patients using the medicine under existing PBS criteria.
‘While it is not specifically reimbursed for kidney disease risk reduction, Novo Nordisk continues to engage with government stakeholders to explore opportunities for broader access to our medicines for Australians living with chronic conditions,’ a spokesperson for Novo Nordisk told Australian Pharmacist.
With Ozempic no longer in shortage, will access open up?
Last month (18 July), the TGA officially removed Ozempic from its medicine shortages list, with previous supply restrictions now lifted. Now that Ozempic stocks have returned to a sufficient level, new patients can be initiated on the medicine. But Ozempic prescribed for weight loss is still off-label, with no update to the indication for weight loss. So the PBS criteria on this front also remain unchanged, and it’s uncertain if this will change any time soon.
‘We have semaglutide 2.4 mg (Wegovy) available – it is indicated for the treatment of patients with obesity or overweight and established cardiovascular disease,’ the Novo Nordisk spokesperson said.
But experts hope that subsidy and accessibility will improve over time as demand and evidence grow.
‘There’s no doubt that both cost and availability present a barrier to the more widespread use of semaglutide at the moment,’ Prof Perkovic said. ‘But I’m sure that over time that situation will change and the drugs will become more widely available.’
[post_title] => Ozempic now indicated to prevent CKD progression
[post_excerpt] => Ozempic is the first medicine in Australia approved to slow kidney disease progression in patients with both type 2 diabetes and CKD.
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[post_content] => This national resource supports frontline assessment, management and prompt referral of burn injuries.
Community pharmacists are often the first point of contact for health concerns and public health initiatives, including burns, said Rebecca Schrale, Burns Nurse Practitioner at the Royal Hobart Hospital’s Burns Unit and Australian and New Zealand Burn Association (ANZBA) Burns Prevention Representative for Tasmania.
‘[So] community pharmacists are in a unique position to provide education on initial first aid, referral and wound care,’ she said. ‘They also have an important role in prevention of burn injuries, educating the community and reducing risk.’
To that end, ANZBA, PSA and the National Australian Pharmacy Students’ Association (NAPSA) collaborated to develop guidelines specifically for pharmacists to assist with the assessment and management of burns.
Australian Pharmacist investigates what pharmacists should look out for and how to manage and refer burns appropriately.
What burns do community pharmacists typically encounter?
The full spectrum – from minor to severe, said PSA Tasmania State Manager Dr Ella van Tienen FPS.
‘A lot of it is advice for minor sunburn or small burns,’ she said. ‘But you do get some more serious burns when people aren’t sure what to do with them, or whether they’re serious enough to [require further attention].’
Burns are more likely to occur out of hours, such as on weekends and public holidays – particularly among children – when general practices are typically closed.
‘That’s when kids are home,’ Dr van Tienen added.
Common causes of burns in children include hot water scalds due to access to kettles or stove tops.
‘Teenagers who are newly independent and off at the beach on their own, also present with blistering sunburn,’ she said.
What impact do burns have on the community?
It’s important to remember that even minor burns can have long-term effects on the patient in regard to range of movement, function and the look and feel of the scar, Ms Schrale said.
‘All burn injuries – whether large or small can have a psychological effect on the individual and their family,’ she said. ‘And it’s imperative that patients are referred to burns clinicians in a timely manner.’
Deep burn injuries will result in scarring and could restrict the function of the area that is affected.
‘Pharmacies are often open after hours and on weekends so again they provide clients and their families with timely advice, education and support,’ Ms Schrale said.
What does the burns resource involve?
The new Pharmacists Advisory Card and A3 Poster are new iterations of an old resource, Dr van Tienen said.
‘The original resource had been around for many years, and it needed to be updated,’ she said.
The refreshed burns advisory resource provides pharmacists with up-to-date information on Burns First Aid, and assessment – including burn depth, assessment and minor burn wound care, Ms Schrale said.
‘With this knowledge they are equipped to then follow the ANZBA referral guidelines, highlighting who requires discussion or referral to primary [care] or the local emergency department (ED),’ she said. ‘The updated card ensures the messaging is consistent across pharmacies, community health, primary care and EDs nationally.’
What new information is included?
The new version of the card focuses on information that will assist in early assessment, management and referral of minor burns, Ms Schrale said.
‘It also provides simple and consistent messaging on wound care and medical emergencies – such as large surface area burns, airway burns, circumferential burns and infection,’ she said.
‘The other new addition is the inclusion of information on burns scar management based on evidence-based practice and encouraging referral for any patient who sustains a scar from a burn injury.’
How can the burns resource be used in practice?
Let’s say a parent presents to the pharmacy with a child who has sustained a burn after accidentally knocking over a pot of boiling water while cooking pasta on the stove.
‘If the child has a small [dermal] burn that’s not significantly blistered, the pharmacist could appropriately treat it in the community by providing first aid and dressing advice,’ Dr van Tienen said.
‘The pharmacist should advise the parent to watch out for [significant] blistering, the blisters breaking, any signs of infection or excessive [levels] of pain.’
Indicators that should prompt further action include if the child:
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[post_content] => Too many people are taking way too much Vitamin B6. Here are the risks of high doses and how the Therapeutic Goods Administration (TGA) is responding.
What is the concern about Vitamin B6?
High doses and/or prolonged use of Vitamin B6 above the recommended daily intake (RDI) have been linked to peripheral neuropathy. Most cases have been reported at doses exceeding 500 mg/day, although cases at lower doses have been reported.1
The TGA’s adverse events notification database contains 174 reports1 of peripheral neuropathy, peripheral sensory neuropathy, small fibre neuropathy or chronic polyneuropathy for products containing Vitamin B6.1
The primary concern is the risk of overconsumption of Vitamin B6 from a variety of sources, particularly in individuals using multiple multivitamin and supplement products.1
How many products have Vitamin B6 in them?
Lots! There are over 1,500 products listed on the Australian Register of Therapeutic Goods (ARTG) which contain Vitamin B6. Approximately 100 of these products have more than 50 mg of Vitamin B6 as the single active ingredient.
The inclusion of Vitamin B6 in these products is rarely prominently displayed. And labelling of Vitamin B6 is often not visible to or understood by consumers, instead being referenced as pyridoxine, pyridoxine hydrochloride, pyridoxal 5-phosphate and pyridoxal 5-phosphate monohydrate.1
What is the TGA doing?
The TGA Delegate has made an interim decision to amend the scheduling of medicines containing more than 50 mg of Vitamin B6 but less than 200 mg (per recommended daily dose) to classify them as Pharmacist Only Medicines (Schedule 3).
If the TGA Delegate’s interim decision is confirmed, the schedule changes will take effect on 1 February 2027.
What should pharmacists do differently?
Ensure all consumers are asked if they are taking multiple vitamin or mineral supplements every time a Vitamin B6-containing product is requested or supplied. Where this is the case, it’s important to consider total Vitamin B6 dose, including dietary sources, and ensure it does not exceed 200 mg daily.
Pharmacists should also warn of early signs of neuropathy, such as tingling, burning or numbness – and advise they cease the medicine and seek medical review if this occurs.
Should pharmacists still supply Vitamin B6 for use in pregnancy?
There are a couple of different treatment regimens for pyridoxine (Vitamin B6) tablets for nausea and vomiting of pregnancy which involve divided doses.2–4 Some references caution against quality of evidence and modest benefit.
The maximum daily dose should not exceed 200 mg. This upper dose is generally considered to be safe for the duration of pregnancy.
References
- Australian Government Department of Health, Disability and Ageing. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard in relation to pyridoxine, pyridoxal or pyridoxamine (vitamin B6). 2025. At: www.tga.gov.au/sites/default/files/2025-06/notice-interim-decision-amend-or-not-amend-current-poisons-standard-pyridoxine-pyridoxal-pyridoxamine-vitaminb6.pdf
- Therapeutic Guidelines: Nausea and vomiting during pregnancy. 2025. At: www.tg.org.au
- Government of Western Australia. North Metropolitan Health Service Women and Newborn Health Service. Pyridoxine (Vitamin B6). 2024. At: www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-MPs/Pyridoxine---Vitamin-B6.pdf?thn=0
- Safer Care Victoria. Medications to treat hyperemesis. 2025. At: www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/maternity/nausea-and-vomiting#goto-table1.-medications-to-treat-hyperemesis
[post_title] => How pharmacists should address rising B6 overuse
[post_excerpt] => Too many people are taking way too much Vitamin B6. A senior pharmacist explains the risks of high doses, and how the TGA is responding.
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[post_content] => Pharmacist prescribing is emerging as a powerful extension of primary care in Australia – one that has the potential to improve access, enhance patient outcomes and reshape the profession.
For patients, it means timely, evidence-based treatment without the long waits often associated with GP appointments. For pharmacists, it represents an opportunity to practise to full scope, strengthen professional relationships and deliver care with immediacy and depth.
But becoming a prescriber is not just a new credential – it’s a mindset shift, demanding confidence, competence and a willingness to explore every aspect of a patient’s life to inform safe and effective decisions.
Kate Gunthorpe MPS, a Queensland-based pharmacist prescriber who recently presented at PSA25 and received special commendation in the PSA Symbion Early Career Pharmacist of the Year award category, explained to Australian Pharmacist what budding pharmacist prescribers should expect.
Pharmacist prescribing to become standard practice
According to Ms Gunthorpe, it is no longer a question of if, but when, pharmacist prescribing will become a normal part of primary care in Australia – as it already is in other countries.
‘Our scope will continue to expand. It’s not about replacing anyone, it’s about using every healthcare professional’s skills to their fullest,’ she said. ‘Pharmacist prescribing will also bring more students into the profession, and improve job satisfaction and retention.’
For Ms Gunthorpe, becoming a prescriber was a quest to close the gap between what patients needed and what she could offer.
‘I was often the first health professional someone would see, but without the ability to diagnose and treat within my scope, I sometimes felt like I was sending them away with half the solution,’ she said. ‘Prescribing gives me the ability to act in that moment, keep care local, and make a real difference straight away.’
Patients can often wait weeks to see a GP – or avoid care altogether because it feels too hard. Pharmacist prescribing gives them another safe, qualified option, and helps to ease pressure on other parts of the health system.
‘I’ve seen people walk in with something that’s been bothering them for months, and walk out with a treatment plan in under half an hour,’ Ms Gunthorpe said. ‘For some, it’s the difference between getting treated and just living with the problem.’
From a patient perspective, the feedback on the service has been overwhelmingly positive.
‘People are often surprised that pharmacists can now prescribe, but once they experience it, they appreciate the convenience and thoroughness,’ she said. ‘Many have told me they wish this had been available years ago and I’ve already had several patients come back for other prescribing services because they trust the process.’
Evolving your practice mindset
Becoming a pharmacist prescriber is not a box-ticking exercise – it’s a mindset shift.
Pharmacists are already great at taking medication histories. Asking, ‘Do you have any allergies? Have you had this before? What medications are you taking? Have you had any adverse effects?’ is par for the course.
But effectively growing into full scope requires pharmacists to push the envelope further. Take acne management for example.
As part of standard pharmacist care, acne consultations are mainly about over-the-counter options and suggesting a GP review for more severe cases.
‘Now, [as a pharmacist prescriber], I take a full patient history – incorporating their biopsychosocial factors – to assess the severity and check for underlying causes,’ she said. ‘I can [also] initiate prescription-only treatments when appropriate. It means I can manage the condition from start to finish, rather than just being a stepping stone.’
Sometimes it can be a matter of life or death. Ms Gunthorpe recalled a case where a patient presented with nausea and vomiting. After reviewing his symptoms and social history, a diagnosis of viral or bacterial gastroenteritis didn’t quite fit. So, she probed further:
Q: ‘What do you do for work?’
A: ‘I'm an electrician.’
Q: ‘So did you work today?’
A: ‘Yeah.’
Q: ‘How was work? Anything a bit unusual happen today? Did you bump your head or anything like that?’
A: ‘I stood up in a room today and hit the back of my head so hard I've had a raging headache ever since and I feel dizzy.’
Following this interaction, Ms Gunthorpe sent the patient to the emergency department straight away.
‘If I had just provided him with some ondansetron, he could have not woken up that night,’ she said. ‘So think about how that impacted his treatment plan, just because I asked him what his occupation is.’
Encouraging patients to open up
It’s not always easy getting the right information out of patients – particularly in a pharmacy environment. So Ms Gunthorpe takes a structured approach to these interactions.
‘I say, “I'm going to ask you a few questions about your life and your lifestyle, just to let me get to know you a little bit more so we can create a unique and shared management plan for you”,’ she said.
This helps patients understand that she’s not just prying – and that each question has a purpose.
‘Then they are more than willing,’ she said. ‘Nothing actually surprises me now about what patients say to me – whether it's recreational drugs or the sexual activity they get up to on the weekend.’
Post-consultation, documentation is an equally important part of the process.
‘Everything you asked, the answers to these questions and what the patient tells you has to be documented,’ Ms Gunthorpe said. ‘If it's not documented, then it didn't happen. That's just a flat out rule.’
In other words, you will not be covered medicolegally if you provide advice and there is no paper trail.
‘I encourage you to start documenting – even if it doesn't feel like it's too important,’ she said. ‘That’s something we as a whole industry need to start doing better.’
Redesigning workflows and upskilling staff
While embracing a prescribing mindset is crucial, so is maintaining the dispensary – allowing for uninterrupted patient consultations.
‘We need to ensure our dispensary keeps running while we are off the floor,’ Ms Gunthorpe said. ‘I’ve never worried that someone will burst into the room [when I'm seeing a] GP mid-consult – so we need to create that same protected environment in pharmacy.’
Upskilling pharmacy assistants and dispensary technicians has been key to making this possible. Staff now take patient details before the consultation, manage the consult rooms, and triage patients when Ms Gunthorpe is unavailable – a role they have embraced with enthusiasm.
‘When I’m not there, they need to make appointments, explain our services, and direct patients to me when I am in consults,’ she said. ‘It’s been really satisfying for them to step into expanded roles.’
Reframing relationships with general practice
Pharmacist prescribing is not intended to replace GPs, but to create more accessible, collaborative and timely care – relying on strong relationships, shared responsibility and open communication.
‘Think of prescribing as stepping into a shared space, not taking over someone else’s. Let’s do it together, with confidence, compassion, and clinical excellence,’ Ms Gunthorpe said.
In some cases referral to a GP is necessary, particularly when additional diagnostics are required. This can cause frustration if patients pay for a consultation but leave without medicines. So strengthening GP-pharmacist relationships is essential to making the model work.
‘We want this to be a shared space where we both feel safe and respected when referring either way,’ she said. ‘If a GP is booked out for 2 weeks and a child has otitis media, we want the receptionist to be able to say, “Kate down the road has consults available this afternoon”. That’s the collaboration we’re aiming for.’
Queensland Government funding for pharmacists to undertake prescribing training remains open. For more information and to check eligibility visit Pharmacist Prescribing Scope of Practice Training Program.
[post_title] => The mindset shift that’s key to prescribing success
[post_excerpt] => Pharmacist prescribing is emerging as a powerful extension of primary care, with potential to improve access and enhance patient outcomes.
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[post_content] => Case scenario
Mrs Nguyen, a 68-year-old woman, consults you about over-the-counter treatments for light-headedness, particularly when getting out of bed. She denies a spinning sensation, nausea or hearing issues. Her symptoms began 2 weeks ago, shortly after starting perindopril for hypertension.
After reading this article, pharmacists should be able to:
|
Dizziness is a non-specific term patients use to describe various sensations that can be categorised into light-headedness, vertigo, imbalance, or the feeling of fainting.1 Vertigo, as a subtype of dizziness, is typically caused by an imbalance in the vestibular system,2 which includes inner ear balance organs responsible for spatial orientation and coordination.3
The most common causes of vertigo are vestibular neuritis and benign paroxysmal positional vertigo (BPPV), which can be triggered by changes in the head’s position, particularly when rolling over in bed or looking upward.2,4 Although less common, central causes of vertigo other than vestibular migraine exist and will be briefly discussed in this article.5 Dizziness or vertigo can be burdensome to the extent that it significantly impacts quality of life.6 In older people, this symptom alone may increase the risk of falls.7
Pharmacists can guide appropriate management for the acute presentation of vertigo or refer to healthcare providers when necessary for further evaluation.
It is important to note that vertigo is a symptom rather than a diagnosis.8 Symptoms of dizziness or vertigo account for up to 16% of all primary care visits globally, with the most common cause related to the vestibular system.9 A 2009 Australian cohort study that included 2,751 community-dwelling adults revealed that 36% (n = 995) of people over the age of 50 years self-reported symptoms of dizziness or vertigo.10 Additionally, vestibular vertigo and non-vestibular vertigo were reported by 10% (276) and 14% (391) of the cohort respectively.10 In the study, the prevalence of dizziness and vestibular vertigo were reported to be significantly higher in women than men. A 10-year follow-up study in 2024 further re-examined the participants (aged 55 years and older) available for follow-up.6 The incidence of symptoms of dizziness or vertigo, vestibular vertigo and non-vestibular vertigo were 40%, 27% and 12% respectively.6
Dizziness and imbalance are especially common in older people, with the prevalence increasing with age.11 While the causes are multifactorial (complex interplay of neurological, cardiovascular, visual, vestibular or psychological issues), these symptoms are more commonly due to an age-related decline of vestibular function.11
The underlying aetiology associated with vertigo can be categorised as either peripheral or central causes.
Peripheral causes of vertigo are related to pathology in the inner ear and are more common than central causes. Peripheral vertigo is caused by an imbalance in the vestibular system.2 For instance, in BPPV, the sudden onset of spinning sensation is caused by a displacement of otoliths (calcium debris) located in the posterior semicircular canal following a rapid head movement.8 Other common peripheral causes include Ménière’s disease and vestibular neuritis.8 See Table 1 for more information on the various causes of vertigo.
[caption id="attachment_30304" align="aligncenter" width="1035"] Table 1 – Types of vertigo (non-exhaustive list)[/caption]
Central causes of vertigo, on the other hand, are related to a pathology that affects vestibular pathways in the central nervous system, specifically the brain stem, cerebellum and cortex.5 Central causes are uncommon with the exception of vestibular migraine.12 A report from Migraine Australia in 2021 indicated that vestibular migraine is one of the many subtypes of migraine that may be largely undiagnosed.13 A cohort study found that age and migraine are significantly associated with an increased risk of dizziness or vertigo symptoms.6
Vertigo is most often described as a spinning sensation, which is typically a rotatory illusion of motion, but could also be linear with a sensation of falling.5 Other autonomic symptoms commonly accompanied by vertigo include nausea and/or vomiting, sweating or pallor.5,14 Symptoms of vertigo are typically acute and tend to improve over hours to days as central vestibular compensation occurs, or once the contributing factor has been removed.2
The clinical presentation of vertigo can be useful in differentiating whether the cause is peripheral or central. Peripheral features include auditory symptoms such as hearing loss, tinnitus, the feeling of blockage in the ear, or a positive head impulse test.5 The head impulse test is a manoeuvre test conducted by a clinician to test the patient’s vestibulo-ocular reflex function and subsequently identify peripheral vestibular dysfunctions.15 On the other hand, central features of vertigo include movement abnormalities (e.g. gait ataxia out of proportion to the extent of vertigo, limb weakness and ataxia), vision abnormalities (e.g. direction-changing nystagmus, skew deviation, visual field loss, diplopia), slurred speech, difficulty swallowing or hemisensory loss.16
Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
As discussed in Table 1, the treatment approach for vertigo is tailored to the underlying cause and generally involves reassurance and management of symptoms.17
When required for acute vertigo, symptomatic treatment of nausea and vomiting should only be for a short period of time (<48 hours). This is because prolonged treatment can increase the risk of neurological adverse effects (See Precautions and adverse effects).20 Treatment options are listed below.
Nausea (without vomiting)
For nausea (without vomiting), oral prochlorperazine or promethazine may be used for up to 2 days.20 If not effective or tolerated, diazepam or ondansetron may be considered for up to 2 days.20
Vomiting
If the patient is vomiting, other routes of administration are used, including20:
Prochlorperazine is a dopamine antagonist that blocks dopamine type 2 (D2) receptors centrally in the chemoreceptor trigger zone of the brainstem and peripherally in the gastrointestinal tract.21 At high doses, blockage at other receptors (serotonin, histamine, adrenergic and muscarinic receptors) may be seen.21 Prochlorperazine can cause anticholinergic adverse effects (e.g. constipation, dry mouth, blurred vision) and other adverse effects including sedation and extrapyramidal adverse effects (e.g. akathisia, parkinsonism).22 Long-term use of prochlorperazine should be avoided due to the acute and episodic nature of the condition.20 The risk of tardive dyskinesia increases with prolonged treatment duration and higher cumulative doses.22 In older people, these adverse effects may be severe and lead to cognitive impairment, falls, fractures and increased all-cause mortality.21,23
Promethazine is a sedating antihistamine that acts by blocking H1 receptors, muscarinic receptors and dopamine D2 receptors.21 Promethazine is commonly associated with anticholinergic adverse effects (including confusion, dry mouth, constipation), dizziness and sedation.24 Similar to prochlorperazine, it may have some antidopaminergic activity, thus causing extrapyramidal adverse effects.21,24
Appropriate management of ongoing falls risk is especially important in older people when using antiemetics, as some adverse effects can increase the risk of falls.17 Antiemetic medicines, if used, should be at the lowest effective dose for the shortest period possible with close monitoring for adverse effects. The harms of long-term prochlorperazine use are likely to outweigh the benefits in most cases. Guidelines suggest offering deprescribing to older people taking long-term prochlorperazine when originally prescribed for a short-term indication (e.g. acute vertigo).25 Patients who present with chronic and/or progressive vertigo symptoms in the absence of a clear diagnosis should be referred to a specialist promptly to identify an underlying cause.17
It is crucial to note that isolated vertigo can be a symptom of transient ischaemic attacks, which require emergency care.19 This is particularly relevant to pharmacists practising in a primary care setting to be able to identify and recognise initial symptoms indicative of a stroke at first medical contact. In general, patients presenting with the following symptoms should be immediately referred to the emergency department26:
In addition to these diseases, many medicines can also cause symptoms of dizziness and/or vertigo, including but not limited to medicines associated with vestibulotoxicity.27 In particular, cardiovascular medicines (e.g. antihypertensives) and antidepressants are commonly associated with dizziness and/or vertigo as an adverse effect. An inappropriate prescribing cascade may occur when a new medicine is being prescribed to manage an adverse reaction to another drug.28 For instance, if prochlorperazine is prescribed to treat dizziness from antihypertensive use.28
In older people, dizziness significantly increases the risk of falls.7 Implementing appropriate interventions to address modifiable risk factors such as dizziness is of paramount importance. In cases of drug-induced dizziness, deprescribing can be considered if the medicine can be safely reduced, discontinued or substituted to prevent inappropriate prescribing cascades of potentially inappropriate medicines (PIM), especially in the context of older people.29
When patients present with dizziness, it can often indicate a broad range of underlying conditions, including vestibular disorders, making it essential for pharmacists to carefully assess the patient’s health history and medicines.
Pharmacists have the knowledge to determine when referral to other healthcare providers is warranted. Through medicine reviews, pharmacists can identify medicines (such as antihypertensives, sedatives and anticholinergics) that may contribute to symptoms resembling vertigo. They can then collaborate with healthcare providers to adjust medicines as needed. Additionally, pharmacists have a crucial role in providing patient education to ensure patients understand the proper use of antiemetics and provide guidance on safety precautions during episodes of dizziness. They also play a key role in monitoring medicine use and managing any adverse effects that arise.
Pharmacists can promote the quality use of medicines by offering deprescribing recommendations to patients and their prescribers when there is an unclear, unknown or lack of persistent indication for a medicine. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
The treatment of vertigo largely depends on its underlying cause. Targeted non-pharmacological treatments like repositioning manoeuvres and physical therapy are effective in managing motion-induced vertigo. With appropriate treatment and patient education, most patients can experience significant symptom improvement and a reduced impact on daily life. Pharmacists are integral to achieving these positive outcomes. Through timely interventions, medicine optimisation, patient education, and collaboration with other healthcare providers, pharmacists can help ensure the effective management of vertigo.
Case scenario continuedRecognising dizziness as a common adverse effect of perindopril, you explain the possibility of drug-induced dizziness and recommend that Mrs Nguyen see her doctor for a review. You also provide advice on managing dizziness in the meantime, such as avoiding sudden movements and standing up slowly to minimise the risk of falls. Two weeks later, Mrs Nguyen returns to the pharmacy with a new prescription to trial a different antihypertensive. Within a week, Mrs Nguyen reports significant improvement in her dizziness, which allows her to resume her daily activities with greater confidence. She also sees a noticeable improvement in her overall quality of life, and she thanks you for your help. |
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and the director of the Centre for Optimisation of Medicines at UWA’s School of Allied Health.
Hana Numan (she/her) BPharm, PGCertClinPharm, PGDipClinPharm
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) Scholarship at the University of Western Australia.
Amy Page is supported by the Western Australian Future Health Research and Innovation Fund/Western Australian Department of Health, Grant ID WANMA/EL2022/1. She is an employee of the University of Western Australia and a practitioner member of the Pharmacy Board of Australia.
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