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AUSTRALIAN PHARMACIST
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            [post_content] => New avenues for nurse prescribing have the potential to reshape frontline care. For pharmacists, it’s a live example of how scope expansion translates into real impact.

Nurse prescribing is entering a new phase in Australia, and pharmacists should be paying close attention. 

While nurse practitioners and endorsed midwives have been able to prescribe Pharmaceutical Benefits Schedule (PBS) subsidised medicines since 2010, a new pathway will soon expand prescribing to a broader group of experienced nurses.

‘A lot of people wouldn't even know that nurses are already prescribing medications that are funded on the PBS,’ said Denise Lyons, President of the Australian Primary Health Care Nurses Association. ‘But there are more than 3,000 nurse practitioners and endorsed midwives in Australia now who are already prescribing.’

Under a new registration standard which came into effect in September last year, suitably qualified registered nurses will be able to prescribe medicines in Schedules 2, 3, 4 and 8 in partnership with an authorised prescriber.

‘It took until this year for universities to start the course that enables registered nurses to meet [the new standard],’ Ms Lyons said. ‘Most are 6-month postgraduate courses … So it will probably be around July 2026 that we will see the first [wave] of nurses completing the educational requirement.’

For pharmacists, this shift offers a live view of how prescribing reform is built – through legislation, governance, defined scope and, crucially, access to the PBS.

      What’s changing?
      
The new framework is deliberately cautious. To become a designated RN prescriber, a nurse must: 

        
 	
      • complete postgraduate training
        • 
 	
      • have significant prior clinical experience
        • 
 	
      • work within an agreed clinical governance framework with an authorised health practitioner under an active prescribing agreement
        • 
 	
      • complete a 6-month period of clinical mentorship.
        • 

      
 The written prescribing agreement with an authorised prescriber remains in place beyond the initial mentorship period.

‘An authorised prescriber could be a nurse practitioner, endorsed midwife, or it could be a GP,’ Ms Lyons said. ‘And that prescribing agreement is going to articulate what medications are within scope.

‘For example, say you had a registered nurse who has been working in paediatrics [throughout their] career… [They’re] going to be educated and competent to prescribe for some childhood illnesses, so that would be within [their] scope.’

For patients, expanded nurse prescribing could mean faster access to medicines, fewer delays for routine care and less reliance on GP availability.

‘You think about the amount of care that nurses deliver around [things like] aged care, palliative care, community care and sexual health,’ Ms Lyons said. 

‘There's a lot of work done in the community by registered nurses who have a lot of knowledge and experience. And this is going to be a mechanism that lets them use that knowledge and experience in a really helpful way.’

Expanded nurse prescribing will be especially valuable in rural and remote communities, aged care and other underserved settings where nurses are often the main point of contact but medical access can be patchy, she added.

      ‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place.'

denise lyons 
      

      PBS access is the make-or-break issue
      
While the regulatory framework and training pathway are now largely in place, the biggest unresolved issue is PBS access. Nurse practitioners and endorsed midwives already have it. Designated RN prescribers do not – yet.

Without PBS access, nurses may be able to issue prescriptions, but patients would still face out-of-pocket costs that undermine the practical value of the reform.

However, federal legislation now before the Senate would amend the National Health Act 1953 to allow designated RN prescribers to prescribe PBS-subsidised medicines. 

‘We're really hoping the Bill comes through the Senate with no amendments and that it passes into legislation,’ Ms Lyons said. ‘If we don't manage to get access, and the subsidies on the PBS lag behind practice, that will be a real barrier.’ 

Ms Lyons also highlighted the need for national coordination. State and territory variations in drugs and poisons legislation create confusion for both clinicians and patients, as pharmacists know all too well.

‘The work that's being done to harmonise [that] legislation across the states and territories is going to be really important, and we need to all work on that together,’ she said.

      Implications for pharmacists
      
As nurse prescribing expands, pharmacists are likely to see more prescriptions coming from a wider mix of clinicians, potentially changing how care is coordinated in everyday practice.

Rather than care sitting primarily with a single prescriber, it will increasingly be shared across a team – with nurses assessing, prescribing and monitoring within their scope, and pharmacists supporting safe and effective medicines use.

That means collaboration needs to be more deliberate, Ms Lyons said.

‘With quality use of medicines, there [need to be] clear principles around closed-loop communication, agreed-upon goals, rapid feedback on issues and shared protocols,’ she said.

The progress of the nurse prescribing model also provides a useful advocacy roadmap. The model has gained traction by focusing on what it delivers for patients – faster access, fewer delays and more complete care at the point of contact. 

That focus is particularly relevant in pharmacy, where prescribing arrangements currently vary by state and territory, and where the absence of PBS access continues to limit how much patients can benefit.

Like nurse prescribing, expanded pharmacist prescribing will only be truly effective if it’s consistent, supported by clear frameworks and enables affordable access for patients.

‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place,’ Ms Lyons said.
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      Nurse prescribing offers a roadmap for reform

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      Case scenario
      

      Sarah, a 42-year-old woman, presents to the pharmacy reporting a small lump near the anus, occasional bright red bleeding on toilet paper after bowel movements, anal itching and discomfort. She mentions feeling embarrassed to seek advice and has been self-managing with sitz baths. She reports a history of chronic constipation with frequent training during defecation. She is not taking any regular medicines and requests an over-the-counter product to relieve her symptoms. You take the time to explore Sarah’s symptoms in more detail, to help identify any red flags that would require immediate referral. You ask about the duration, severity and other symptoms such as fatigue, unintentional weight loss and changes in bowel habits, all of which she denies.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the classification and causes of anal fissures and haemorrhoids
        • 
 	
      • Identify the clinical features of anal fissures and haemorrhoids
        • 
 	
      • Discuss management strategies for anal fissures and haemorrhoids
        • 
 	
      • Describe the pharmacist’s role in supporting individuals with anal fissures and haemorrhoids.
        • 

      
Competency (2016) standards addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Accreditation code: PSAAP2604HQ

Accreditation expiry: 31/03/2028

Accreditation points: Up to 1 Group 2 CPD      		

      
      

      
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Epidemiology 
      

      Anal fissures and haemorrhoids are commonly encountered, but their epidemiology is not well documented. Haemorrhoids represent the most frequent reason for proctology consultations, followed by anal fissures.1 Haemorrhoids are estimated to affect up to 40% of adults in the general population, although many individuals are asymptomatic.2 Anal fissures occur in approximately 10–15% of the population.3 
      


      

      Aetiology and pathophysiology
      

      An anal fissure is a longitudinal tear in the anal canal, most often occurring in the posterior midline, just below the dentate line.4 Anal fissures are typically classified as primary or secondary, depending on the cause. Primary fissures are usually benign and caused by local trauma, such as the passage of hard stools, prolonged diarrhoea, vaginal delivery, repeated injury or anal penetration.4 Secondary fissures, which are often multiple and located off the midline, are uncommon, accounting for less than 1% of cases.5 They result from underlying conditions like previous anal surgery, inflammatory bowel disease (e.g. Crohn’s disease), colorectal malignancy, infections (e.g. HIV/AIDS), or dermatological conditions (e.g. psoriasis).6 Anal fissures are further described as acute or chronic, with chronic fissures lasting more than 6 weeks.7 
      


[caption id="attachment_31774" align="alignright" width="200"] DR 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.[/caption]

      Anal fissures are often mistaken for haemorrhoids because of their overlapping symptoms. Haemorrhoids differ in that they are normal vascular cushions within the anal canal that maintain continence. Although part of normal anatomy, the term ‘haemorrhoid’ is commonly used when these vascular anal cushions, containing a rich arteriovenous network, become enlarged or displaced.8 Haemorrhoids may be classified as internal (located above the dentate line) or external (located below the dentate line). Factors such as constipation, straining during bowel movements and a low-fibre diet are commonly considered to increase the risk of haemorrhoids.9,10 However, the causal relationship between these factors and the development of haemorrhoids remains unclear. A possible genetic component that predisposes to smooth muscle, epithelial and connective tissue dysfunction, may contribute to haemorrhoids.11
      

      It is important to note that certain medicines can contribute to or worsen constipation as an adverse effect, thereby aggravating haemorrhoids and anal fissures.9,10 Common examples include opioids, anticholinergics, and iron and calcium supplements.12 Regular medication review should be incorporated into comprehensive care to identify opportunities for deprescribing and prevent inappropriate prescribing cascades, with further guidance available in the new deprescribing guidelines.13
      


      Clinical features 
      

      The symptoms of haemorrhoids may include rectal bleeding, anal pruritus, prolapse, faecal seepage and mucus discharge.7 
      

      Internal haemorrhoids are usually painless because the columnar epithelium is insensitive to touch and temperature.8 In contrast, external haemorrhoids are pain sensitive and may become thrombosed, often following straining during defecation.8 
      

      Anal fissures, by comparison, typically cause severe tearing pain that is provoked by defecation.4 A key distinguishing feature is that the pain of an anal fissure typically occurs during or immediately after defecation.
      


      

      Diagnosis and differential diagnoses 
      

      For diagnostic purposes, medical practitioners perform a physical examination with the individual lying on their side, gently parting the buttocks to inspect the posterior midline.4 Several other anorectal disorders may present with similar symptoms to anal fissures and haemorrhoids. Differential diagnoses include anal fistula and solitary rectal ulcer syndrome, which can often be distinguished based on their clinical appearance through careful physical examination. An anal fistula typically presents as a draining skin punctum.14 It is an abnormal hollow tract, most often arising from infection of an anal gland.15 Solitary rectal ulcer syndrome may present with anal pain, rectal bleeding, constipation, mucus discharge, excessive straining and a sensation of incomplete evacuation. Despite its name, the condition does not always involve an ulcer. Diagnosis requires a combination of endoscopic and histopathological findings, together with the individual’s reported symptoms.16
      


      Management approaches 
      

      Haemorrhoids
      


[caption id="attachment_31775" align="alignright" width="200"] Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).[/caption]

      Non-pharmacological treatment options
      

      First-line management for haemorrhoids usually involves lifestyle measures, which include ensuring adequate fluid and fibre intake, reducing prolonged time on the toilet and avoiding excessive straining, the use of sitz baths, and maintaining anal hygiene.10 In practice, dietary and lifestyle modifications are usually recommended as a conservative and preventive measure for haemorrhoids.17
      

      Pharmacological treatment options
      

      Over-the-counter therapies for internal haemorrhoids include ointments and suppositories that contain emollients, mild astringents, local anaesthetics and/or corticosteroids.8 These preparations temporarily relieve itching and discomfort. Prolonged use of topical corticosteroids is not recommended, as it increases the risk of local infections such as candidiasis.8 Similarly, prolonged use of anaesthetic-containing products should be avoided due to potential adverse effects, including skin sensitisation and dermatitis.8
      

      Outpatient procedures and surgery
      

      For individuals who do not respond to conservative measures, other treatment options for haemorrhoids include outpatient procedures and surgery.10 Outpatient procedures include rubber band ligation, infrared coagulation, bipolar probe, heater probe, sclerotherapy and cryotherapy.10 These are generally reserved for people with grade I or grade II haemorrhoids.10 Surgery can be considered for people who do not respond to or cannot tolerate outpatient procedures, as well as those with large external haemorrhoids, or combined internal and external haemorrhoids with prolapse.10
      

      A recent meta-analysis found that surgical treatments, compared with conservative treatments, offer greater symptom relief, quicker recovery and lower recurrence rates.18 However, they do carry risks of procedure-related complications. In contrast, conservative treatments are safer and less invasive, but tend to provide slower symptom improvement and have higher recurrence rates.18 Therefore, treatment decisions should be individualised, taking into account symptom severity, individual preferences and risk tolerance.
      

      Anal fissures
      

      The primary aim of treatment for anal fissures is to reduce anal sphincter spasm, improve blood flow and promote healing.6 First-line management is usually non-operative and includes increasing dietary fibre, use of sitz baths and applying glyceryl trinitrate 0.2% ointment, three times daily for up to 4 weeks to relieve pain.19 Headache is a common adverse effect of glyceryl trinitrate due to systemic absorption, which could limit its use.20 Other topical agents used in clinical practice include lidocaine and hydrocortisone, although these are less effective than a combination of fibre intake and warm sitz baths.4 
      

      Botulinum toxin injections may also be considered and can achieve good healing rates.6,19 However, botulinum toxin may cause temporary reduced control of wind or bowel motions, which usually resolves as the effect of the injection wears off.4 Due to these adverse effects and the invasive nature of the procedure, botulinum toxin is generally reserved as a second-line therapy.4 If these treatment options are unsuccessful, surgical treatment may
be required.6
      

      Secondary or chronic anal fissures warrant additional investigation and multidisciplinary management is advised, especially when malignancy is suspected or confirmed.4 
      


      Knowledge to practice 
      

      Pharmacists play a key role in recognising the symptoms of haemorrhoids and anal fissures, providing timely advice and suggesting a suitable course of action. Pharmacists can also educate individuals on first-line management strategies and provide lifestyle advice where appropriate to prevent recurrence. In addition, pharmacists can advocate for the safe use of over-the-counter treatments, advise on appropriate duration of use and counsel individuals on potential adverse effects.
      

      Referral to a medical practitioner is advisable for individuals who21:
      


        
 	
      • do not respond to over-the-counter medicines and lifestyle changes
        • 
 	
      • have recent changes in bowel habits or
        • 
 	
      • have other co-existing signs and symptoms, including unexplained weight loss and fatigue.
        • 

      

      Conclusion
      

      Anal fissures and haemorrhoids are common conditions encountered in primary care and can greatly impact quality of life. Pharmacists play a critical role in early management and referral, helping prevent complications and improve outcomes.
      


      


      


      Case scenario continued
      
You identify that Sarah has haemorrhoids and provide lifestyle advice, including increasing fluid and dietary fibre intake, avoiding prolonged straining during bowel movements and practising good anal hygiene. For symptomatic relief, you suggest a topical ointment containing cinchocaine 0.5% and zinc oxide 20%, to be applied as needed. You also advise her to consult her general practitioner if she experiences persistent bleeding, ongoing pain or worsening prolapse. With your support and advice, Sarah feels more confident in managing her condition effectively while reducing the risk of recurrence.           		

      
      

      

      [cpd_submit_answer_button]
      


      Key points
      

        
 	
      • Anal fissures and haemorrhoids are common anorectal conditions with overlapping symptoms.
        • 
 	
      • Pain from an anal fissure typically occurs during or immediately after defecation, whereas haemorrhoids may cause itchiness or prolapse.
        • 
 	
      • Anal fissures usually result from trauma or constipation, while haemorrhoids arise from vascular engorgement.
        • 
 	
      • First-line management for both conditions includes conservative dietary and lifestyle measures, as well as topical treatment for symptomatic relief.
        • 
 	
      • Pharmacists can educate individuals on symptom relief, recommend appropriate treatments, advise preventive strategies and provide referrals when necessary.
        • 

      

      Our authors
      

      Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
      

      DR 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.
      


      Our Reviewer
      

      Manisha Pillai (she/her) BPharm
      


      References
      

        
 	
      1. 

        Higuero T. Update on the management of anal fissure. J Visc Surg. 2015;152(2 Suppl):S37–S43.
        

        2. 
 	
      2. 

        Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215–220.
        

        3. 
 	
      3. 

        Vitton V, Bouchard D, Guingand M, Higuero T. Treatment of anal fissures: results from a national survey on French practice. Clin Res Hepatol Gastroenterol. 2022;46(4):101821.
        

        4. 
 	
      4. 

        Schlichtemeier S, Engel A. Anal fissure. Aust Prescr. 2016;39(1):14–17.
        

        5. 
 	
      5. 

        Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg. 2011;24(1):22–30.
        

        6. 
 	
      6. 

        Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019;69(685):409–410.
        

        7. 
 	
      7. 

        Lyle V, Young C. Anal fissures: an update on treatment options. Aust J Gen Pract. 2024;53:33–35.
        

        8. 
 	
      8. 

        Therapeutic Guidelines Limited. Haemorrhoids. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        9. 
 	
      9. 

        Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009–2017.
        

        10. 
 	
      10. 

        Sandler RS, Peery AF. Rethinking what we know about hemorrhoids. Clin Gastroenterol Hepatol. 2019;17(1):8–15.
        

        11. 
 	
      11. 

        Zheng T, Ellinghaus D, Juzenas S, Cossais F, Burmeister G, Mayr G, et al. Genome-wide analysis of 944 133 individuals provides insights into the etiology of haemorrhoidal disease. Gut. 2021;70(8):1538–1549.
        

        12. 
 	
      12. 

        Therapeutic Guidelines Limited. Functional constipation in adults. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        13. 
 	
      13. 

        Quek HW, Reus X, Lee K, Etherton-Beer C, Page A; Guideline Development Group. Deprescribing in older people: a clinical practice guideline. Perth (WA): The University of Western Australia; 2025.
        

        14. 
 	
      14. 

        Stewart D. Anal fissure: clinical manifestations, diagnosis, prevention. UpToDate. 2025. Available from: https://www.uptodate.com/contents/anal-fissure-clinical-manifestations-diagnosis-prevention
        

        15. 
 	
      15. 

        Therapeutic Guidelines Limited. Anorectal abscess and fistula. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        16. 
 	
      16. 

        Sadeghi A, Biglari M, Forootan M, Adibi P. Solitary rectal ulcer syndrome: a narrative review. Middle East J Dig Dis. 2019;11(3):129–134.
        

        17. 
 	
      17. 

        Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist's view. World J Gastroenterol. 2015;21(31):9245–9252.
        

        18. 
 	
      18. 

        Quan L, Bai X, Cheng F, Chen J, Ma H, Wang P, et al. Comparison of efficacy and safety between surgical and conservative treatments for hemorrhoids: a meta-analysis. BMC Gastroenterol. 2025;25(1):492.
        

        19. 
 	
      19. 

        Therapeutic Guidelines Limited. Anal fissure. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        20. 
 	
      20. 

        Australian Medicines Handbook Pty Ltd. Glyceryl trinitrate (rectal). Adelaide: Australian Medicines Handbook Pty Ltd; 2025. Available from: https://amhonline.amh.net.au/
        

        21. 
 	
      21. 

        Allen S. Haemorrhoids and anal fissures. S Afr Pharm J. 2008;75(5):36.
        

        22. 

      
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            [post_content] => Community pharmacies are often the first place people turn when something feels ‘off’. But as pharmacists know, many requests for over-the-counter medicines are more complex than they may initially seem.

AP took a look at some presentations which might signal hidden red flags.

      ‘I just want a multivitamin’
      
When people present to community pharmacies, they often arrive with a solution already in mind. For example, ‘I need a strong painkiller,’ ‘I just want a multivitamin,’ or ‘What do you have for nerve pain?’ 

Nearly always, consistent with professional standards, these invite an open ended question to uncover the rationale for the request

        
 	
      • ‘Tell me what’s been happening.’
        • 
 	
      • ‘What made you choose this product today?’
        • 
 	
      • ‘What symptoms are you hoping to improve?’
        • 

      
That multivitamin request might be because someone is worried about immunity – which should prompt a discussion about immunisation. It could also indicate someone is feeling lethargic, which might start a conversation to rule-out anaemia. Or it might indicate a wish to support someone not eating due to chemotherapy – which obviously prompts a very different and comprehensive discussion.

These open‑ended questions encourage people to share more without slowing workflow, and they help prevent anchoring on a self‑diagnosis that may not reflect the real issue.

[caption id="attachment_31745" align="alignright" width="256"] Gauri Godbole FPS[/caption]

      ‘What’s your strongest painkiller’
      
People often reveal more than they realise. A request for a ‘strong painkiller’ could just be the tip of the iceberg.

For example, peripheral neuropathy is more common than most people realise. It’s also caused by vitamin B6 toxicity from multiple B6‑containing products more often than considered.

So a conversation where you discuss how a painkiller request could actually signal neuropathy from long‑term use of multiple high‑dose multivitamins, energy supplements, or ‘nerve support’ products is critical. Without gentle questioning, the true cause can be easily missed.

There are plenty of other examples that frequently appear, including requests for:

        
 	
      • ‘Something stronger for pain’, which may reflect chronic pain escalation or medicines overuse.
        • 
 	
      • Medicines for diarrhoea, where ongoing or recurrent symptoms can suggest medicine-related adverse effects, infection, malabsorption, or laxative overuse.
        • 

      

        
 	
      • Sleep aids, which could be a sign of stress, grief, burnout or caregiver fatigue.
        • 

      
These small clues are easy to overlook. A simple, empathic, ‘That sounds uncomfortable; let’s take a closer look together’, will usually open the door to a more meaningful conversation.

      Normalising and reframing
      
Normalising language helps people feel safe discussing sensitive issues and reduces defensiveness when the requested product isn’t appropriate. For example:

        
 	
      • ‘Many people don’t realise that too much vitamin B6 can actually cause nerve pain symptoms. Let’s check what you’re already taking.’
        • 
 	
      • ‘A lot of rashes look similar; before choosing a cream, it’s worth making sure we’re treating the right thing.’
        • 

      
This reframes the interaction from a quick sale to a collaborative assessment.
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      OTC requests that often mask deeper issues

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      Case scenario
      

      During peak hour, 19-year-old Enzo and his mother arrive to collect a new prescription for melatonin MR 2 mg. The pharmacy is highly stimulating: background music blares, customers converse loudly nearby, staff assist others in a cramped space, and general noise amplifies the chaos. While processing Enzo’s prescription and attempting to deliver verbal instructions, you observe Enzo avoiding eye contact, fidgeting intensely, and appearing overwhelmed, with reduced capacity to process verbal or non-verbal cues due to sensory overload.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the current prevalence of autism in Australia 
        • 
 	
      • Describe current challenges and opportunities in supporting autistic people in pharmacy practice
        • 
 	
      • Discuss practice adjustments pharmacists can make and/or supports that can improve accessibility for autistic individuals 
        • 
 	
      • Address common myths and misinformation relating to autism that may be encountered in a pharmacy setting.
        • 

      
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.1, 2.2, 2.3, 3.1, 3.5, 3.6, 4.3

Accreditation number:  PSAAP2604YA

Accreditation expiry: 31/03/2028      		

      
      

      
 

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Introduction
      
[caption id="attachment_31687" align="alignright" width="300"] Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism[/caption]

      Neurodevelopmental disorders (NDDs) arise from differences in brain development and typically affect cognition, communication, behaviour and occupational functioning. Common NDDs include attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), referred to as autism in this article, and intellectual developmental disorder (IDD).1 Autism is characterised by persistent social interaction and communication difficulties and restricted behavioural patterns.2 Symptoms begin in early childhood; however, diagnosis can occur at any age.3 Autism affects how the brain processes information, shaping how autistic people see, understand and respond to the world around them, with marked variability in presentation, day-to-day functioning and support needs.3,4 
      

      In Australia, autism prevalence has increased due to evolving diagnostic practices and awareness,5 meaning pharmacists now routinely engage with autistic individuals as part of everyday practice. 
      

      The challenge and opportunity for pharmacy is to shift from a medical model of crisis response, treatments and cures to a neuro-affirming social model that helps autistic individuals thrive, not just survive. 
      

      A neuro-affirming social model conceptualises neurodevelopmental differences as natural variations within human diversity and rejects deficit-based assumptions that frame these differences as disorders.6 Rather than ‘correcting’ individual traits, this approach provides reasonable adjustments while supporting autonomy, community participation and wellbeing, alongside awareness of diagnostic criteria, comorbidities, communication styles, lived realities and the impact of misinformation.6 The shift to a neuro-affirming social model calls for reducing systemic and environmental barriers, while still addressing health needs.6,7 
      

      For pharmacists, it means making practice adjustments in the way that the profession engages with and provides support for autistic individuals. 
      


      Epidemiology 
      

      According to the Australian Bureau of Statistics, approximately 290,900 Australians (1.1%) are reported to have had an autism diagnosis in 2022.5 A recent estimate by Autism Spectrum Australia (Aspect) suggested at least 1 in 40 Australians are autistic.7
      

      Rising prevalence reflects improved awareness and diagnostic practices rather than a true increase in incidence, including better recognition in historically underdiagnosed groups such as females and older adults.7 Autism prevalence peaks in children and adolescents, particularly those aged 10–14 years, and is markedly lower in adults, acknowledging limited adult data.5,8,9 
      

      Autism prevalence rates may appear to vary among ethnic and cultural
groups, reflecting inequities such as access to healthcare, effective communication, diagnostic practices and cultural perceptions.10 
      

      Prevalence remains higher in males than females, with 1.6% of males identified compared with 0.7% of females, and the greatest disparity is seen in children aged 5–9 years.5 Autism in females is frequently underdiagnosed, as characteristics may manifest differently, be masked (e.g. forced eye contact, rehearsed social scripts, suppressing stimming or copying peers), or fail to align with historically male-centred diagnostic criteria, leading to misdiagnosis as mood or personality disorders.11,12 Masking may occur due to a desire to fit in, fear of stigma or bullying, previous negative reactions to autistic behaviours, and expectations of how females are ‘supposed’ to behave.12 Increasing awareness of the under-recognition of autism in females and gender-diverse individuals, and the social drivers of masking, is anticipated to influence future prevalence estimates.4,5,11
      


      Aetiology
      

      There is no single cause of autism, and despite extensive research, aetiology remains incompletely understood. Current evidence indicates autism arises from a complex interaction between genetic susceptibility and environmental influences on neurodevelopment.13
      

      Family history is one of the strongest predictors of autism.13,14 Researchers have identified hundreds of genes, with approximately 10–20% of cases associated with rare genetic variants arising from mutations in sperm or egg cells.14 Autism is considered polygenic, meaning overall risk typically reflects the cumulative effect of multiple inherited variants, each contributing a small effect.14 
      

      The expression of genetic susceptibility is known to be influenced by prenatal, perinatal and postnatal environmental factors.13 Environmental factors appear most relevant during the prenatal period.14 Modest associations have been reported between autism likelihood and maternal factors such as hypertension, gestational diabetes, obesity, alcohol and substance use, poor antenatal care, and infection or fever during pregnancy.15
      

      Imprecise and inconsistent associations have been reported for folate status, exposure to some air pollutants, and the use of some medicines.15–17 Importantly, these findings are largely derived from observational studies and are subject to confounding. While some prenatal medicine exposures show more consistent associations with autism, there is no clear   evidence that associations between autism and other environmental and medicine exposures represent a causal relationship, and any contribution to autism risk remains limited and uncertain.14,17  
      


      

      Diagnosis
      

      Autism is diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria: ‘persistent deficits in social communication and social interaction across multiple contexts’, with the presence of ‘restricted, repetitive patterns of behaviour, interests or activities’.2 
      

      ‘Symptoms must be present in the early development period’, although they may only become fully apparent later in life. 
      

      ‘Symptoms cause clinically significant impairment in social, occupational or other important areas of functioning’ and ‘these disturbances are not better explained by IDD’ although both can co-occur.2 The DSM-5-TR also specifies severity levels (1–3) to indicate the degree of support required.2
      

      In Australia, individuals may pursue an autism diagnosis through public or private pathways.18 Both are typically lengthy and necessitate a degree of health literacy and English proficiency. Diagnostic assessments may be conducted by a multidisciplinary team, including paediatricians, psychiatrists, psychologists, speech pathologists and occupational therapists.4 Multiple appointments may be needed, drawing on input from family, carers or teachers.18,19 
      

      Barriers to diagnosis include limited awareness of early signs among caregivers and clinicians, long wait times and out-of-pocket costs for specialist assessment, socioeconomic and geographic disparities, and bias in recognising diverse presentations.11,20,21 Limited health literacy and the complexity of navigating multidisciplinary assessments and National Disability Insurance Scheme requirements further impede access.21 In some communities, stigma, fear of labelling, and differing cultural interpretations of behaviour may delay help-seeking.22 
      

      A best-practice diagnostic approach should promote cultural safety and sensitivity, acknowledge variations in health literacy, address socioeconomic barriers, and be grounded in person-centred care.
      

      Autism is a spectrum, with each individual having a unique mix of strengths, challenges, interests, needs and way of interacting with the world. Autism advocate Dr Stephen Shore states, ‘If you have met one autistic person, you have met one autistic person’.23 
      


      Beyond the core features
      

      Comorbid NDDs, and psychiatric and medical conditions can create significant challenges for autistic individuals in relation to diagnosis, selection of appropriate interventions, medicines and support services.1,24 
      

      Comorbid NDDs among autistic individuals include ADHD, developmental coordination disorder (dyspraxia), IDD, and specific learning disorders such as dyslexia, dysgraphia and dyscalculia.25 Psychiatric comorbidities are also prevalent, including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder.26 These conditions can intensify social and sensory challenges, increase vulnerability to stress, and impair emotional regulation and executive functioning. 
      

      Autistic individuals experience higher rates and severity of mental and physical health comorbidities than neurotypical individuals. Neurodivergent mental health outcomes are influenced by the interaction between individual differences and environmental and societal factors.25–28 Diagnostic overshadowing, whereby mental health symptoms are erroneously attributed to autism, should be avoided.29 Comorbid conditions warrant assessment and treatment according to the same clinical standards applied to neurotypical individuals, with adaptations made to accommodate the communication, sensory and support needs of autistic people. Neurodivergent individuals experience the full range of medical comorbidities seen in the general population; however, research indicates higher prevalence of certain conditions, including gastrointestinal disorders (e.g. irritable bowel syndrome, chronic constipation), sleep disturbances, epilepsy, and immune or metabolic disorders.30 These conditions may worsen fatigue, concentration and mood regulation, while motor difficulties may contribute to musculoskeletal pain, reduced physical activity and secondary health issues.31 
      

      Physical health conditions may be underdiagnosed when the clinical focus is limited to behavioural or psychological symptoms.29 
      

      Recognising the complex interconnections between physical, psychiatric and NDD health is paramount. Pharmacists can play a vital role in this process. Effective care relies on health professionals working collaboratively to identify how comorbid conditions, treatment burden and medicines may influence behaviour, cognition and developmental outcomes. 
      


      Support and interventions   
      

      Autism is a lifelong NDD for which there is no curative treatment.4 Clinical care focuses on supporting health, functioning and community participation, addressing comorbidities, and optimising quality of life, while recognising and respecting the individual strengths, capabilities and perspectives of autistic individuals.3
      


      Non-pharmacological support
      

      Supports and interventions are individualised and typically involve a multidisciplinary team to address evolving needs.10 Allied health professionals may include speech pathologists to support communication, occupational therapists to address sensory processing and daily living skills, and psychologists to support emotional regulation and mental health. Physiotherapists may support gross motor skills, while dietitians support feeding and nutritional adequacy, alongside specialist educational support and therapy (e.g. play therapy, art therapy).3 Effective management relies on coordinated care, regular goal review and clear communication between the autistic individual, families and carers, and the multidisciplinary team.24
      


      Pharmacological support 
      

      There is no evidence to support the use of medicines, exclusion diets or other biological treatment for the core features of autism.32,33 To support comorbidities, psychotropic medicines, antiepileptics and sleep agents may be used short term and under specific circumstances. Off-label use is common and requires careful assessment of risk-benefit balance, adverse effects, formulation choice, monitoring, cumulative treatment
burden, and very careful consideration if the medicine is being prescribed as a
chemical restraint.4
      


      

      Myths and misconceptions
      

      Autism is subject to persistent myths that pharmacists may encounter. The most damaging is the long-debunked claim that vaccines cause autism.14 The retracted 1998 Lancet study by Andrew Wakefield that claimed a link between the measles, mumps, rubella (MMR) vaccine and autism was a small, flawed study (with only 12 participants) and was exposed for unethical processes, methodological misconduct, and undisclosed conflicts of interest.14 Despite retraction, its claims were (and continue to be) amplified, eroding trust in public health and fuelling vaccine hesitancy. A Cochrane review published in 2021 found no credible evidence of an association between MMR and MMRV vaccines and autism.34 
      

      Two medicines made headlines in 2025: paracetamol and leucovorin (folinic acid or calcium folinate) claimed as a cause and treatment of autism respectively. Antenatal paracetamol exposure was alleged to increase autism and ADHD risk; however, major studies have not demonstrated a causal relationship.9 Stronger evidence from a large Swedish population-based cohort of 2,480,797 children born between 1995 and 2019 found no association between paracetamol use during pregnancy and autism, ADHD or IDD in sibling-controlled analysis.16 Cerebral folate deficiency (CFD) has been reported in a subset of autistic individuals, related to impaired folate transport into the brain, and may be associated with symptoms of speech difficulties, seizures and IDD, often within early childhood.35,36 Leucovorin, a folinic acid derivative, has been investigated as a potential treatment for autistic children with CFD. Leucovorin can bypass impaired folate transport, increasing central nervous system folate availability.36 Although some small-scale trials indicate potential minor behavioural improvements, supporting evidence remains limited, inconsistent, and not independently replicated.15,37
      

      As medicines experts, pharmacists are well placed to counter common myths. Responses should prioritise empathetic, respectful communication and the provision of clear, evidence-based information and resources. 
      


      Knowledge to practice 
      

      Accessibility, strong communication skills, medicines expertise, understanding of health system navigation and ability to synthesise information, position pharmacists to provide continuity of care for autistic individuals. Pharmacists can serve as an integrative link within multidisciplinary teams, supporting autistic individuals and their families across the healthcare continuum. 
      


      Communication tips 
      

      Effective communication underpins person-centred pharmacy practice. Pharmacists supporting autistic individuals should adapt both verbal and non-verbal communication to meet diverse needs.38 Autism can influence communication and sensory processing in unique ways, with some individuals experiencing sensory sensitivities to sound, light, smell, touch and visual stimuli.3,4,33 Some autistic individuals regulate sensory input through stimming (self-stimulatory behaviour), which may present as repetitive movements or sounds such as fidgeting, rocking or hand-flapping.39 Flexibility, empathy and understanding of sensory needs ensure equitable access to healthcare and fosters the relationship between patient and pharmacist. Verbal communication with autistic individuals should be clear and structured. Pharmacists should use straightforward, unambiguous language and present information in small, logical steps, allowing time for processing and response. Offering a calm, quiet space can both minimise sensory overload and facilitate a more comfortable environment for communication.38,40 
      

      Non-verbal communication requires equal attention. Eye contact, facial expressions and gestures can carry unintended meaning for autistic individuals. Some avoid eye contact
as a coping mechanism, not as disinterest.38 Pharmacists should avoid assumptions and focus on open, calm body language and a reassuring tone. Visual supports can reinforce verbal explanations to provide ongoing reference, especially for individuals who process visual information more effectively than spoken language.40
      

      A person-centred approach requires pharmacists to recognise, respond and adapt to the communication preferences of each autistic individual. If a caregiver or support worker is present, collaboration should occur while directing communication towards the patient whenever possible.40 Empathy, flexibility and inclusive communication techniques ensure care that is respectful and accessible and upholds an individual’s dignity and autonomy.
      


      Conclusion
      

      By adopting inclusive, neuro-affirming approaches, pharmacists strengthen equity, accessibility and person-centredness within healthcare. In doing so, they uphold the profession’s commitment to compassionate, evidence-based practice and help ensure autistic Australians receive the respect, understanding and tailored support needed to achieve optimal health and wellbeing.
      


      


      


      Case scenario continued
      
Enzo’s mother discloses Enzo’s autism diagnosis and requests a quiet area and slower, step-by-step instructions. You offer a consultation room with dimmed lights, minimal visual clutter and no background noise. Enzo settles, visibly calmer.

In this adapted space, you employ person-centred strategies: a soft, steady voice; paced delivery; short, simple sentences; pauses after each point for processing; confirming understanding via yes/no questions or thumbs-up signals; and a clear, written handout with bullet points, icons (e.g. clock for bedtime), and appropriate font. Enzo engages, maintaining partial eye contact and nodding, while his mother clarifies. These modifications demonstrate empathy, flexibility and equitable care, minimising distress, enhancing information access and supporting Enzo’s autonomy.      		

      
      

      
[cpd_submit_answer_button]

      Key points
      

        
 	
      • Shift to a neuro-affirming social model – pharmacists must transition to a social model that fosters neuro-affirming environments and services.
        • 
 	
      • Use clear and visual communication – use straightforward, unambiguous language, present information in small, logical steps, and utilise visual supports to reinforce verbal explanations.
        • 
 	
      • Ensure environmental accessibility – acknowledge sensory differences and offer calm, quiet spaces to reduce sensory overload.
        • 
 	
      • Pharmacists should act as an integrative care link within multidisciplinary teams – bridging care gaps for individuals and families.
        • 
 	
      • Manage comorbidity holistically – apply pharmacological expertise to manage physical, psychiatric and neurodevelopmental health.
        • 
 	
      • Correct misinformation – deliver evidence-based information, empathetically, compassionately and respectfully.
        • 

      

      Our author
      

      Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism is an accredited clinical pharmacist with over 20 years’ experience across aged care, consultancy, community pharmacy and hospital pharmacy. In 2020, she launched The Spectrum Pharmacist to increase awareness, promote inclusion, and provide education and support for neurodevelopmental disorders.
      


      Our Reviewer
      

      Victor Senescall (he/him) BPharm (Hons)
      


      References
      

        
 	
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        Estrin GL, Milner V, Spain D, et al. Barriers to autism spectrum disorder diagnosis for young women and girls: a systematic review. Rev J Autism Dev Disord. 2021;8(4):454–470.
        

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        Allen-Meares P, Lowry B, Estrella ML, et al. Health literacy barriers in the health care system: barriers and opportunities for the profession. Health Soc Work. 2020;45(1):62–64.
        

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        Khalil A, Yatcilla J, Christie N, et al. A systematic review of help-seeking barriers for racial-ethnic minority caregivers accessing autism diagnostic and intervention services. J Racial Ethn Health Disparities. 2025.
        

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        Bonti E, Zerva IK, Koundourou C, et al. The high rates of comorbidity among neurodevelopmental disorders: reconsidering the clinical utility of distinct diagnostic categories. J Pers Med. 2024;14(3):300.
        

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        Lai M-C, Kassee C, Besney R, et al. Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. Lancet Psychiatry. 2019;6(10):819–829.
        

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        Mazurek MO, Sadikova E, Cheak-Zamora N, et al. Health care needs, experiences, and perspectives of autistic adults. Autism Adulthood. 2023;5(1):51–62.
        

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        Barlattani T, D'Amelio C, Cavatassi A, et al. Autism spectrum disorders and psychiatric comorbidities: a narrative review. J Psychopathol. 2023;29(1):3–24.
        

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        Blair J. Diagnostic overshadowing: see beyond the diagnosis. 2017. Available from: www.intellectualdisability.info/changing-values/diagnostic-overshadowing-see-beyond-the-diagnosis
        

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        Al-Beltagi M. Autism medical comorbidities. World J Clin Pediatr. 2021;10(3):15–28.
        

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        Sung Y-S, Loh SC, Lin L-Y. Physical activity and motor performance: a comparison between young children with and without autism spectrum disorder. Neuropsychiatr Dis Treat. 2021;17:3743–3751.
        

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        Turner M. The role of drugs in the treatment of autism. Aust Prescr. 2020;43:185–190.
        

        33. 
 	
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        Mayo Clinic. Autism spectrum disorder. 2025. Available from: www.mayoclinic.org/diseases-conditions/autism-spectrum-disorder/diagnosis-treatment/drc-20352934
        

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        Di Pietrantonj C, Rivetti A, Marchione P, et al. Vaccines for measles, mumps, rubella, and varicella in children. Cochrane Database Syst Rev. 2021;(11):CD004407.
        

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        Wong A, Frye RE, Ohnemus-Kawamura B, et al. Cerebral folate deficiency. 2019. Available from: https://rarediseases.org/rare-diseases/cerebral-folate-deficiency/
        

        36. 
 	
      36. 

        Ramaekers VTH, Quadros EV. Cerebral folate deficiency syndrome: early diagnosis, intervention and treatment strategies. Nutrients. 2022;14(15):3096.
        

        37. 
 	
      37. 

        Sheppeard A. What is leucovorin, and can it cure autism? 2025. Available from: www.medicalrepublic.com.au/what-is-leucovorin-and-can-it-cure-autism/120175
        

        38. 
 	
      38. 

        Norris JE, Milton D, Heasman B. Adapting communication with autistic service users: a participatory study. Autism. 2024.
        

        39. 
 	
      39. 

        National Autistic Society. Repeated movements and behaviour (stimming). 2026. Available from: www.autism.org.uk/advice-and-guidance/topics/about-autism/repeated-movements-and-behaviour-stimming
        

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        National Autistic Society. Autism and communication. 2024. Available from: www.autism.org.uk/advice-and-guidance/topics/about-autism/autism-and-communication
        

        41. 

      
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            [post_content] => As fuel costs climb and shortages loom, community pharmacies are facing mounting uncertainty on supply chains, workforce mobility, and equitable patient access.

Fuel shortages and escalating petrol costs are emerging as a significant disruptor for Australian workforces – including pharmacists, with exposure to the downstream impacts  potentially affecting medicines delivery, patient access to care and workforce logistics.

      


      
Addressing the national fuel crisis

        
 	
      • A National Cabinet was held on Monday (30 March), with Prime Minister Anthony Albanese announcing a four-step National Security Plan. We are currently at stage two, which involves localised fuel disruptions.
        • 
 	
      • Fuel excise will be halved for 3 months to address this, which will lower the cost of petrol by $0.26/L.
        • 
 	
      • The heavy vehicle road user charge will also be removed for 3 months.
        • 
 	
      • Stage three of the plan will incorporate collective fuel reduction through measures such as working from home, while stage four will involve a stricter set of rules to protect crucial services. 
        • 

      
      		

      
      

      
Ongoing geopolitical tensions in the Middle East stemming from the US-Israel war with Iran have taken the shape of catastrophic implications, driving global energy instability, including exacerbated cost-of-living effects, leaving essential sectors in vulnerable positions.

AP looks at the potential impacts on pharmacists and patients.

      Workforce pain and travel relief
      
Workforce mobility may be constrained as rising fuel shortages complicate staff travel. While some jurisdictions are offering relief, others are holding firm. 

Tasmania has announced that public transport will be free for the next 3 months, saving commuters between $20 and $88 per week. 

In Victoria, all public transport will be free until after April. ‘This is a temporary measure to help with the cost of living; it will take pressure off the pump and help you save,’ Premier Jacinta Allan stated.

However, public transport is usually not a straightforward option for much of the pharmacy workforce due to after-hours shifts, indirect public transport options or family commitments. And in regional and remote areas, commuter public transport is usually non-existent.

      

      Supply and delivery of medicines
      
Vital delivery providers, including Australia Post and StarTrack, have already increased surcharges – signaling the beginning of broader cost increases. For community pharmacies, this is likely to increase the price of medicines delivery and postage costs for consumers.

Liz de Somer, CEO of Medicines Australia said, ‘The fact that Australia is in a difficult geographical location presents some challenges. As we know, medicines are part of our national security, so it is having an impact on the industry’s costs and an ability to bring medicines to Australia, however … they’re doing everything in their power to ensure the supplies are available.’ 

Ryan Collins, Operations Manager at OTC distributor Be Med told AP, reflecting that wholesalers are, ‘already feeling the pressure through higher freight charges and fuel levies, which are starting to squeeze margins’.

‘If oil prices keep climbing, we expect suppliers to pass on cost increases, meaning higher landed costs for us. There’s also concern around longer lead times if transport capacity tightens,’ he said.

Price increases are also significantly impacting delivery schedules, meaning pharmacists might need to consider how and when they order medicines.

‘Although deliveries are still running, we're seeing less flexibility from carriers,’ Mr Collins  told AP.

‘Some routes are being consolidated, and delivery windows are getting tighter. We’re preparing for potential reductions in frequency if costs continue to rise. 

‘We’re [also] starting to notice more cautious ordering from customers, with some stocking up earlier to avoid future price increases. We expect availability to become less predictable if conditions worsen.’

In terms of equity, Mr Collins said that regional areas are more exposed. 

‘Freight costs are higher, and service levels are more likely to be affected. We’re managing this by planning orders more carefully, encouraging earlier ordering, and trying to consolidate deliveries where possible to keep costs down,’ he said.

‘We’re already having to pass on freight costs from 1 April, as they’ve become impossible for us to absorb. Beyond that, we’re looking at increasing safety stock on key lines, reviewing supplier options, and prioritising essential products.’

      Impacts on medicines review services
      
Fuel pressures are also placing stress on Home Medicines Review (HMR) services, potentially placing vulnerable patients at risk, which would flow directly down the line to pressures on our hospital system.

These challenges are felt acutely in regional areas where long travel distances are commonplace, and staff-mobility is restricted for essential at-home services, which poses challenges for  equity and continuity of care. 

The PSA has called for greater access to services to ensure patients receive care and pharmacists are able to deliver services to patients who are unable to travel, enhancing access for those in a compromised position.

‘We need to see some [changes] in service delivery, such as bringing back telehealth,’ PSA’s Head of Policy and Strategy Chris Campbell FPS said.

PSA National President Professor Mark Naunton MPS agreed, emphasising that patients need and deserve timely, trusted care. ‘That is our highest priority. We can’t have patients languishing or, worst case, dying on waiting lists. Telehealth solves this instantly,’ he said.

‘Telehealth is one of the most equitable measures we have to deliver HMRs to Australians no matter where they live. It ensures that someone in a regional or remote community or even in a metropolitan area is not penalised simply because of their postcode.

Telehealth also keeps pharmacists safe by eliminating the need for them to drive long distances, especially during the current petrol crisis, Prof Naunton said.

‘Pharmacists in regional areas know this better than most, we have real workforce issues to contend with and telehealth is an excellent option that does not compromise patient wellbeing,’ he said.

‘We are clearly in a petrol-related crisis now that is bringing its own immediate pressures but as pharmacists we are regularly dealing with problems accessing patients, be it natural disasters like flooding or bushfires to questions of road access and safety.’

PSA’s 2026–27 Federal Budget Submission, released 25 February 2026, identifies reform of HMRs, including telehealth flexibility, as a priority under the First Pharmacy Programs Reform Package.
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      Fuel shortages pose emerging risks for pharmacy

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            [post_content] => New avenues for nurse prescribing have the potential to reshape frontline care. For pharmacists, it’s a live example of how scope expansion translates into real impact.

Nurse prescribing is entering a new phase in Australia, and pharmacists should be paying close attention. 

While nurse practitioners and endorsed midwives have been able to prescribe Pharmaceutical Benefits Schedule (PBS) subsidised medicines since 2010, a new pathway will soon expand prescribing to a broader group of experienced nurses.

‘A lot of people wouldn't even know that nurses are already prescribing medications that are funded on the PBS,’ said Denise Lyons, President of the Australian Primary Health Care Nurses Association. ‘But there are more than 3,000 nurse practitioners and endorsed midwives in Australia now who are already prescribing.’

Under a new registration standard which came into effect in September last year, suitably qualified registered nurses will be able to prescribe medicines in Schedules 2, 3, 4 and 8 in partnership with an authorised prescriber.

‘It took until this year for universities to start the course that enables registered nurses to meet [the new standard],’ Ms Lyons said. ‘Most are 6-month postgraduate courses … So it will probably be around July 2026 that we will see the first [wave] of nurses completing the educational requirement.’

For pharmacists, this shift offers a live view of how prescribing reform is built – through legislation, governance, defined scope and, crucially, access to the PBS.

      What’s changing?
      
The new framework is deliberately cautious. To become a designated RN prescriber, a nurse must: 

        
 	
      • complete postgraduate training
        • 
 	
      • have significant prior clinical experience
        • 
 	
      • work within an agreed clinical governance framework with an authorised health practitioner under an active prescribing agreement
        • 
 	
      • complete a 6-month period of clinical mentorship.
        • 

      
 The written prescribing agreement with an authorised prescriber remains in place beyond the initial mentorship period.

‘An authorised prescriber could be a nurse practitioner, endorsed midwife, or it could be a GP,’ Ms Lyons said. ‘And that prescribing agreement is going to articulate what medications are within scope.

‘For example, say you had a registered nurse who has been working in paediatrics [throughout their] career… [They’re] going to be educated and competent to prescribe for some childhood illnesses, so that would be within [their] scope.’

For patients, expanded nurse prescribing could mean faster access to medicines, fewer delays for routine care and less reliance on GP availability.

‘You think about the amount of care that nurses deliver around [things like] aged care, palliative care, community care and sexual health,’ Ms Lyons said. 

‘There's a lot of work done in the community by registered nurses who have a lot of knowledge and experience. And this is going to be a mechanism that lets them use that knowledge and experience in a really helpful way.’

Expanded nurse prescribing will be especially valuable in rural and remote communities, aged care and other underserved settings where nurses are often the main point of contact but medical access can be patchy, she added.

      ‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place.'

denise lyons 
      

      PBS access is the make-or-break issue
      
While the regulatory framework and training pathway are now largely in place, the biggest unresolved issue is PBS access. Nurse practitioners and endorsed midwives already have it. Designated RN prescribers do not – yet.

Without PBS access, nurses may be able to issue prescriptions, but patients would still face out-of-pocket costs that undermine the practical value of the reform.

However, federal legislation now before the Senate would amend the National Health Act 1953 to allow designated RN prescribers to prescribe PBS-subsidised medicines. 

‘We're really hoping the Bill comes through the Senate with no amendments and that it passes into legislation,’ Ms Lyons said. ‘If we don't manage to get access, and the subsidies on the PBS lag behind practice, that will be a real barrier.’ 

Ms Lyons also highlighted the need for national coordination. State and territory variations in drugs and poisons legislation create confusion for both clinicians and patients, as pharmacists know all too well.

‘The work that's being done to harmonise [that] legislation across the states and territories is going to be really important, and we need to all work on that together,’ she said.

      Implications for pharmacists
      
As nurse prescribing expands, pharmacists are likely to see more prescriptions coming from a wider mix of clinicians, potentially changing how care is coordinated in everyday practice.

Rather than care sitting primarily with a single prescriber, it will increasingly be shared across a team – with nurses assessing, prescribing and monitoring within their scope, and pharmacists supporting safe and effective medicines use.

That means collaboration needs to be more deliberate, Ms Lyons said.

‘With quality use of medicines, there [need to be] clear principles around closed-loop communication, agreed-upon goals, rapid feedback on issues and shared protocols,’ she said.

The progress of the nurse prescribing model also provides a useful advocacy roadmap. The model has gained traction by focusing on what it delivers for patients – faster access, fewer delays and more complete care at the point of contact. 

That focus is particularly relevant in pharmacy, where prescribing arrangements currently vary by state and territory, and where the absence of PBS access continues to limit how much patients can benefit.

Like nurse prescribing, expanded pharmacist prescribing will only be truly effective if it’s consistent, supported by clear frameworks and enables affordable access for patients.

‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place,’ Ms Lyons said.
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      Case scenario
      

      Sarah, a 42-year-old woman, presents to the pharmacy reporting a small lump near the anus, occasional bright red bleeding on toilet paper after bowel movements, anal itching and discomfort. She mentions feeling embarrassed to seek advice and has been self-managing with sitz baths. She reports a history of chronic constipation with frequent training during defecation. She is not taking any regular medicines and requests an over-the-counter product to relieve her symptoms. You take the time to explore Sarah’s symptoms in more detail, to help identify any red flags that would require immediate referral. You ask about the duration, severity and other symptoms such as fatigue, unintentional weight loss and changes in bowel habits, all of which she denies.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the classification and causes of anal fissures and haemorrhoids
        • 
 	
      • Identify the clinical features of anal fissures and haemorrhoids
        • 
 	
      • Discuss management strategies for anal fissures and haemorrhoids
        • 
 	
      • Describe the pharmacist’s role in supporting individuals with anal fissures and haemorrhoids.
        • 

      
Competency (2016) standards addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Accreditation code: PSAAP2604HQ

Accreditation expiry: 31/03/2028

Accreditation points: Up to 1 Group 2 CPD      		

      
      

      
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Epidemiology 
      

      Anal fissures and haemorrhoids are commonly encountered, but their epidemiology is not well documented. Haemorrhoids represent the most frequent reason for proctology consultations, followed by anal fissures.1 Haemorrhoids are estimated to affect up to 40% of adults in the general population, although many individuals are asymptomatic.2 Anal fissures occur in approximately 10–15% of the population.3 
      


      

      Aetiology and pathophysiology
      

      An anal fissure is a longitudinal tear in the anal canal, most often occurring in the posterior midline, just below the dentate line.4 Anal fissures are typically classified as primary or secondary, depending on the cause. Primary fissures are usually benign and caused by local trauma, such as the passage of hard stools, prolonged diarrhoea, vaginal delivery, repeated injury or anal penetration.4 Secondary fissures, which are often multiple and located off the midline, are uncommon, accounting for less than 1% of cases.5 They result from underlying conditions like previous anal surgery, inflammatory bowel disease (e.g. Crohn’s disease), colorectal malignancy, infections (e.g. HIV/AIDS), or dermatological conditions (e.g. psoriasis).6 Anal fissures are further described as acute or chronic, with chronic fissures lasting more than 6 weeks.7 
      


[caption id="attachment_31774" align="alignright" width="200"] DR 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.[/caption]

      Anal fissures are often mistaken for haemorrhoids because of their overlapping symptoms. Haemorrhoids differ in that they are normal vascular cushions within the anal canal that maintain continence. Although part of normal anatomy, the term ‘haemorrhoid’ is commonly used when these vascular anal cushions, containing a rich arteriovenous network, become enlarged or displaced.8 Haemorrhoids may be classified as internal (located above the dentate line) or external (located below the dentate line). Factors such as constipation, straining during bowel movements and a low-fibre diet are commonly considered to increase the risk of haemorrhoids.9,10 However, the causal relationship between these factors and the development of haemorrhoids remains unclear. A possible genetic component that predisposes to smooth muscle, epithelial and connective tissue dysfunction, may contribute to haemorrhoids.11
      

      It is important to note that certain medicines can contribute to or worsen constipation as an adverse effect, thereby aggravating haemorrhoids and anal fissures.9,10 Common examples include opioids, anticholinergics, and iron and calcium supplements.12 Regular medication review should be incorporated into comprehensive care to identify opportunities for deprescribing and prevent inappropriate prescribing cascades, with further guidance available in the new deprescribing guidelines.13
      


      Clinical features 
      

      The symptoms of haemorrhoids may include rectal bleeding, anal pruritus, prolapse, faecal seepage and mucus discharge.7 
      

      Internal haemorrhoids are usually painless because the columnar epithelium is insensitive to touch and temperature.8 In contrast, external haemorrhoids are pain sensitive and may become thrombosed, often following straining during defecation.8 
      

      Anal fissures, by comparison, typically cause severe tearing pain that is provoked by defecation.4 A key distinguishing feature is that the pain of an anal fissure typically occurs during or immediately after defecation.
      


      

      Diagnosis and differential diagnoses 
      

      For diagnostic purposes, medical practitioners perform a physical examination with the individual lying on their side, gently parting the buttocks to inspect the posterior midline.4 Several other anorectal disorders may present with similar symptoms to anal fissures and haemorrhoids. Differential diagnoses include anal fistula and solitary rectal ulcer syndrome, which can often be distinguished based on their clinical appearance through careful physical examination. An anal fistula typically presents as a draining skin punctum.14 It is an abnormal hollow tract, most often arising from infection of an anal gland.15 Solitary rectal ulcer syndrome may present with anal pain, rectal bleeding, constipation, mucus discharge, excessive straining and a sensation of incomplete evacuation. Despite its name, the condition does not always involve an ulcer. Diagnosis requires a combination of endoscopic and histopathological findings, together with the individual’s reported symptoms.16
      


      Management approaches 
      

      Haemorrhoids
      


[caption id="attachment_31775" align="alignright" width="200"] Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).[/caption]

      Non-pharmacological treatment options
      

      First-line management for haemorrhoids usually involves lifestyle measures, which include ensuring adequate fluid and fibre intake, reducing prolonged time on the toilet and avoiding excessive straining, the use of sitz baths, and maintaining anal hygiene.10 In practice, dietary and lifestyle modifications are usually recommended as a conservative and preventive measure for haemorrhoids.17
      

      Pharmacological treatment options
      

      Over-the-counter therapies for internal haemorrhoids include ointments and suppositories that contain emollients, mild astringents, local anaesthetics and/or corticosteroids.8 These preparations temporarily relieve itching and discomfort. Prolonged use of topical corticosteroids is not recommended, as it increases the risk of local infections such as candidiasis.8 Similarly, prolonged use of anaesthetic-containing products should be avoided due to potential adverse effects, including skin sensitisation and dermatitis.8
      

      Outpatient procedures and surgery
      

      For individuals who do not respond to conservative measures, other treatment options for haemorrhoids include outpatient procedures and surgery.10 Outpatient procedures include rubber band ligation, infrared coagulation, bipolar probe, heater probe, sclerotherapy and cryotherapy.10 These are generally reserved for people with grade I or grade II haemorrhoids.10 Surgery can be considered for people who do not respond to or cannot tolerate outpatient procedures, as well as those with large external haemorrhoids, or combined internal and external haemorrhoids with prolapse.10
      

      A recent meta-analysis found that surgical treatments, compared with conservative treatments, offer greater symptom relief, quicker recovery and lower recurrence rates.18 However, they do carry risks of procedure-related complications. In contrast, conservative treatments are safer and less invasive, but tend to provide slower symptom improvement and have higher recurrence rates.18 Therefore, treatment decisions should be individualised, taking into account symptom severity, individual preferences and risk tolerance.
      

      Anal fissures
      

      The primary aim of treatment for anal fissures is to reduce anal sphincter spasm, improve blood flow and promote healing.6 First-line management is usually non-operative and includes increasing dietary fibre, use of sitz baths and applying glyceryl trinitrate 0.2% ointment, three times daily for up to 4 weeks to relieve pain.19 Headache is a common adverse effect of glyceryl trinitrate due to systemic absorption, which could limit its use.20 Other topical agents used in clinical practice include lidocaine and hydrocortisone, although these are less effective than a combination of fibre intake and warm sitz baths.4 
      

      Botulinum toxin injections may also be considered and can achieve good healing rates.6,19 However, botulinum toxin may cause temporary reduced control of wind or bowel motions, which usually resolves as the effect of the injection wears off.4 Due to these adverse effects and the invasive nature of the procedure, botulinum toxin is generally reserved as a second-line therapy.4 If these treatment options are unsuccessful, surgical treatment may
be required.6
      

      Secondary or chronic anal fissures warrant additional investigation and multidisciplinary management is advised, especially when malignancy is suspected or confirmed.4 
      


      Knowledge to practice 
      

      Pharmacists play a key role in recognising the symptoms of haemorrhoids and anal fissures, providing timely advice and suggesting a suitable course of action. Pharmacists can also educate individuals on first-line management strategies and provide lifestyle advice where appropriate to prevent recurrence. In addition, pharmacists can advocate for the safe use of over-the-counter treatments, advise on appropriate duration of use and counsel individuals on potential adverse effects.
      

      Referral to a medical practitioner is advisable for individuals who21:
      


        
 	
      • do not respond to over-the-counter medicines and lifestyle changes
        • 
 	
      • have recent changes in bowel habits or
        • 
 	
      • have other co-existing signs and symptoms, including unexplained weight loss and fatigue.
        • 

      

      Conclusion
      

      Anal fissures and haemorrhoids are common conditions encountered in primary care and can greatly impact quality of life. Pharmacists play a critical role in early management and referral, helping prevent complications and improve outcomes.
      


      


      


      Case scenario continued
      
You identify that Sarah has haemorrhoids and provide lifestyle advice, including increasing fluid and dietary fibre intake, avoiding prolonged straining during bowel movements and practising good anal hygiene. For symptomatic relief, you suggest a topical ointment containing cinchocaine 0.5% and zinc oxide 20%, to be applied as needed. You also advise her to consult her general practitioner if she experiences persistent bleeding, ongoing pain or worsening prolapse. With your support and advice, Sarah feels more confident in managing her condition effectively while reducing the risk of recurrence.           		

      
      

      

      [cpd_submit_answer_button]
      


      Key points
      

        
 	
      • Anal fissures and haemorrhoids are common anorectal conditions with overlapping symptoms.
        • 
 	
      • Pain from an anal fissure typically occurs during or immediately after defecation, whereas haemorrhoids may cause itchiness or prolapse.
        • 
 	
      • Anal fissures usually result from trauma or constipation, while haemorrhoids arise from vascular engorgement.
        • 
 	
      • First-line management for both conditions includes conservative dietary and lifestyle measures, as well as topical treatment for symptomatic relief.
        • 
 	
      • Pharmacists can educate individuals on symptom relief, recommend appropriate treatments, advise preventive strategies and provide referrals when necessary.
        • 

      

      Our authors
      

      Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
      

      DR 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.
      


      Our Reviewer
      

      Manisha Pillai (she/her) BPharm
      


      References
      

        
 	
      1. 

        Higuero T. Update on the management of anal fissure. J Visc Surg. 2015;152(2 Suppl):S37–S43.
        

        2. 
 	
      2. 

        Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215–220.
        

        3. 
 	
      3. 

        Vitton V, Bouchard D, Guingand M, Higuero T. Treatment of anal fissures: results from a national survey on French practice. Clin Res Hepatol Gastroenterol. 2022;46(4):101821.
        

        4. 
 	
      4. 

        Schlichtemeier S, Engel A. Anal fissure. Aust Prescr. 2016;39(1):14–17.
        

        5. 
 	
      5. 

        Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg. 2011;24(1):22–30.
        

        6. 
 	
      6. 

        Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019;69(685):409–410.
        

        7. 
 	
      7. 

        Lyle V, Young C. Anal fissures: an update on treatment options. Aust J Gen Pract. 2024;53:33–35.
        

        8. 
 	
      8. 

        Therapeutic Guidelines Limited. Haemorrhoids. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        9. 
 	
      9. 

        Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009–2017.
        

        10. 
 	
      10. 

        Sandler RS, Peery AF. Rethinking what we know about hemorrhoids. Clin Gastroenterol Hepatol. 2019;17(1):8–15.
        

        11. 
 	
      11. 

        Zheng T, Ellinghaus D, Juzenas S, Cossais F, Burmeister G, Mayr G, et al. Genome-wide analysis of 944 133 individuals provides insights into the etiology of haemorrhoidal disease. Gut. 2021;70(8):1538–1549.
        

        12. 
 	
      12. 

        Therapeutic Guidelines Limited. Functional constipation in adults. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        13. 
 	
      13. 

        Quek HW, Reus X, Lee K, Etherton-Beer C, Page A; Guideline Development Group. Deprescribing in older people: a clinical practice guideline. Perth (WA): The University of Western Australia; 2025.
        

        14. 
 	
      14. 

        Stewart D. Anal fissure: clinical manifestations, diagnosis, prevention. UpToDate. 2025. Available from: https://www.uptodate.com/contents/anal-fissure-clinical-manifestations-diagnosis-prevention
        

        15. 
 	
      15. 

        Therapeutic Guidelines Limited. Anorectal abscess and fistula. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        16. 
 	
      16. 

        Sadeghi A, Biglari M, Forootan M, Adibi P. Solitary rectal ulcer syndrome: a narrative review. Middle East J Dig Dis. 2019;11(3):129–134.
        

        17. 
 	
      17. 

        Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist's view. World J Gastroenterol. 2015;21(31):9245–9252.
        

        18. 
 	
      18. 

        Quan L, Bai X, Cheng F, Chen J, Ma H, Wang P, et al. Comparison of efficacy and safety between surgical and conservative treatments for hemorrhoids: a meta-analysis. BMC Gastroenterol. 2025;25(1):492.
        

        19. 
 	
      19. 

        Therapeutic Guidelines Limited. Anal fissure. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        20. 
 	
      20. 

        Australian Medicines Handbook Pty Ltd. Glyceryl trinitrate (rectal). Adelaide: Australian Medicines Handbook Pty Ltd; 2025. Available from: https://amhonline.amh.net.au/
        

        21. 
 	
      21. 

        Allen S. Haemorrhoids and anal fissures. S Afr Pharm J. 2008;75(5):36.
        

        22. 

      
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            [post_content] => Community pharmacies are often the first place people turn when something feels ‘off’. But as pharmacists know, many requests for over-the-counter medicines are more complex than they may initially seem.

AP took a look at some presentations which might signal hidden red flags.

      ‘I just want a multivitamin’
      
When people present to community pharmacies, they often arrive with a solution already in mind. For example, ‘I need a strong painkiller,’ ‘I just want a multivitamin,’ or ‘What do you have for nerve pain?’ 

Nearly always, consistent with professional standards, these invite an open ended question to uncover the rationale for the request

        
 	
      • ‘Tell me what’s been happening.’
        • 
 	
      • ‘What made you choose this product today?’
        • 
 	
      • ‘What symptoms are you hoping to improve?’
        • 

      
That multivitamin request might be because someone is worried about immunity – which should prompt a discussion about immunisation. It could also indicate someone is feeling lethargic, which might start a conversation to rule-out anaemia. Or it might indicate a wish to support someone not eating due to chemotherapy – which obviously prompts a very different and comprehensive discussion.

These open‑ended questions encourage people to share more without slowing workflow, and they help prevent anchoring on a self‑diagnosis that may not reflect the real issue.

[caption id="attachment_31745" align="alignright" width="256"] Gauri Godbole FPS[/caption]

      ‘What’s your strongest painkiller’
      
People often reveal more than they realise. A request for a ‘strong painkiller’ could just be the tip of the iceberg.

For example, peripheral neuropathy is more common than most people realise. It’s also caused by vitamin B6 toxicity from multiple B6‑containing products more often than considered.

So a conversation where you discuss how a painkiller request could actually signal neuropathy from long‑term use of multiple high‑dose multivitamins, energy supplements, or ‘nerve support’ products is critical. Without gentle questioning, the true cause can be easily missed.

There are plenty of other examples that frequently appear, including requests for:

        
 	
      • ‘Something stronger for pain’, which may reflect chronic pain escalation or medicines overuse.
        • 
 	
      • Medicines for diarrhoea, where ongoing or recurrent symptoms can suggest medicine-related adverse effects, infection, malabsorption, or laxative overuse.
        • 

      

        
 	
      • Sleep aids, which could be a sign of stress, grief, burnout or caregiver fatigue.
        • 

      
These small clues are easy to overlook. A simple, empathic, ‘That sounds uncomfortable; let’s take a closer look together’, will usually open the door to a more meaningful conversation.

      Normalising and reframing
      
Normalising language helps people feel safe discussing sensitive issues and reduces defensiveness when the requested product isn’t appropriate. For example:

        
 	
      • ‘Many people don’t realise that too much vitamin B6 can actually cause nerve pain symptoms. Let’s check what you’re already taking.’
        • 
 	
      • ‘A lot of rashes look similar; before choosing a cream, it’s worth making sure we’re treating the right thing.’
        • 

      
This reframes the interaction from a quick sale to a collaborative assessment.
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      Case scenario
      

      During peak hour, 19-year-old Enzo and his mother arrive to collect a new prescription for melatonin MR 2 mg. The pharmacy is highly stimulating: background music blares, customers converse loudly nearby, staff assist others in a cramped space, and general noise amplifies the chaos. While processing Enzo’s prescription and attempting to deliver verbal instructions, you observe Enzo avoiding eye contact, fidgeting intensely, and appearing overwhelmed, with reduced capacity to process verbal or non-verbal cues due to sensory overload.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the current prevalence of autism in Australia 
        • 
 	
      • Describe current challenges and opportunities in supporting autistic people in pharmacy practice
        • 
 	
      • Discuss practice adjustments pharmacists can make and/or supports that can improve accessibility for autistic individuals 
        • 
 	
      • Address common myths and misinformation relating to autism that may be encountered in a pharmacy setting.
        • 

      
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.1, 2.2, 2.3, 3.1, 3.5, 3.6, 4.3

Accreditation number:  PSAAP2604YA

Accreditation expiry: 31/03/2028      		

      
      

      
 

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Introduction
      
[caption id="attachment_31687" align="alignright" width="300"] Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism[/caption]

      Neurodevelopmental disorders (NDDs) arise from differences in brain development and typically affect cognition, communication, behaviour and occupational functioning. Common NDDs include attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), referred to as autism in this article, and intellectual developmental disorder (IDD).1 Autism is characterised by persistent social interaction and communication difficulties and restricted behavioural patterns.2 Symptoms begin in early childhood; however, diagnosis can occur at any age.3 Autism affects how the brain processes information, shaping how autistic people see, understand and respond to the world around them, with marked variability in presentation, day-to-day functioning and support needs.3,4 
      

      In Australia, autism prevalence has increased due to evolving diagnostic practices and awareness,5 meaning pharmacists now routinely engage with autistic individuals as part of everyday practice. 
      

      The challenge and opportunity for pharmacy is to shift from a medical model of crisis response, treatments and cures to a neuro-affirming social model that helps autistic individuals thrive, not just survive. 
      

      A neuro-affirming social model conceptualises neurodevelopmental differences as natural variations within human diversity and rejects deficit-based assumptions that frame these differences as disorders.6 Rather than ‘correcting’ individual traits, this approach provides reasonable adjustments while supporting autonomy, community participation and wellbeing, alongside awareness of diagnostic criteria, comorbidities, communication styles, lived realities and the impact of misinformation.6 The shift to a neuro-affirming social model calls for reducing systemic and environmental barriers, while still addressing health needs.6,7 
      

      For pharmacists, it means making practice adjustments in the way that the profession engages with and provides support for autistic individuals. 
      


      Epidemiology 
      

      According to the Australian Bureau of Statistics, approximately 290,900 Australians (1.1%) are reported to have had an autism diagnosis in 2022.5 A recent estimate by Autism Spectrum Australia (Aspect) suggested at least 1 in 40 Australians are autistic.7
      

      Rising prevalence reflects improved awareness and diagnostic practices rather than a true increase in incidence, including better recognition in historically underdiagnosed groups such as females and older adults.7 Autism prevalence peaks in children and adolescents, particularly those aged 10–14 years, and is markedly lower in adults, acknowledging limited adult data.5,8,9 
      

      Autism prevalence rates may appear to vary among ethnic and cultural
groups, reflecting inequities such as access to healthcare, effective communication, diagnostic practices and cultural perceptions.10 
      

      Prevalence remains higher in males than females, with 1.6% of males identified compared with 0.7% of females, and the greatest disparity is seen in children aged 5–9 years.5 Autism in females is frequently underdiagnosed, as characteristics may manifest differently, be masked (e.g. forced eye contact, rehearsed social scripts, suppressing stimming or copying peers), or fail to align with historically male-centred diagnostic criteria, leading to misdiagnosis as mood or personality disorders.11,12 Masking may occur due to a desire to fit in, fear of stigma or bullying, previous negative reactions to autistic behaviours, and expectations of how females are ‘supposed’ to behave.12 Increasing awareness of the under-recognition of autism in females and gender-diverse individuals, and the social drivers of masking, is anticipated to influence future prevalence estimates.4,5,11
      


      Aetiology
      

      There is no single cause of autism, and despite extensive research, aetiology remains incompletely understood. Current evidence indicates autism arises from a complex interaction between genetic susceptibility and environmental influences on neurodevelopment.13
      

      Family history is one of the strongest predictors of autism.13,14 Researchers have identified hundreds of genes, with approximately 10–20% of cases associated with rare genetic variants arising from mutations in sperm or egg cells.14 Autism is considered polygenic, meaning overall risk typically reflects the cumulative effect of multiple inherited variants, each contributing a small effect.14 
      

      The expression of genetic susceptibility is known to be influenced by prenatal, perinatal and postnatal environmental factors.13 Environmental factors appear most relevant during the prenatal period.14 Modest associations have been reported between autism likelihood and maternal factors such as hypertension, gestational diabetes, obesity, alcohol and substance use, poor antenatal care, and infection or fever during pregnancy.15
      

      Imprecise and inconsistent associations have been reported for folate status, exposure to some air pollutants, and the use of some medicines.15–17 Importantly, these findings are largely derived from observational studies and are subject to confounding. While some prenatal medicine exposures show more consistent associations with autism, there is no clear   evidence that associations between autism and other environmental and medicine exposures represent a causal relationship, and any contribution to autism risk remains limited and uncertain.14,17  
      


      

      Diagnosis
      

      Autism is diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria: ‘persistent deficits in social communication and social interaction across multiple contexts’, with the presence of ‘restricted, repetitive patterns of behaviour, interests or activities’.2 
      

      ‘Symptoms must be present in the early development period’, although they may only become fully apparent later in life. 
      

      ‘Symptoms cause clinically significant impairment in social, occupational or other important areas of functioning’ and ‘these disturbances are not better explained by IDD’ although both can co-occur.2 The DSM-5-TR also specifies severity levels (1–3) to indicate the degree of support required.2
      

      In Australia, individuals may pursue an autism diagnosis through public or private pathways.18 Both are typically lengthy and necessitate a degree of health literacy and English proficiency. Diagnostic assessments may be conducted by a multidisciplinary team, including paediatricians, psychiatrists, psychologists, speech pathologists and occupational therapists.4 Multiple appointments may be needed, drawing on input from family, carers or teachers.18,19 
      

      Barriers to diagnosis include limited awareness of early signs among caregivers and clinicians, long wait times and out-of-pocket costs for specialist assessment, socioeconomic and geographic disparities, and bias in recognising diverse presentations.11,20,21 Limited health literacy and the complexity of navigating multidisciplinary assessments and National Disability Insurance Scheme requirements further impede access.21 In some communities, stigma, fear of labelling, and differing cultural interpretations of behaviour may delay help-seeking.22 
      

      A best-practice diagnostic approach should promote cultural safety and sensitivity, acknowledge variations in health literacy, address socioeconomic barriers, and be grounded in person-centred care.
      

      Autism is a spectrum, with each individual having a unique mix of strengths, challenges, interests, needs and way of interacting with the world. Autism advocate Dr Stephen Shore states, ‘If you have met one autistic person, you have met one autistic person’.23 
      


      Beyond the core features
      

      Comorbid NDDs, and psychiatric and medical conditions can create significant challenges for autistic individuals in relation to diagnosis, selection of appropriate interventions, medicines and support services.1,24 
      

      Comorbid NDDs among autistic individuals include ADHD, developmental coordination disorder (dyspraxia), IDD, and specific learning disorders such as dyslexia, dysgraphia and dyscalculia.25 Psychiatric comorbidities are also prevalent, including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder.26 These conditions can intensify social and sensory challenges, increase vulnerability to stress, and impair emotional regulation and executive functioning. 
      

      Autistic individuals experience higher rates and severity of mental and physical health comorbidities than neurotypical individuals. Neurodivergent mental health outcomes are influenced by the interaction between individual differences and environmental and societal factors.25–28 Diagnostic overshadowing, whereby mental health symptoms are erroneously attributed to autism, should be avoided.29 Comorbid conditions warrant assessment and treatment according to the same clinical standards applied to neurotypical individuals, with adaptations made to accommodate the communication, sensory and support needs of autistic people. Neurodivergent individuals experience the full range of medical comorbidities seen in the general population; however, research indicates higher prevalence of certain conditions, including gastrointestinal disorders (e.g. irritable bowel syndrome, chronic constipation), sleep disturbances, epilepsy, and immune or metabolic disorders.30 These conditions may worsen fatigue, concentration and mood regulation, while motor difficulties may contribute to musculoskeletal pain, reduced physical activity and secondary health issues.31 
      

      Physical health conditions may be underdiagnosed when the clinical focus is limited to behavioural or psychological symptoms.29 
      

      Recognising the complex interconnections between physical, psychiatric and NDD health is paramount. Pharmacists can play a vital role in this process. Effective care relies on health professionals working collaboratively to identify how comorbid conditions, treatment burden and medicines may influence behaviour, cognition and developmental outcomes. 
      


      Support and interventions   
      

      Autism is a lifelong NDD for which there is no curative treatment.4 Clinical care focuses on supporting health, functioning and community participation, addressing comorbidities, and optimising quality of life, while recognising and respecting the individual strengths, capabilities and perspectives of autistic individuals.3
      


      Non-pharmacological support
      

      Supports and interventions are individualised and typically involve a multidisciplinary team to address evolving needs.10 Allied health professionals may include speech pathologists to support communication, occupational therapists to address sensory processing and daily living skills, and psychologists to support emotional regulation and mental health. Physiotherapists may support gross motor skills, while dietitians support feeding and nutritional adequacy, alongside specialist educational support and therapy (e.g. play therapy, art therapy).3 Effective management relies on coordinated care, regular goal review and clear communication between the autistic individual, families and carers, and the multidisciplinary team.24
      


      Pharmacological support 
      

      There is no evidence to support the use of medicines, exclusion diets or other biological treatment for the core features of autism.32,33 To support comorbidities, psychotropic medicines, antiepileptics and sleep agents may be used short term and under specific circumstances. Off-label use is common and requires careful assessment of risk-benefit balance, adverse effects, formulation choice, monitoring, cumulative treatment
burden, and very careful consideration if the medicine is being prescribed as a
chemical restraint.4
      


      

      Myths and misconceptions
      

      Autism is subject to persistent myths that pharmacists may encounter. The most damaging is the long-debunked claim that vaccines cause autism.14 The retracted 1998 Lancet study by Andrew Wakefield that claimed a link between the measles, mumps, rubella (MMR) vaccine and autism was a small, flawed study (with only 12 participants) and was exposed for unethical processes, methodological misconduct, and undisclosed conflicts of interest.14 Despite retraction, its claims were (and continue to be) amplified, eroding trust in public health and fuelling vaccine hesitancy. A Cochrane review published in 2021 found no credible evidence of an association between MMR and MMRV vaccines and autism.34 
      

      Two medicines made headlines in 2025: paracetamol and leucovorin (folinic acid or calcium folinate) claimed as a cause and treatment of autism respectively. Antenatal paracetamol exposure was alleged to increase autism and ADHD risk; however, major studies have not demonstrated a causal relationship.9 Stronger evidence from a large Swedish population-based cohort of 2,480,797 children born between 1995 and 2019 found no association between paracetamol use during pregnancy and autism, ADHD or IDD in sibling-controlled analysis.16 Cerebral folate deficiency (CFD) has been reported in a subset of autistic individuals, related to impaired folate transport into the brain, and may be associated with symptoms of speech difficulties, seizures and IDD, often within early childhood.35,36 Leucovorin, a folinic acid derivative, has been investigated as a potential treatment for autistic children with CFD. Leucovorin can bypass impaired folate transport, increasing central nervous system folate availability.36 Although some small-scale trials indicate potential minor behavioural improvements, supporting evidence remains limited, inconsistent, and not independently replicated.15,37
      

      As medicines experts, pharmacists are well placed to counter common myths. Responses should prioritise empathetic, respectful communication and the provision of clear, evidence-based information and resources. 
      


      Knowledge to practice 
      

      Accessibility, strong communication skills, medicines expertise, understanding of health system navigation and ability to synthesise information, position pharmacists to provide continuity of care for autistic individuals. Pharmacists can serve as an integrative link within multidisciplinary teams, supporting autistic individuals and their families across the healthcare continuum. 
      


      Communication tips 
      

      Effective communication underpins person-centred pharmacy practice. Pharmacists supporting autistic individuals should adapt both verbal and non-verbal communication to meet diverse needs.38 Autism can influence communication and sensory processing in unique ways, with some individuals experiencing sensory sensitivities to sound, light, smell, touch and visual stimuli.3,4,33 Some autistic individuals regulate sensory input through stimming (self-stimulatory behaviour), which may present as repetitive movements or sounds such as fidgeting, rocking or hand-flapping.39 Flexibility, empathy and understanding of sensory needs ensure equitable access to healthcare and fosters the relationship between patient and pharmacist. Verbal communication with autistic individuals should be clear and structured. Pharmacists should use straightforward, unambiguous language and present information in small, logical steps, allowing time for processing and response. Offering a calm, quiet space can both minimise sensory overload and facilitate a more comfortable environment for communication.38,40 
      

      Non-verbal communication requires equal attention. Eye contact, facial expressions and gestures can carry unintended meaning for autistic individuals. Some avoid eye contact
as a coping mechanism, not as disinterest.38 Pharmacists should avoid assumptions and focus on open, calm body language and a reassuring tone. Visual supports can reinforce verbal explanations to provide ongoing reference, especially for individuals who process visual information more effectively than spoken language.40
      

      A person-centred approach requires pharmacists to recognise, respond and adapt to the communication preferences of each autistic individual. If a caregiver or support worker is present, collaboration should occur while directing communication towards the patient whenever possible.40 Empathy, flexibility and inclusive communication techniques ensure care that is respectful and accessible and upholds an individual’s dignity and autonomy.
      


      Conclusion
      

      By adopting inclusive, neuro-affirming approaches, pharmacists strengthen equity, accessibility and person-centredness within healthcare. In doing so, they uphold the profession’s commitment to compassionate, evidence-based practice and help ensure autistic Australians receive the respect, understanding and tailored support needed to achieve optimal health and wellbeing.
      


      


      


      Case scenario continued
      
Enzo’s mother discloses Enzo’s autism diagnosis and requests a quiet area and slower, step-by-step instructions. You offer a consultation room with dimmed lights, minimal visual clutter and no background noise. Enzo settles, visibly calmer.

In this adapted space, you employ person-centred strategies: a soft, steady voice; paced delivery; short, simple sentences; pauses after each point for processing; confirming understanding via yes/no questions or thumbs-up signals; and a clear, written handout with bullet points, icons (e.g. clock for bedtime), and appropriate font. Enzo engages, maintaining partial eye contact and nodding, while his mother clarifies. These modifications demonstrate empathy, flexibility and equitable care, minimising distress, enhancing information access and supporting Enzo’s autonomy.      		

      
      

      
[cpd_submit_answer_button]

      Key points
      

        
 	
      • Shift to a neuro-affirming social model – pharmacists must transition to a social model that fosters neuro-affirming environments and services.
        • 
 	
      • Use clear and visual communication – use straightforward, unambiguous language, present information in small, logical steps, and utilise visual supports to reinforce verbal explanations.
        • 
 	
      • Ensure environmental accessibility – acknowledge sensory differences and offer calm, quiet spaces to reduce sensory overload.
        • 
 	
      • Pharmacists should act as an integrative care link within multidisciplinary teams – bridging care gaps for individuals and families.
        • 
 	
      • Manage comorbidity holistically – apply pharmacological expertise to manage physical, psychiatric and neurodevelopmental health.
        • 
 	
      • Correct misinformation – deliver evidence-based information, empathetically, compassionately and respectfully.
        • 

      

      Our author
      

      Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism is an accredited clinical pharmacist with over 20 years’ experience across aged care, consultancy, community pharmacy and hospital pharmacy. In 2020, she launched The Spectrum Pharmacist to increase awareness, promote inclusion, and provide education and support for neurodevelopmental disorders.
      


      Our Reviewer
      

      Victor Senescall (he/him) BPharm (Hons)
      


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        Wong A, Frye RE, Ohnemus-Kawamura B, et al. Cerebral folate deficiency. 2019. Available from: https://rarediseases.org/rare-diseases/cerebral-folate-deficiency/
        

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        Ramaekers VTH, Quadros EV. Cerebral folate deficiency syndrome: early diagnosis, intervention and treatment strategies. Nutrients. 2022;14(15):3096.
        

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        Sheppeard A. What is leucovorin, and can it cure autism? 2025. Available from: www.medicalrepublic.com.au/what-is-leucovorin-and-can-it-cure-autism/120175
        

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        Norris JE, Milton D, Heasman B. Adapting communication with autistic service users: a participatory study. Autism. 2024.
        

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        National Autistic Society. Repeated movements and behaviour (stimming). 2026. Available from: www.autism.org.uk/advice-and-guidance/topics/about-autism/repeated-movements-and-behaviour-stimming
        

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        National Autistic Society. Autism and communication. 2024. Available from: www.autism.org.uk/advice-and-guidance/topics/about-autism/autism-and-communication
        

        41. 

      
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    [title] => Pharmacy’s neuro-affirming approach to autism
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      Pharmacy’s neuro-affirming approach to autism

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            [post_content] => As fuel costs climb and shortages loom, community pharmacies are facing mounting uncertainty on supply chains, workforce mobility, and equitable patient access.

Fuel shortages and escalating petrol costs are emerging as a significant disruptor for Australian workforces – including pharmacists, with exposure to the downstream impacts  potentially affecting medicines delivery, patient access to care and workforce logistics.

      


      
Addressing the national fuel crisis

        
 	
      • A National Cabinet was held on Monday (30 March), with Prime Minister Anthony Albanese announcing a four-step National Security Plan. We are currently at stage two, which involves localised fuel disruptions.
        • 
 	
      • Fuel excise will be halved for 3 months to address this, which will lower the cost of petrol by $0.26/L.
        • 
 	
      • The heavy vehicle road user charge will also be removed for 3 months.
        • 
 	
      • Stage three of the plan will incorporate collective fuel reduction through measures such as working from home, while stage four will involve a stricter set of rules to protect crucial services. 
        • 

      
      		

      
      

      
Ongoing geopolitical tensions in the Middle East stemming from the US-Israel war with Iran have taken the shape of catastrophic implications, driving global energy instability, including exacerbated cost-of-living effects, leaving essential sectors in vulnerable positions.

AP looks at the potential impacts on pharmacists and patients.

      Workforce pain and travel relief
      
Workforce mobility may be constrained as rising fuel shortages complicate staff travel. While some jurisdictions are offering relief, others are holding firm. 

Tasmania has announced that public transport will be free for the next 3 months, saving commuters between $20 and $88 per week. 

In Victoria, all public transport will be free until after April. ‘This is a temporary measure to help with the cost of living; it will take pressure off the pump and help you save,’ Premier Jacinta Allan stated.

However, public transport is usually not a straightforward option for much of the pharmacy workforce due to after-hours shifts, indirect public transport options or family commitments. And in regional and remote areas, commuter public transport is usually non-existent.

      

      Supply and delivery of medicines
      
Vital delivery providers, including Australia Post and StarTrack, have already increased surcharges – signaling the beginning of broader cost increases. For community pharmacies, this is likely to increase the price of medicines delivery and postage costs for consumers.

Liz de Somer, CEO of Medicines Australia said, ‘The fact that Australia is in a difficult geographical location presents some challenges. As we know, medicines are part of our national security, so it is having an impact on the industry’s costs and an ability to bring medicines to Australia, however … they’re doing everything in their power to ensure the supplies are available.’ 

Ryan Collins, Operations Manager at OTC distributor Be Med told AP, reflecting that wholesalers are, ‘already feeling the pressure through higher freight charges and fuel levies, which are starting to squeeze margins’.

‘If oil prices keep climbing, we expect suppliers to pass on cost increases, meaning higher landed costs for us. There’s also concern around longer lead times if transport capacity tightens,’ he said.

Price increases are also significantly impacting delivery schedules, meaning pharmacists might need to consider how and when they order medicines.

‘Although deliveries are still running, we're seeing less flexibility from carriers,’ Mr Collins  told AP.

‘Some routes are being consolidated, and delivery windows are getting tighter. We’re preparing for potential reductions in frequency if costs continue to rise. 

‘We’re [also] starting to notice more cautious ordering from customers, with some stocking up earlier to avoid future price increases. We expect availability to become less predictable if conditions worsen.’

In terms of equity, Mr Collins said that regional areas are more exposed. 

‘Freight costs are higher, and service levels are more likely to be affected. We’re managing this by planning orders more carefully, encouraging earlier ordering, and trying to consolidate deliveries where possible to keep costs down,’ he said.

‘We’re already having to pass on freight costs from 1 April, as they’ve become impossible for us to absorb. Beyond that, we’re looking at increasing safety stock on key lines, reviewing supplier options, and prioritising essential products.’

      Impacts on medicines review services
      
Fuel pressures are also placing stress on Home Medicines Review (HMR) services, potentially placing vulnerable patients at risk, which would flow directly down the line to pressures on our hospital system.

These challenges are felt acutely in regional areas where long travel distances are commonplace, and staff-mobility is restricted for essential at-home services, which poses challenges for  equity and continuity of care. 

The PSA has called for greater access to services to ensure patients receive care and pharmacists are able to deliver services to patients who are unable to travel, enhancing access for those in a compromised position.

‘We need to see some [changes] in service delivery, such as bringing back telehealth,’ PSA’s Head of Policy and Strategy Chris Campbell FPS said.

PSA National President Professor Mark Naunton MPS agreed, emphasising that patients need and deserve timely, trusted care. ‘That is our highest priority. We can’t have patients languishing or, worst case, dying on waiting lists. Telehealth solves this instantly,’ he said.

‘Telehealth is one of the most equitable measures we have to deliver HMRs to Australians no matter where they live. It ensures that someone in a regional or remote community or even in a metropolitan area is not penalised simply because of their postcode.

Telehealth also keeps pharmacists safe by eliminating the need for them to drive long distances, especially during the current petrol crisis, Prof Naunton said.

‘Pharmacists in regional areas know this better than most, we have real workforce issues to contend with and telehealth is an excellent option that does not compromise patient wellbeing,’ he said.

‘We are clearly in a petrol-related crisis now that is bringing its own immediate pressures but as pharmacists we are regularly dealing with problems accessing patients, be it natural disasters like flooding or bushfires to questions of road access and safety.’

PSA’s 2026–27 Federal Budget Submission, released 25 February 2026, identifies reform of HMRs, including telehealth flexibility, as a priority under the First Pharmacy Programs Reform Package.
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      Fuel shortages pose emerging risks for pharmacy

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            [post_content] => New avenues for nurse prescribing have the potential to reshape frontline care. For pharmacists, it’s a live example of how scope expansion translates into real impact.

Nurse prescribing is entering a new phase in Australia, and pharmacists should be paying close attention. 

While nurse practitioners and endorsed midwives have been able to prescribe Pharmaceutical Benefits Schedule (PBS) subsidised medicines since 2010, a new pathway will soon expand prescribing to a broader group of experienced nurses.

‘A lot of people wouldn't even know that nurses are already prescribing medications that are funded on the PBS,’ said Denise Lyons, President of the Australian Primary Health Care Nurses Association. ‘But there are more than 3,000 nurse practitioners and endorsed midwives in Australia now who are already prescribing.’

Under a new registration standard which came into effect in September last year, suitably qualified registered nurses will be able to prescribe medicines in Schedules 2, 3, 4 and 8 in partnership with an authorised prescriber.

‘It took until this year for universities to start the course that enables registered nurses to meet [the new standard],’ Ms Lyons said. ‘Most are 6-month postgraduate courses … So it will probably be around July 2026 that we will see the first [wave] of nurses completing the educational requirement.’

For pharmacists, this shift offers a live view of how prescribing reform is built – through legislation, governance, defined scope and, crucially, access to the PBS.

      What’s changing?
      
The new framework is deliberately cautious. To become a designated RN prescriber, a nurse must: 

        
 	
      • complete postgraduate training
        • 
 	
      • have significant prior clinical experience
        • 
 	
      • work within an agreed clinical governance framework with an authorised health practitioner under an active prescribing agreement
        • 
 	
      • complete a 6-month period of clinical mentorship.
        • 

      
 The written prescribing agreement with an authorised prescriber remains in place beyond the initial mentorship period.

‘An authorised prescriber could be a nurse practitioner, endorsed midwife, or it could be a GP,’ Ms Lyons said. ‘And that prescribing agreement is going to articulate what medications are within scope.

‘For example, say you had a registered nurse who has been working in paediatrics [throughout their] career… [They’re] going to be educated and competent to prescribe for some childhood illnesses, so that would be within [their] scope.’

For patients, expanded nurse prescribing could mean faster access to medicines, fewer delays for routine care and less reliance on GP availability.

‘You think about the amount of care that nurses deliver around [things like] aged care, palliative care, community care and sexual health,’ Ms Lyons said. 

‘There's a lot of work done in the community by registered nurses who have a lot of knowledge and experience. And this is going to be a mechanism that lets them use that knowledge and experience in a really helpful way.’

Expanded nurse prescribing will be especially valuable in rural and remote communities, aged care and other underserved settings where nurses are often the main point of contact but medical access can be patchy, she added.

      ‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place.'

denise lyons 
      

      PBS access is the make-or-break issue
      
While the regulatory framework and training pathway are now largely in place, the biggest unresolved issue is PBS access. Nurse practitioners and endorsed midwives already have it. Designated RN prescribers do not – yet.

Without PBS access, nurses may be able to issue prescriptions, but patients would still face out-of-pocket costs that undermine the practical value of the reform.

However, federal legislation now before the Senate would amend the National Health Act 1953 to allow designated RN prescribers to prescribe PBS-subsidised medicines. 

‘We're really hoping the Bill comes through the Senate with no amendments and that it passes into legislation,’ Ms Lyons said. ‘If we don't manage to get access, and the subsidies on the PBS lag behind practice, that will be a real barrier.’ 

Ms Lyons also highlighted the need for national coordination. State and territory variations in drugs and poisons legislation create confusion for both clinicians and patients, as pharmacists know all too well.

‘The work that's being done to harmonise [that] legislation across the states and territories is going to be really important, and we need to all work on that together,’ she said.

      Implications for pharmacists
      
As nurse prescribing expands, pharmacists are likely to see more prescriptions coming from a wider mix of clinicians, potentially changing how care is coordinated in everyday practice.

Rather than care sitting primarily with a single prescriber, it will increasingly be shared across a team – with nurses assessing, prescribing and monitoring within their scope, and pharmacists supporting safe and effective medicines use.

That means collaboration needs to be more deliberate, Ms Lyons said.

‘With quality use of medicines, there [need to be] clear principles around closed-loop communication, agreed-upon goals, rapid feedback on issues and shared protocols,’ she said.

The progress of the nurse prescribing model also provides a useful advocacy roadmap. The model has gained traction by focusing on what it delivers for patients – faster access, fewer delays and more complete care at the point of contact. 

That focus is particularly relevant in pharmacy, where prescribing arrangements currently vary by state and territory, and where the absence of PBS access continues to limit how much patients can benefit.

Like nurse prescribing, expanded pharmacist prescribing will only be truly effective if it’s consistent, supported by clear frameworks and enables affordable access for patients.

‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place,’ Ms Lyons said.
            [post_title] => Nurse prescribing offers a roadmap for reform
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      Nurse prescribing offers a roadmap for reform

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      Case scenario
      

      Sarah, a 42-year-old woman, presents to the pharmacy reporting a small lump near the anus, occasional bright red bleeding on toilet paper after bowel movements, anal itching and discomfort. She mentions feeling embarrassed to seek advice and has been self-managing with sitz baths. She reports a history of chronic constipation with frequent training during defecation. She is not taking any regular medicines and requests an over-the-counter product to relieve her symptoms. You take the time to explore Sarah’s symptoms in more detail, to help identify any red flags that would require immediate referral. You ask about the duration, severity and other symptoms such as fatigue, unintentional weight loss and changes in bowel habits, all of which she denies.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the classification and causes of anal fissures and haemorrhoids
        • 
 	
      • Identify the clinical features of anal fissures and haemorrhoids
        • 
 	
      • Discuss management strategies for anal fissures and haemorrhoids
        • 
 	
      • Describe the pharmacist’s role in supporting individuals with anal fissures and haemorrhoids.
        • 

      
Competency (2016) standards addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Accreditation code: PSAAP2604HQ

Accreditation expiry: 31/03/2028

Accreditation points: Up to 1 Group 2 CPD      		

      
      

      
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Epidemiology 
      

      Anal fissures and haemorrhoids are commonly encountered, but their epidemiology is not well documented. Haemorrhoids represent the most frequent reason for proctology consultations, followed by anal fissures.1 Haemorrhoids are estimated to affect up to 40% of adults in the general population, although many individuals are asymptomatic.2 Anal fissures occur in approximately 10–15% of the population.3 
      


      

      Aetiology and pathophysiology
      

      An anal fissure is a longitudinal tear in the anal canal, most often occurring in the posterior midline, just below the dentate line.4 Anal fissures are typically classified as primary or secondary, depending on the cause. Primary fissures are usually benign and caused by local trauma, such as the passage of hard stools, prolonged diarrhoea, vaginal delivery, repeated injury or anal penetration.4 Secondary fissures, which are often multiple and located off the midline, are uncommon, accounting for less than 1% of cases.5 They result from underlying conditions like previous anal surgery, inflammatory bowel disease (e.g. Crohn’s disease), colorectal malignancy, infections (e.g. HIV/AIDS), or dermatological conditions (e.g. psoriasis).6 Anal fissures are further described as acute or chronic, with chronic fissures lasting more than 6 weeks.7 
      


[caption id="attachment_31774" align="alignright" width="200"] DR 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.[/caption]

      Anal fissures are often mistaken for haemorrhoids because of their overlapping symptoms. Haemorrhoids differ in that they are normal vascular cushions within the anal canal that maintain continence. Although part of normal anatomy, the term ‘haemorrhoid’ is commonly used when these vascular anal cushions, containing a rich arteriovenous network, become enlarged or displaced.8 Haemorrhoids may be classified as internal (located above the dentate line) or external (located below the dentate line). Factors such as constipation, straining during bowel movements and a low-fibre diet are commonly considered to increase the risk of haemorrhoids.9,10 However, the causal relationship between these factors and the development of haemorrhoids remains unclear. A possible genetic component that predisposes to smooth muscle, epithelial and connective tissue dysfunction, may contribute to haemorrhoids.11
      

      It is important to note that certain medicines can contribute to or worsen constipation as an adverse effect, thereby aggravating haemorrhoids and anal fissures.9,10 Common examples include opioids, anticholinergics, and iron and calcium supplements.12 Regular medication review should be incorporated into comprehensive care to identify opportunities for deprescribing and prevent inappropriate prescribing cascades, with further guidance available in the new deprescribing guidelines.13
      


      Clinical features 
      

      The symptoms of haemorrhoids may include rectal bleeding, anal pruritus, prolapse, faecal seepage and mucus discharge.7 
      

      Internal haemorrhoids are usually painless because the columnar epithelium is insensitive to touch and temperature.8 In contrast, external haemorrhoids are pain sensitive and may become thrombosed, often following straining during defecation.8 
      

      Anal fissures, by comparison, typically cause severe tearing pain that is provoked by defecation.4 A key distinguishing feature is that the pain of an anal fissure typically occurs during or immediately after defecation.
      


      

      Diagnosis and differential diagnoses 
      

      For diagnostic purposes, medical practitioners perform a physical examination with the individual lying on their side, gently parting the buttocks to inspect the posterior midline.4 Several other anorectal disorders may present with similar symptoms to anal fissures and haemorrhoids. Differential diagnoses include anal fistula and solitary rectal ulcer syndrome, which can often be distinguished based on their clinical appearance through careful physical examination. An anal fistula typically presents as a draining skin punctum.14 It is an abnormal hollow tract, most often arising from infection of an anal gland.15 Solitary rectal ulcer syndrome may present with anal pain, rectal bleeding, constipation, mucus discharge, excessive straining and a sensation of incomplete evacuation. Despite its name, the condition does not always involve an ulcer. Diagnosis requires a combination of endoscopic and histopathological findings, together with the individual’s reported symptoms.16
      


      Management approaches 
      

      Haemorrhoids
      


[caption id="attachment_31775" align="alignright" width="200"] Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).[/caption]

      Non-pharmacological treatment options
      

      First-line management for haemorrhoids usually involves lifestyle measures, which include ensuring adequate fluid and fibre intake, reducing prolonged time on the toilet and avoiding excessive straining, the use of sitz baths, and maintaining anal hygiene.10 In practice, dietary and lifestyle modifications are usually recommended as a conservative and preventive measure for haemorrhoids.17
      

      Pharmacological treatment options
      

      Over-the-counter therapies for internal haemorrhoids include ointments and suppositories that contain emollients, mild astringents, local anaesthetics and/or corticosteroids.8 These preparations temporarily relieve itching and discomfort. Prolonged use of topical corticosteroids is not recommended, as it increases the risk of local infections such as candidiasis.8 Similarly, prolonged use of anaesthetic-containing products should be avoided due to potential adverse effects, including skin sensitisation and dermatitis.8
      

      Outpatient procedures and surgery
      

      For individuals who do not respond to conservative measures, other treatment options for haemorrhoids include outpatient procedures and surgery.10 Outpatient procedures include rubber band ligation, infrared coagulation, bipolar probe, heater probe, sclerotherapy and cryotherapy.10 These are generally reserved for people with grade I or grade II haemorrhoids.10 Surgery can be considered for people who do not respond to or cannot tolerate outpatient procedures, as well as those with large external haemorrhoids, or combined internal and external haemorrhoids with prolapse.10
      

      A recent meta-analysis found that surgical treatments, compared with conservative treatments, offer greater symptom relief, quicker recovery and lower recurrence rates.18 However, they do carry risks of procedure-related complications. In contrast, conservative treatments are safer and less invasive, but tend to provide slower symptom improvement and have higher recurrence rates.18 Therefore, treatment decisions should be individualised, taking into account symptom severity, individual preferences and risk tolerance.
      

      Anal fissures
      

      The primary aim of treatment for anal fissures is to reduce anal sphincter spasm, improve blood flow and promote healing.6 First-line management is usually non-operative and includes increasing dietary fibre, use of sitz baths and applying glyceryl trinitrate 0.2% ointment, three times daily for up to 4 weeks to relieve pain.19 Headache is a common adverse effect of glyceryl trinitrate due to systemic absorption, which could limit its use.20 Other topical agents used in clinical practice include lidocaine and hydrocortisone, although these are less effective than a combination of fibre intake and warm sitz baths.4 
      

      Botulinum toxin injections may also be considered and can achieve good healing rates.6,19 However, botulinum toxin may cause temporary reduced control of wind or bowel motions, which usually resolves as the effect of the injection wears off.4 Due to these adverse effects and the invasive nature of the procedure, botulinum toxin is generally reserved as a second-line therapy.4 If these treatment options are unsuccessful, surgical treatment may
be required.6
      

      Secondary or chronic anal fissures warrant additional investigation and multidisciplinary management is advised, especially when malignancy is suspected or confirmed.4 
      


      Knowledge to practice 
      

      Pharmacists play a key role in recognising the symptoms of haemorrhoids and anal fissures, providing timely advice and suggesting a suitable course of action. Pharmacists can also educate individuals on first-line management strategies and provide lifestyle advice where appropriate to prevent recurrence. In addition, pharmacists can advocate for the safe use of over-the-counter treatments, advise on appropriate duration of use and counsel individuals on potential adverse effects.
      

      Referral to a medical practitioner is advisable for individuals who21:
      


        
 	
      • do not respond to over-the-counter medicines and lifestyle changes
        • 
 	
      • have recent changes in bowel habits or
        • 
 	
      • have other co-existing signs and symptoms, including unexplained weight loss and fatigue.
        • 

      

      Conclusion
      

      Anal fissures and haemorrhoids are common conditions encountered in primary care and can greatly impact quality of life. Pharmacists play a critical role in early management and referral, helping prevent complications and improve outcomes.
      


      


      


      Case scenario continued
      
You identify that Sarah has haemorrhoids and provide lifestyle advice, including increasing fluid and dietary fibre intake, avoiding prolonged straining during bowel movements and practising good anal hygiene. For symptomatic relief, you suggest a topical ointment containing cinchocaine 0.5% and zinc oxide 20%, to be applied as needed. You also advise her to consult her general practitioner if she experiences persistent bleeding, ongoing pain or worsening prolapse. With your support and advice, Sarah feels more confident in managing her condition effectively while reducing the risk of recurrence.           		

      
      

      

      [cpd_submit_answer_button]
      


      Key points
      

        
 	
      • Anal fissures and haemorrhoids are common anorectal conditions with overlapping symptoms.
        • 
 	
      • Pain from an anal fissure typically occurs during or immediately after defecation, whereas haemorrhoids may cause itchiness or prolapse.
        • 
 	
      • Anal fissures usually result from trauma or constipation, while haemorrhoids arise from vascular engorgement.
        • 
 	
      • First-line management for both conditions includes conservative dietary and lifestyle measures, as well as topical treatment for symptomatic relief.
        • 
 	
      • Pharmacists can educate individuals on symptom relief, recommend appropriate treatments, advise preventive strategies and provide referrals when necessary.
        • 

      

      Our authors
      

      Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
      

      DR 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.
      


      Our Reviewer
      

      Manisha Pillai (she/her) BPharm
      


      References
      

        
 	
      1. 

        Higuero T. Update on the management of anal fissure. J Visc Surg. 2015;152(2 Suppl):S37–S43.
        

        2. 
 	
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        Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215–220.
        

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        Vitton V, Bouchard D, Guingand M, Higuero T. Treatment of anal fissures: results from a national survey on French practice. Clin Res Hepatol Gastroenterol. 2022;46(4):101821.
        

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        Schlichtemeier S, Engel A. Anal fissure. Aust Prescr. 2016;39(1):14–17.
        

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        Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019;69(685):409–410.
        

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        Lyle V, Young C. Anal fissures: an update on treatment options. Aust J Gen Pract. 2024;53:33–35.
        

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        Therapeutic Guidelines Limited. Haemorrhoids. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

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        Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009–2017.
        

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        Sandler RS, Peery AF. Rethinking what we know about hemorrhoids. Clin Gastroenterol Hepatol. 2019;17(1):8–15.
        

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        Zheng T, Ellinghaus D, Juzenas S, Cossais F, Burmeister G, Mayr G, et al. Genome-wide analysis of 944 133 individuals provides insights into the etiology of haemorrhoidal disease. Gut. 2021;70(8):1538–1549.
        

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        Therapeutic Guidelines Limited. Functional constipation in adults. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        13. 
 	
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        Quek HW, Reus X, Lee K, Etherton-Beer C, Page A; Guideline Development Group. Deprescribing in older people: a clinical practice guideline. Perth (WA): The University of Western Australia; 2025.
        

        14. 
 	
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        Stewart D. Anal fissure: clinical manifestations, diagnosis, prevention. UpToDate. 2025. Available from: https://www.uptodate.com/contents/anal-fissure-clinical-manifestations-diagnosis-prevention
        

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        Therapeutic Guidelines Limited. Anorectal abscess and fistula. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

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        Sadeghi A, Biglari M, Forootan M, Adibi P. Solitary rectal ulcer syndrome: a narrative review. Middle East J Dig Dis. 2019;11(3):129–134.
        

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        Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist's view. World J Gastroenterol. 2015;21(31):9245–9252.
        

        18. 
 	
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        Quan L, Bai X, Cheng F, Chen J, Ma H, Wang P, et al. Comparison of efficacy and safety between surgical and conservative treatments for hemorrhoids: a meta-analysis. BMC Gastroenterol. 2025;25(1):492.
        

        19. 
 	
      19. 

        Therapeutic Guidelines Limited. Anal fissure. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        20. 
 	
      20. 

        Australian Medicines Handbook Pty Ltd. Glyceryl trinitrate (rectal). Adelaide: Australian Medicines Handbook Pty Ltd; 2025. Available from: https://amhonline.amh.net.au/
        

        21. 
 	
      21. 

        Allen S. Haemorrhoids and anal fissures. S Afr Pharm J. 2008;75(5):36.
        

        22. 

      
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            [post_content] => Community pharmacies are often the first place people turn when something feels ‘off’. But as pharmacists know, many requests for over-the-counter medicines are more complex than they may initially seem.

AP took a look at some presentations which might signal hidden red flags.

      ‘I just want a multivitamin’
      
When people present to community pharmacies, they often arrive with a solution already in mind. For example, ‘I need a strong painkiller,’ ‘I just want a multivitamin,’ or ‘What do you have for nerve pain?’ 

Nearly always, consistent with professional standards, these invite an open ended question to uncover the rationale for the request

        
 	
      • ‘Tell me what’s been happening.’
        • 
 	
      • ‘What made you choose this product today?’
        • 
 	
      • ‘What symptoms are you hoping to improve?’
        • 

      
That multivitamin request might be because someone is worried about immunity – which should prompt a discussion about immunisation. It could also indicate someone is feeling lethargic, which might start a conversation to rule-out anaemia. Or it might indicate a wish to support someone not eating due to chemotherapy – which obviously prompts a very different and comprehensive discussion.

These open‑ended questions encourage people to share more without slowing workflow, and they help prevent anchoring on a self‑diagnosis that may not reflect the real issue.

[caption id="attachment_31745" align="alignright" width="256"] Gauri Godbole FPS[/caption]

      ‘What’s your strongest painkiller’
      
People often reveal more than they realise. A request for a ‘strong painkiller’ could just be the tip of the iceberg.

For example, peripheral neuropathy is more common than most people realise. It’s also caused by vitamin B6 toxicity from multiple B6‑containing products more often than considered.

So a conversation where you discuss how a painkiller request could actually signal neuropathy from long‑term use of multiple high‑dose multivitamins, energy supplements, or ‘nerve support’ products is critical. Without gentle questioning, the true cause can be easily missed.

There are plenty of other examples that frequently appear, including requests for:

        
 	
      • ‘Something stronger for pain’, which may reflect chronic pain escalation or medicines overuse.
        • 
 	
      • Medicines for diarrhoea, where ongoing or recurrent symptoms can suggest medicine-related adverse effects, infection, malabsorption, or laxative overuse.
        • 

      

        
 	
      • Sleep aids, which could be a sign of stress, grief, burnout or caregiver fatigue.
        • 

      
These small clues are easy to overlook. A simple, empathic, ‘That sounds uncomfortable; let’s take a closer look together’, will usually open the door to a more meaningful conversation.

      Normalising and reframing
      
Normalising language helps people feel safe discussing sensitive issues and reduces defensiveness when the requested product isn’t appropriate. For example:

        
 	
      • ‘Many people don’t realise that too much vitamin B6 can actually cause nerve pain symptoms. Let’s check what you’re already taking.’
        • 
 	
      • ‘A lot of rashes look similar; before choosing a cream, it’s worth making sure we’re treating the right thing.’
        • 

      
This reframes the interaction from a quick sale to a collaborative assessment.
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      Case scenario
      

      During peak hour, 19-year-old Enzo and his mother arrive to collect a new prescription for melatonin MR 2 mg. The pharmacy is highly stimulating: background music blares, customers converse loudly nearby, staff assist others in a cramped space, and general noise amplifies the chaos. While processing Enzo’s prescription and attempting to deliver verbal instructions, you observe Enzo avoiding eye contact, fidgeting intensely, and appearing overwhelmed, with reduced capacity to process verbal or non-verbal cues due to sensory overload.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the current prevalence of autism in Australia 
        • 
 	
      • Describe current challenges and opportunities in supporting autistic people in pharmacy practice
        • 
 	
      • Discuss practice adjustments pharmacists can make and/or supports that can improve accessibility for autistic individuals 
        • 
 	
      • Address common myths and misinformation relating to autism that may be encountered in a pharmacy setting.
        • 

      
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.1, 2.2, 2.3, 3.1, 3.5, 3.6, 4.3

Accreditation number:  PSAAP2604YA

Accreditation expiry: 31/03/2028      		

      
      

      
 

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Introduction
      
[caption id="attachment_31687" align="alignright" width="300"] Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism[/caption]

      Neurodevelopmental disorders (NDDs) arise from differences in brain development and typically affect cognition, communication, behaviour and occupational functioning. Common NDDs include attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), referred to as autism in this article, and intellectual developmental disorder (IDD).1 Autism is characterised by persistent social interaction and communication difficulties and restricted behavioural patterns.2 Symptoms begin in early childhood; however, diagnosis can occur at any age.3 Autism affects how the brain processes information, shaping how autistic people see, understand and respond to the world around them, with marked variability in presentation, day-to-day functioning and support needs.3,4 
      

      In Australia, autism prevalence has increased due to evolving diagnostic practices and awareness,5 meaning pharmacists now routinely engage with autistic individuals as part of everyday practice. 
      

      The challenge and opportunity for pharmacy is to shift from a medical model of crisis response, treatments and cures to a neuro-affirming social model that helps autistic individuals thrive, not just survive. 
      

      A neuro-affirming social model conceptualises neurodevelopmental differences as natural variations within human diversity and rejects deficit-based assumptions that frame these differences as disorders.6 Rather than ‘correcting’ individual traits, this approach provides reasonable adjustments while supporting autonomy, community participation and wellbeing, alongside awareness of diagnostic criteria, comorbidities, communication styles, lived realities and the impact of misinformation.6 The shift to a neuro-affirming social model calls for reducing systemic and environmental barriers, while still addressing health needs.6,7 
      

      For pharmacists, it means making practice adjustments in the way that the profession engages with and provides support for autistic individuals. 
      


      Epidemiology 
      

      According to the Australian Bureau of Statistics, approximately 290,900 Australians (1.1%) are reported to have had an autism diagnosis in 2022.5 A recent estimate by Autism Spectrum Australia (Aspect) suggested at least 1 in 40 Australians are autistic.7
      

      Rising prevalence reflects improved awareness and diagnostic practices rather than a true increase in incidence, including better recognition in historically underdiagnosed groups such as females and older adults.7 Autism prevalence peaks in children and adolescents, particularly those aged 10–14 years, and is markedly lower in adults, acknowledging limited adult data.5,8,9 
      

      Autism prevalence rates may appear to vary among ethnic and cultural
groups, reflecting inequities such as access to healthcare, effective communication, diagnostic practices and cultural perceptions.10 
      

      Prevalence remains higher in males than females, with 1.6% of males identified compared with 0.7% of females, and the greatest disparity is seen in children aged 5–9 years.5 Autism in females is frequently underdiagnosed, as characteristics may manifest differently, be masked (e.g. forced eye contact, rehearsed social scripts, suppressing stimming or copying peers), or fail to align with historically male-centred diagnostic criteria, leading to misdiagnosis as mood or personality disorders.11,12 Masking may occur due to a desire to fit in, fear of stigma or bullying, previous negative reactions to autistic behaviours, and expectations of how females are ‘supposed’ to behave.12 Increasing awareness of the under-recognition of autism in females and gender-diverse individuals, and the social drivers of masking, is anticipated to influence future prevalence estimates.4,5,11
      


      Aetiology
      

      There is no single cause of autism, and despite extensive research, aetiology remains incompletely understood. Current evidence indicates autism arises from a complex interaction between genetic susceptibility and environmental influences on neurodevelopment.13
      

      Family history is one of the strongest predictors of autism.13,14 Researchers have identified hundreds of genes, with approximately 10–20% of cases associated with rare genetic variants arising from mutations in sperm or egg cells.14 Autism is considered polygenic, meaning overall risk typically reflects the cumulative effect of multiple inherited variants, each contributing a small effect.14 
      

      The expression of genetic susceptibility is known to be influenced by prenatal, perinatal and postnatal environmental factors.13 Environmental factors appear most relevant during the prenatal period.14 Modest associations have been reported between autism likelihood and maternal factors such as hypertension, gestational diabetes, obesity, alcohol and substance use, poor antenatal care, and infection or fever during pregnancy.15
      

      Imprecise and inconsistent associations have been reported for folate status, exposure to some air pollutants, and the use of some medicines.15–17 Importantly, these findings are largely derived from observational studies and are subject to confounding. While some prenatal medicine exposures show more consistent associations with autism, there is no clear   evidence that associations between autism and other environmental and medicine exposures represent a causal relationship, and any contribution to autism risk remains limited and uncertain.14,17  
      


      

      Diagnosis
      

      Autism is diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria: ‘persistent deficits in social communication and social interaction across multiple contexts’, with the presence of ‘restricted, repetitive patterns of behaviour, interests or activities’.2 
      

      ‘Symptoms must be present in the early development period’, although they may only become fully apparent later in life. 
      

      ‘Symptoms cause clinically significant impairment in social, occupational or other important areas of functioning’ and ‘these disturbances are not better explained by IDD’ although both can co-occur.2 The DSM-5-TR also specifies severity levels (1–3) to indicate the degree of support required.2
      

      In Australia, individuals may pursue an autism diagnosis through public or private pathways.18 Both are typically lengthy and necessitate a degree of health literacy and English proficiency. Diagnostic assessments may be conducted by a multidisciplinary team, including paediatricians, psychiatrists, psychologists, speech pathologists and occupational therapists.4 Multiple appointments may be needed, drawing on input from family, carers or teachers.18,19 
      

      Barriers to diagnosis include limited awareness of early signs among caregivers and clinicians, long wait times and out-of-pocket costs for specialist assessment, socioeconomic and geographic disparities, and bias in recognising diverse presentations.11,20,21 Limited health literacy and the complexity of navigating multidisciplinary assessments and National Disability Insurance Scheme requirements further impede access.21 In some communities, stigma, fear of labelling, and differing cultural interpretations of behaviour may delay help-seeking.22 
      

      A best-practice diagnostic approach should promote cultural safety and sensitivity, acknowledge variations in health literacy, address socioeconomic barriers, and be grounded in person-centred care.
      

      Autism is a spectrum, with each individual having a unique mix of strengths, challenges, interests, needs and way of interacting with the world. Autism advocate Dr Stephen Shore states, ‘If you have met one autistic person, you have met one autistic person’.23 
      


      Beyond the core features
      

      Comorbid NDDs, and psychiatric and medical conditions can create significant challenges for autistic individuals in relation to diagnosis, selection of appropriate interventions, medicines and support services.1,24 
      

      Comorbid NDDs among autistic individuals include ADHD, developmental coordination disorder (dyspraxia), IDD, and specific learning disorders such as dyslexia, dysgraphia and dyscalculia.25 Psychiatric comorbidities are also prevalent, including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder.26 These conditions can intensify social and sensory challenges, increase vulnerability to stress, and impair emotional regulation and executive functioning. 
      

      Autistic individuals experience higher rates and severity of mental and physical health comorbidities than neurotypical individuals. Neurodivergent mental health outcomes are influenced by the interaction between individual differences and environmental and societal factors.25–28 Diagnostic overshadowing, whereby mental health symptoms are erroneously attributed to autism, should be avoided.29 Comorbid conditions warrant assessment and treatment according to the same clinical standards applied to neurotypical individuals, with adaptations made to accommodate the communication, sensory and support needs of autistic people. Neurodivergent individuals experience the full range of medical comorbidities seen in the general population; however, research indicates higher prevalence of certain conditions, including gastrointestinal disorders (e.g. irritable bowel syndrome, chronic constipation), sleep disturbances, epilepsy, and immune or metabolic disorders.30 These conditions may worsen fatigue, concentration and mood regulation, while motor difficulties may contribute to musculoskeletal pain, reduced physical activity and secondary health issues.31 
      

      Physical health conditions may be underdiagnosed when the clinical focus is limited to behavioural or psychological symptoms.29 
      

      Recognising the complex interconnections between physical, psychiatric and NDD health is paramount. Pharmacists can play a vital role in this process. Effective care relies on health professionals working collaboratively to identify how comorbid conditions, treatment burden and medicines may influence behaviour, cognition and developmental outcomes. 
      


      Support and interventions   
      

      Autism is a lifelong NDD for which there is no curative treatment.4 Clinical care focuses on supporting health, functioning and community participation, addressing comorbidities, and optimising quality of life, while recognising and respecting the individual strengths, capabilities and perspectives of autistic individuals.3
      


      Non-pharmacological support
      

      Supports and interventions are individualised and typically involve a multidisciplinary team to address evolving needs.10 Allied health professionals may include speech pathologists to support communication, occupational therapists to address sensory processing and daily living skills, and psychologists to support emotional regulation and mental health. Physiotherapists may support gross motor skills, while dietitians support feeding and nutritional adequacy, alongside specialist educational support and therapy (e.g. play therapy, art therapy).3 Effective management relies on coordinated care, regular goal review and clear communication between the autistic individual, families and carers, and the multidisciplinary team.24
      


      Pharmacological support 
      

      There is no evidence to support the use of medicines, exclusion diets or other biological treatment for the core features of autism.32,33 To support comorbidities, psychotropic medicines, antiepileptics and sleep agents may be used short term and under specific circumstances. Off-label use is common and requires careful assessment of risk-benefit balance, adverse effects, formulation choice, monitoring, cumulative treatment
burden, and very careful consideration if the medicine is being prescribed as a
chemical restraint.4
      


      

      Myths and misconceptions
      

      Autism is subject to persistent myths that pharmacists may encounter. The most damaging is the long-debunked claim that vaccines cause autism.14 The retracted 1998 Lancet study by Andrew Wakefield that claimed a link between the measles, mumps, rubella (MMR) vaccine and autism was a small, flawed study (with only 12 participants) and was exposed for unethical processes, methodological misconduct, and undisclosed conflicts of interest.14 Despite retraction, its claims were (and continue to be) amplified, eroding trust in public health and fuelling vaccine hesitancy. A Cochrane review published in 2021 found no credible evidence of an association between MMR and MMRV vaccines and autism.34 
      

      Two medicines made headlines in 2025: paracetamol and leucovorin (folinic acid or calcium folinate) claimed as a cause and treatment of autism respectively. Antenatal paracetamol exposure was alleged to increase autism and ADHD risk; however, major studies have not demonstrated a causal relationship.9 Stronger evidence from a large Swedish population-based cohort of 2,480,797 children born between 1995 and 2019 found no association between paracetamol use during pregnancy and autism, ADHD or IDD in sibling-controlled analysis.16 Cerebral folate deficiency (CFD) has been reported in a subset of autistic individuals, related to impaired folate transport into the brain, and may be associated with symptoms of speech difficulties, seizures and IDD, often within early childhood.35,36 Leucovorin, a folinic acid derivative, has been investigated as a potential treatment for autistic children with CFD. Leucovorin can bypass impaired folate transport, increasing central nervous system folate availability.36 Although some small-scale trials indicate potential minor behavioural improvements, supporting evidence remains limited, inconsistent, and not independently replicated.15,37
      

      As medicines experts, pharmacists are well placed to counter common myths. Responses should prioritise empathetic, respectful communication and the provision of clear, evidence-based information and resources. 
      


      Knowledge to practice 
      

      Accessibility, strong communication skills, medicines expertise, understanding of health system navigation and ability to synthesise information, position pharmacists to provide continuity of care for autistic individuals. Pharmacists can serve as an integrative link within multidisciplinary teams, supporting autistic individuals and their families across the healthcare continuum. 
      


      Communication tips 
      

      Effective communication underpins person-centred pharmacy practice. Pharmacists supporting autistic individuals should adapt both verbal and non-verbal communication to meet diverse needs.38 Autism can influence communication and sensory processing in unique ways, with some individuals experiencing sensory sensitivities to sound, light, smell, touch and visual stimuli.3,4,33 Some autistic individuals regulate sensory input through stimming (self-stimulatory behaviour), which may present as repetitive movements or sounds such as fidgeting, rocking or hand-flapping.39 Flexibility, empathy and understanding of sensory needs ensure equitable access to healthcare and fosters the relationship between patient and pharmacist. Verbal communication with autistic individuals should be clear and structured. Pharmacists should use straightforward, unambiguous language and present information in small, logical steps, allowing time for processing and response. Offering a calm, quiet space can both minimise sensory overload and facilitate a more comfortable environment for communication.38,40 
      

      Non-verbal communication requires equal attention. Eye contact, facial expressions and gestures can carry unintended meaning for autistic individuals. Some avoid eye contact
as a coping mechanism, not as disinterest.38 Pharmacists should avoid assumptions and focus on open, calm body language and a reassuring tone. Visual supports can reinforce verbal explanations to provide ongoing reference, especially for individuals who process visual information more effectively than spoken language.40
      

      A person-centred approach requires pharmacists to recognise, respond and adapt to the communication preferences of each autistic individual. If a caregiver or support worker is present, collaboration should occur while directing communication towards the patient whenever possible.40 Empathy, flexibility and inclusive communication techniques ensure care that is respectful and accessible and upholds an individual’s dignity and autonomy.
      


      Conclusion
      

      By adopting inclusive, neuro-affirming approaches, pharmacists strengthen equity, accessibility and person-centredness within healthcare. In doing so, they uphold the profession’s commitment to compassionate, evidence-based practice and help ensure autistic Australians receive the respect, understanding and tailored support needed to achieve optimal health and wellbeing.
      


      


      


      Case scenario continued
      
Enzo’s mother discloses Enzo’s autism diagnosis and requests a quiet area and slower, step-by-step instructions. You offer a consultation room with dimmed lights, minimal visual clutter and no background noise. Enzo settles, visibly calmer.

In this adapted space, you employ person-centred strategies: a soft, steady voice; paced delivery; short, simple sentences; pauses after each point for processing; confirming understanding via yes/no questions or thumbs-up signals; and a clear, written handout with bullet points, icons (e.g. clock for bedtime), and appropriate font. Enzo engages, maintaining partial eye contact and nodding, while his mother clarifies. These modifications demonstrate empathy, flexibility and equitable care, minimising distress, enhancing information access and supporting Enzo’s autonomy.      		

      
      

      
[cpd_submit_answer_button]

      Key points
      

        
 	
      • Shift to a neuro-affirming social model – pharmacists must transition to a social model that fosters neuro-affirming environments and services.
        • 
 	
      • Use clear and visual communication – use straightforward, unambiguous language, present information in small, logical steps, and utilise visual supports to reinforce verbal explanations.
        • 
 	
      • Ensure environmental accessibility – acknowledge sensory differences and offer calm, quiet spaces to reduce sensory overload.
        • 
 	
      • Pharmacists should act as an integrative care link within multidisciplinary teams – bridging care gaps for individuals and families.
        • 
 	
      • Manage comorbidity holistically – apply pharmacological expertise to manage physical, psychiatric and neurodevelopmental health.
        • 
 	
      • Correct misinformation – deliver evidence-based information, empathetically, compassionately and respectfully.
        • 

      

      Our author
      

      Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism is an accredited clinical pharmacist with over 20 years’ experience across aged care, consultancy, community pharmacy and hospital pharmacy. In 2020, she launched The Spectrum Pharmacist to increase awareness, promote inclusion, and provide education and support for neurodevelopmental disorders.
      


      Our Reviewer
      

      Victor Senescall (he/him) BPharm (Hons)
      


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        Lai M-C, Kassee C, Besney R, et al. Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. Lancet Psychiatry. 2019;6(10):819–829.
        

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        Mazurek MO, Sadikova E, Cheak-Zamora N, et al. Health care needs, experiences, and perspectives of autistic adults. Autism Adulthood. 2023;5(1):51–62.
        

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        Barlattani T, D'Amelio C, Cavatassi A, et al. Autism spectrum disorders and psychiatric comorbidities: a narrative review. J Psychopathol. 2023;29(1):3–24.
        

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        Blair J. Diagnostic overshadowing: see beyond the diagnosis. 2017. Available from: www.intellectualdisability.info/changing-values/diagnostic-overshadowing-see-beyond-the-diagnosis
        

        30. 
 	
      30. 

        Al-Beltagi M. Autism medical comorbidities. World J Clin Pediatr. 2021;10(3):15–28.
        

        31. 
 	
      31. 

        Sung Y-S, Loh SC, Lin L-Y. Physical activity and motor performance: a comparison between young children with and without autism spectrum disorder. Neuropsychiatr Dis Treat. 2021;17:3743–3751.
        

        32. 
 	
      32. 

        Turner M. The role of drugs in the treatment of autism. Aust Prescr. 2020;43:185–190.
        

        33. 
 	
      33. 

        Mayo Clinic. Autism spectrum disorder. 2025. Available from: www.mayoclinic.org/diseases-conditions/autism-spectrum-disorder/diagnosis-treatment/drc-20352934
        

        34. 
 	
      34. 

        Di Pietrantonj C, Rivetti A, Marchione P, et al. Vaccines for measles, mumps, rubella, and varicella in children. Cochrane Database Syst Rev. 2021;(11):CD004407.
        

        35. 
 	
      35. 

        Wong A, Frye RE, Ohnemus-Kawamura B, et al. Cerebral folate deficiency. 2019. Available from: https://rarediseases.org/rare-diseases/cerebral-folate-deficiency/
        

        36. 
 	
      36. 

        Ramaekers VTH, Quadros EV. Cerebral folate deficiency syndrome: early diagnosis, intervention and treatment strategies. Nutrients. 2022;14(15):3096.
        

        37. 
 	
      37. 

        Sheppeard A. What is leucovorin, and can it cure autism? 2025. Available from: www.medicalrepublic.com.au/what-is-leucovorin-and-can-it-cure-autism/120175
        

        38. 
 	
      38. 

        Norris JE, Milton D, Heasman B. Adapting communication with autistic service users: a participatory study. Autism. 2024.
        

        39. 
 	
      39. 

        National Autistic Society. Repeated movements and behaviour (stimming). 2026. Available from: www.autism.org.uk/advice-and-guidance/topics/about-autism/repeated-movements-and-behaviour-stimming
        

        40. 
 	
      40. 

        National Autistic Society. Autism and communication. 2024. Available from: www.autism.org.uk/advice-and-guidance/topics/about-autism/autism-and-communication
        

        41. 

      
            [post_title] => Pharmacy’s neuro-affirming approach to autism
            [post_excerpt] => By adopting neuro-affirming approaches pharmacists can reduce barriers to deliver more personalised care to autistic individuals.
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      Pharmacy’s neuro-affirming approach to autism

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            [post_content] => As fuel costs climb and shortages loom, community pharmacies are facing mounting uncertainty on supply chains, workforce mobility, and equitable patient access.

Fuel shortages and escalating petrol costs are emerging as a significant disruptor for Australian workforces – including pharmacists, with exposure to the downstream impacts  potentially affecting medicines delivery, patient access to care and workforce logistics.

      


      
Addressing the national fuel crisis

        
 	
      • A National Cabinet was held on Monday (30 March), with Prime Minister Anthony Albanese announcing a four-step National Security Plan. We are currently at stage two, which involves localised fuel disruptions.
        • 
 	
      • Fuel excise will be halved for 3 months to address this, which will lower the cost of petrol by $0.26/L.
        • 
 	
      • The heavy vehicle road user charge will also be removed for 3 months.
        • 
 	
      • Stage three of the plan will incorporate collective fuel reduction through measures such as working from home, while stage four will involve a stricter set of rules to protect crucial services. 
        • 

      
      		

      
      

      
Ongoing geopolitical tensions in the Middle East stemming from the US-Israel war with Iran have taken the shape of catastrophic implications, driving global energy instability, including exacerbated cost-of-living effects, leaving essential sectors in vulnerable positions.

AP looks at the potential impacts on pharmacists and patients.

      Workforce pain and travel relief
      
Workforce mobility may be constrained as rising fuel shortages complicate staff travel. While some jurisdictions are offering relief, others are holding firm. 

Tasmania has announced that public transport will be free for the next 3 months, saving commuters between $20 and $88 per week. 

In Victoria, all public transport will be free until after April. ‘This is a temporary measure to help with the cost of living; it will take pressure off the pump and help you save,’ Premier Jacinta Allan stated.

However, public transport is usually not a straightforward option for much of the pharmacy workforce due to after-hours shifts, indirect public transport options or family commitments. And in regional and remote areas, commuter public transport is usually non-existent.

      

      Supply and delivery of medicines
      
Vital delivery providers, including Australia Post and StarTrack, have already increased surcharges – signaling the beginning of broader cost increases. For community pharmacies, this is likely to increase the price of medicines delivery and postage costs for consumers.

Liz de Somer, CEO of Medicines Australia said, ‘The fact that Australia is in a difficult geographical location presents some challenges. As we know, medicines are part of our national security, so it is having an impact on the industry’s costs and an ability to bring medicines to Australia, however … they’re doing everything in their power to ensure the supplies are available.’ 

Ryan Collins, Operations Manager at OTC distributor Be Med told AP, reflecting that wholesalers are, ‘already feeling the pressure through higher freight charges and fuel levies, which are starting to squeeze margins’.

‘If oil prices keep climbing, we expect suppliers to pass on cost increases, meaning higher landed costs for us. There’s also concern around longer lead times if transport capacity tightens,’ he said.

Price increases are also significantly impacting delivery schedules, meaning pharmacists might need to consider how and when they order medicines.

‘Although deliveries are still running, we're seeing less flexibility from carriers,’ Mr Collins  told AP.

‘Some routes are being consolidated, and delivery windows are getting tighter. We’re preparing for potential reductions in frequency if costs continue to rise. 

‘We’re [also] starting to notice more cautious ordering from customers, with some stocking up earlier to avoid future price increases. We expect availability to become less predictable if conditions worsen.’

In terms of equity, Mr Collins said that regional areas are more exposed. 

‘Freight costs are higher, and service levels are more likely to be affected. We’re managing this by planning orders more carefully, encouraging earlier ordering, and trying to consolidate deliveries where possible to keep costs down,’ he said.

‘We’re already having to pass on freight costs from 1 April, as they’ve become impossible for us to absorb. Beyond that, we’re looking at increasing safety stock on key lines, reviewing supplier options, and prioritising essential products.’

      Impacts on medicines review services
      
Fuel pressures are also placing stress on Home Medicines Review (HMR) services, potentially placing vulnerable patients at risk, which would flow directly down the line to pressures on our hospital system.

These challenges are felt acutely in regional areas where long travel distances are commonplace, and staff-mobility is restricted for essential at-home services, which poses challenges for  equity and continuity of care. 

The PSA has called for greater access to services to ensure patients receive care and pharmacists are able to deliver services to patients who are unable to travel, enhancing access for those in a compromised position.

‘We need to see some [changes] in service delivery, such as bringing back telehealth,’ PSA’s Head of Policy and Strategy Chris Campbell FPS said.

PSA National President Professor Mark Naunton MPS agreed, emphasising that patients need and deserve timely, trusted care. ‘That is our highest priority. We can’t have patients languishing or, worst case, dying on waiting lists. Telehealth solves this instantly,’ he said.

‘Telehealth is one of the most equitable measures we have to deliver HMRs to Australians no matter where they live. It ensures that someone in a regional or remote community or even in a metropolitan area is not penalised simply because of their postcode.

Telehealth also keeps pharmacists safe by eliminating the need for them to drive long distances, especially during the current petrol crisis, Prof Naunton said.

‘Pharmacists in regional areas know this better than most, we have real workforce issues to contend with and telehealth is an excellent option that does not compromise patient wellbeing,’ he said.

‘We are clearly in a petrol-related crisis now that is bringing its own immediate pressures but as pharmacists we are regularly dealing with problems accessing patients, be it natural disasters like flooding or bushfires to questions of road access and safety.’

PSA’s 2026–27 Federal Budget Submission, released 25 February 2026, identifies reform of HMRs, including telehealth flexibility, as a priority under the First Pharmacy Programs Reform Package.
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      Fuel shortages pose emerging risks for pharmacy

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            [post_content] => New avenues for nurse prescribing have the potential to reshape frontline care. For pharmacists, it’s a live example of how scope expansion translates into real impact.

Nurse prescribing is entering a new phase in Australia, and pharmacists should be paying close attention. 

While nurse practitioners and endorsed midwives have been able to prescribe Pharmaceutical Benefits Schedule (PBS) subsidised medicines since 2010, a new pathway will soon expand prescribing to a broader group of experienced nurses.

‘A lot of people wouldn't even know that nurses are already prescribing medications that are funded on the PBS,’ said Denise Lyons, President of the Australian Primary Health Care Nurses Association. ‘But there are more than 3,000 nurse practitioners and endorsed midwives in Australia now who are already prescribing.’

Under a new registration standard which came into effect in September last year, suitably qualified registered nurses will be able to prescribe medicines in Schedules 2, 3, 4 and 8 in partnership with an authorised prescriber.

‘It took until this year for universities to start the course that enables registered nurses to meet [the new standard],’ Ms Lyons said. ‘Most are 6-month postgraduate courses … So it will probably be around July 2026 that we will see the first [wave] of nurses completing the educational requirement.’

For pharmacists, this shift offers a live view of how prescribing reform is built – through legislation, governance, defined scope and, crucially, access to the PBS.

      What’s changing?
      
The new framework is deliberately cautious. To become a designated RN prescriber, a nurse must: 

        
 	
      • complete postgraduate training
        • 
 	
      • have significant prior clinical experience
        • 
 	
      • work within an agreed clinical governance framework with an authorised health practitioner under an active prescribing agreement
        • 
 	
      • complete a 6-month period of clinical mentorship.
        • 

      
 The written prescribing agreement with an authorised prescriber remains in place beyond the initial mentorship period.

‘An authorised prescriber could be a nurse practitioner, endorsed midwife, or it could be a GP,’ Ms Lyons said. ‘And that prescribing agreement is going to articulate what medications are within scope.

‘For example, say you had a registered nurse who has been working in paediatrics [throughout their] career… [They’re] going to be educated and competent to prescribe for some childhood illnesses, so that would be within [their] scope.’

For patients, expanded nurse prescribing could mean faster access to medicines, fewer delays for routine care and less reliance on GP availability.

‘You think about the amount of care that nurses deliver around [things like] aged care, palliative care, community care and sexual health,’ Ms Lyons said. 

‘There's a lot of work done in the community by registered nurses who have a lot of knowledge and experience. And this is going to be a mechanism that lets them use that knowledge and experience in a really helpful way.’

Expanded nurse prescribing will be especially valuable in rural and remote communities, aged care and other underserved settings where nurses are often the main point of contact but medical access can be patchy, she added.

      ‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place.'

denise lyons 
      

      PBS access is the make-or-break issue
      
While the regulatory framework and training pathway are now largely in place, the biggest unresolved issue is PBS access. Nurse practitioners and endorsed midwives already have it. Designated RN prescribers do not – yet.

Without PBS access, nurses may be able to issue prescriptions, but patients would still face out-of-pocket costs that undermine the practical value of the reform.

However, federal legislation now before the Senate would amend the National Health Act 1953 to allow designated RN prescribers to prescribe PBS-subsidised medicines. 

‘We're really hoping the Bill comes through the Senate with no amendments and that it passes into legislation,’ Ms Lyons said. ‘If we don't manage to get access, and the subsidies on the PBS lag behind practice, that will be a real barrier.’ 

Ms Lyons also highlighted the need for national coordination. State and territory variations in drugs and poisons legislation create confusion for both clinicians and patients, as pharmacists know all too well.

‘The work that's being done to harmonise [that] legislation across the states and territories is going to be really important, and we need to all work on that together,’ she said.

      Implications for pharmacists
      
As nurse prescribing expands, pharmacists are likely to see more prescriptions coming from a wider mix of clinicians, potentially changing how care is coordinated in everyday practice.

Rather than care sitting primarily with a single prescriber, it will increasingly be shared across a team – with nurses assessing, prescribing and monitoring within their scope, and pharmacists supporting safe and effective medicines use.

That means collaboration needs to be more deliberate, Ms Lyons said.

‘With quality use of medicines, there [need to be] clear principles around closed-loop communication, agreed-upon goals, rapid feedback on issues and shared protocols,’ she said.

The progress of the nurse prescribing model also provides a useful advocacy roadmap. The model has gained traction by focusing on what it delivers for patients – faster access, fewer delays and more complete care at the point of contact. 

That focus is particularly relevant in pharmacy, where prescribing arrangements currently vary by state and territory, and where the absence of PBS access continues to limit how much patients can benefit.

Like nurse prescribing, expanded pharmacist prescribing will only be truly effective if it’s consistent, supported by clear frameworks and enables affordable access for patients.

‘Pharmacists and nurses are often people's first point of contact with the healthcare system, and it's really good if we can work to the top of our scope and do what we know we can do, with the right guardrails in place,’ Ms Lyons said.
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      Case scenario
      

      Sarah, a 42-year-old woman, presents to the pharmacy reporting a small lump near the anus, occasional bright red bleeding on toilet paper after bowel movements, anal itching and discomfort. She mentions feeling embarrassed to seek advice and has been self-managing with sitz baths. She reports a history of chronic constipation with frequent training during defecation. She is not taking any regular medicines and requests an over-the-counter product to relieve her symptoms. You take the time to explore Sarah’s symptoms in more detail, to help identify any red flags that would require immediate referral. You ask about the duration, severity and other symptoms such as fatigue, unintentional weight loss and changes in bowel habits, all of which she denies.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the classification and causes of anal fissures and haemorrhoids
        • 
 	
      • Identify the clinical features of anal fissures and haemorrhoids
        • 
 	
      • Discuss management strategies for anal fissures and haemorrhoids
        • 
 	
      • Describe the pharmacist’s role in supporting individuals with anal fissures and haemorrhoids.
        • 

      
Competency (2016) standards addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Accreditation code: PSAAP2604HQ

Accreditation expiry: 31/03/2028

Accreditation points: Up to 1 Group 2 CPD      		

      
      

      
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Epidemiology 
      

      Anal fissures and haemorrhoids are commonly encountered, but their epidemiology is not well documented. Haemorrhoids represent the most frequent reason for proctology consultations, followed by anal fissures.1 Haemorrhoids are estimated to affect up to 40% of adults in the general population, although many individuals are asymptomatic.2 Anal fissures occur in approximately 10–15% of the population.3 
      


      

      Aetiology and pathophysiology
      

      An anal fissure is a longitudinal tear in the anal canal, most often occurring in the posterior midline, just below the dentate line.4 Anal fissures are typically classified as primary or secondary, depending on the cause. Primary fissures are usually benign and caused by local trauma, such as the passage of hard stools, prolonged diarrhoea, vaginal delivery, repeated injury or anal penetration.4 Secondary fissures, which are often multiple and located off the midline, are uncommon, accounting for less than 1% of cases.5 They result from underlying conditions like previous anal surgery, inflammatory bowel disease (e.g. Crohn’s disease), colorectal malignancy, infections (e.g. HIV/AIDS), or dermatological conditions (e.g. psoriasis).6 Anal fissures are further described as acute or chronic, with chronic fissures lasting more than 6 weeks.7 
      


[caption id="attachment_31774" align="alignright" width="200"] DR 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.[/caption]

      Anal fissures are often mistaken for haemorrhoids because of their overlapping symptoms. Haemorrhoids differ in that they are normal vascular cushions within the anal canal that maintain continence. Although part of normal anatomy, the term ‘haemorrhoid’ is commonly used when these vascular anal cushions, containing a rich arteriovenous network, become enlarged or displaced.8 Haemorrhoids may be classified as internal (located above the dentate line) or external (located below the dentate line). Factors such as constipation, straining during bowel movements and a low-fibre diet are commonly considered to increase the risk of haemorrhoids.9,10 However, the causal relationship between these factors and the development of haemorrhoids remains unclear. A possible genetic component that predisposes to smooth muscle, epithelial and connective tissue dysfunction, may contribute to haemorrhoids.11
      

      It is important to note that certain medicines can contribute to or worsen constipation as an adverse effect, thereby aggravating haemorrhoids and anal fissures.9,10 Common examples include opioids, anticholinergics, and iron and calcium supplements.12 Regular medication review should be incorporated into comprehensive care to identify opportunities for deprescribing and prevent inappropriate prescribing cascades, with further guidance available in the new deprescribing guidelines.13
      


      Clinical features 
      

      The symptoms of haemorrhoids may include rectal bleeding, anal pruritus, prolapse, faecal seepage and mucus discharge.7 
      

      Internal haemorrhoids are usually painless because the columnar epithelium is insensitive to touch and temperature.8 In contrast, external haemorrhoids are pain sensitive and may become thrombosed, often following straining during defecation.8 
      

      Anal fissures, by comparison, typically cause severe tearing pain that is provoked by defecation.4 A key distinguishing feature is that the pain of an anal fissure typically occurs during or immediately after defecation.
      


      

      Diagnosis and differential diagnoses 
      

      For diagnostic purposes, medical practitioners perform a physical examination with the individual lying on their side, gently parting the buttocks to inspect the posterior midline.4 Several other anorectal disorders may present with similar symptoms to anal fissures and haemorrhoids. Differential diagnoses include anal fistula and solitary rectal ulcer syndrome, which can often be distinguished based on their clinical appearance through careful physical examination. An anal fistula typically presents as a draining skin punctum.14 It is an abnormal hollow tract, most often arising from infection of an anal gland.15 Solitary rectal ulcer syndrome may present with anal pain, rectal bleeding, constipation, mucus discharge, excessive straining and a sensation of incomplete evacuation. Despite its name, the condition does not always involve an ulcer. Diagnosis requires a combination of endoscopic and histopathological findings, together with the individual’s reported symptoms.16
      


      Management approaches 
      

      Haemorrhoids
      


[caption id="attachment_31775" align="alignright" width="200"] Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).[/caption]

      Non-pharmacological treatment options
      

      First-line management for haemorrhoids usually involves lifestyle measures, which include ensuring adequate fluid and fibre intake, reducing prolonged time on the toilet and avoiding excessive straining, the use of sitz baths, and maintaining anal hygiene.10 In practice, dietary and lifestyle modifications are usually recommended as a conservative and preventive measure for haemorrhoids.17
      

      Pharmacological treatment options
      

      Over-the-counter therapies for internal haemorrhoids include ointments and suppositories that contain emollients, mild astringents, local anaesthetics and/or corticosteroids.8 These preparations temporarily relieve itching and discomfort. Prolonged use of topical corticosteroids is not recommended, as it increases the risk of local infections such as candidiasis.8 Similarly, prolonged use of anaesthetic-containing products should be avoided due to potential adverse effects, including skin sensitisation and dermatitis.8
      

      Outpatient procedures and surgery
      

      For individuals who do not respond to conservative measures, other treatment options for haemorrhoids include outpatient procedures and surgery.10 Outpatient procedures include rubber band ligation, infrared coagulation, bipolar probe, heater probe, sclerotherapy and cryotherapy.10 These are generally reserved for people with grade I or grade II haemorrhoids.10 Surgery can be considered for people who do not respond to or cannot tolerate outpatient procedures, as well as those with large external haemorrhoids, or combined internal and external haemorrhoids with prolapse.10
      

      A recent meta-analysis found that surgical treatments, compared with conservative treatments, offer greater symptom relief, quicker recovery and lower recurrence rates.18 However, they do carry risks of procedure-related complications. In contrast, conservative treatments are safer and less invasive, but tend to provide slower symptom improvement and have higher recurrence rates.18 Therefore, treatment decisions should be individualised, taking into account symptom severity, individual preferences and risk tolerance.
      

      Anal fissures
      

      The primary aim of treatment for anal fissures is to reduce anal sphincter spasm, improve blood flow and promote healing.6 First-line management is usually non-operative and includes increasing dietary fibre, use of sitz baths and applying glyceryl trinitrate 0.2% ointment, three times daily for up to 4 weeks to relieve pain.19 Headache is a common adverse effect of glyceryl trinitrate due to systemic absorption, which could limit its use.20 Other topical agents used in clinical practice include lidocaine and hydrocortisone, although these are less effective than a combination of fibre intake and warm sitz baths.4 
      

      Botulinum toxin injections may also be considered and can achieve good healing rates.6,19 However, botulinum toxin may cause temporary reduced control of wind or bowel motions, which usually resolves as the effect of the injection wears off.4 Due to these adverse effects and the invasive nature of the procedure, botulinum toxin is generally reserved as a second-line therapy.4 If these treatment options are unsuccessful, surgical treatment may
be required.6
      

      Secondary or chronic anal fissures warrant additional investigation and multidisciplinary management is advised, especially when malignancy is suspected or confirmed.4 
      


      Knowledge to practice 
      

      Pharmacists play a key role in recognising the symptoms of haemorrhoids and anal fissures, providing timely advice and suggesting a suitable course of action. Pharmacists can also educate individuals on first-line management strategies and provide lifestyle advice where appropriate to prevent recurrence. In addition, pharmacists can advocate for the safe use of over-the-counter treatments, advise on appropriate duration of use and counsel individuals on potential adverse effects.
      

      Referral to a medical practitioner is advisable for individuals who21:
      


        
 	
      • do not respond to over-the-counter medicines and lifestyle changes
        • 
 	
      • have recent changes in bowel habits or
        • 
 	
      • have other co-existing signs and symptoms, including unexplained weight loss and fatigue.
        • 

      

      Conclusion
      

      Anal fissures and haemorrhoids are common conditions encountered in primary care and can greatly impact quality of life. Pharmacists play a critical role in early management and referral, helping prevent complications and improve outcomes.
      


      


      


      Case scenario continued
      
You identify that Sarah has haemorrhoids and provide lifestyle advice, including increasing fluid and dietary fibre intake, avoiding prolonged straining during bowel movements and practising good anal hygiene. For symptomatic relief, you suggest a topical ointment containing cinchocaine 0.5% and zinc oxide 20%, to be applied as needed. You also advise her to consult her general practitioner if she experiences persistent bleeding, ongoing pain or worsening prolapse. With your support and advice, Sarah feels more confident in managing her condition effectively while reducing the risk of recurrence.           		

      
      

      

      [cpd_submit_answer_button]
      


      Key points
      

        
 	
      • Anal fissures and haemorrhoids are common anorectal conditions with overlapping symptoms.
        • 
 	
      • Pain from an anal fissure typically occurs during or immediately after defecation, whereas haemorrhoids may cause itchiness or prolapse.
        • 
 	
      • Anal fissures usually result from trauma or constipation, while haemorrhoids arise from vascular engorgement.
        • 
 	
      • First-line management for both conditions includes conservative dietary and lifestyle measures, as well as topical treatment for symptomatic relief.
        • 
 	
      • Pharmacists can educate individuals on symptom relief, recommend appropriate treatments, advise preventive strategies and provide referrals when necessary.
        • 

      

      Our authors
      

      Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia (UWA).
      

      DR 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.
      


      Our Reviewer
      

      Manisha Pillai (she/her) BPharm
      


      References
      

        
 	
      1. 

        Higuero T. Update on the management of anal fissure. J Visc Surg. 2015;152(2 Suppl):S37–S43.
        

        2. 
 	
      2. 

        Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215–220.
        

        3. 
 	
      3. 

        Vitton V, Bouchard D, Guingand M, Higuero T. Treatment of anal fissures: results from a national survey on French practice. Clin Res Hepatol Gastroenterol. 2022;46(4):101821.
        

        4. 
 	
      4. 

        Schlichtemeier S, Engel A. Anal fissure. Aust Prescr. 2016;39(1):14–17.
        

        5. 
 	
      5. 

        Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg. 2011;24(1):22–30.
        

        6. 
 	
      6. 

        Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019;69(685):409–410.
        

        7. 
 	
      7. 

        Lyle V, Young C. Anal fissures: an update on treatment options. Aust J Gen Pract. 2024;53:33–35.
        

        8. 
 	
      8. 

        Therapeutic Guidelines Limited. Haemorrhoids. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        9. 
 	
      9. 

        Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009–2017.
        

        10. 
 	
      10. 

        Sandler RS, Peery AF. Rethinking what we know about hemorrhoids. Clin Gastroenterol Hepatol. 2019;17(1):8–15.
        

        11. 
 	
      11. 

        Zheng T, Ellinghaus D, Juzenas S, Cossais F, Burmeister G, Mayr G, et al. Genome-wide analysis of 944 133 individuals provides insights into the etiology of haemorrhoidal disease. Gut. 2021;70(8):1538–1549.
        

        12. 
 	
      12. 

        Therapeutic Guidelines Limited. Functional constipation in adults. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        13. 
 	
      13. 

        Quek HW, Reus X, Lee K, Etherton-Beer C, Page A; Guideline Development Group. Deprescribing in older people: a clinical practice guideline. Perth (WA): The University of Western Australia; 2025.
        

        14. 
 	
      14. 

        Stewart D. Anal fissure: clinical manifestations, diagnosis, prevention. UpToDate. 2025. Available from: https://www.uptodate.com/contents/anal-fissure-clinical-manifestations-diagnosis-prevention
        

        15. 
 	
      15. 

        Therapeutic Guidelines Limited. Anorectal abscess and fistula. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        16. 
 	
      16. 

        Sadeghi A, Biglari M, Forootan M, Adibi P. Solitary rectal ulcer syndrome: a narrative review. Middle East J Dig Dis. 2019;11(3):129–134.
        

        17. 
 	
      17. 

        Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist's view. World J Gastroenterol. 2015;21(31):9245–9252.
        

        18. 
 	
      18. 

        Quan L, Bai X, Cheng F, Chen J, Ma H, Wang P, et al. Comparison of efficacy and safety between surgical and conservative treatments for hemorrhoids: a meta-analysis. BMC Gastroenterol. 2025;25(1):492.
        

        19. 
 	
      19. 

        Therapeutic Guidelines Limited. Anal fissure. Melbourne: Therapeutic Guidelines Limited; 2022. Available from: https://www.tg.org.au
        

        20. 
 	
      20. 

        Australian Medicines Handbook Pty Ltd. Glyceryl trinitrate (rectal). Adelaide: Australian Medicines Handbook Pty Ltd; 2025. Available from: https://amhonline.amh.net.au/
        

        21. 
 	
      21. 

        Allen S. Haemorrhoids and anal fissures. S Afr Pharm J. 2008;75(5):36.
        

        22. 

      
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            [post_content] => Community pharmacies are often the first place people turn when something feels ‘off’. But as pharmacists know, many requests for over-the-counter medicines are more complex than they may initially seem.

AP took a look at some presentations which might signal hidden red flags.

      ‘I just want a multivitamin’
      
When people present to community pharmacies, they often arrive with a solution already in mind. For example, ‘I need a strong painkiller,’ ‘I just want a multivitamin,’ or ‘What do you have for nerve pain?’ 

Nearly always, consistent with professional standards, these invite an open ended question to uncover the rationale for the request

        
 	
      • ‘Tell me what’s been happening.’
        • 
 	
      • ‘What made you choose this product today?’
        • 
 	
      • ‘What symptoms are you hoping to improve?’
        • 

      
That multivitamin request might be because someone is worried about immunity – which should prompt a discussion about immunisation. It could also indicate someone is feeling lethargic, which might start a conversation to rule-out anaemia. Or it might indicate a wish to support someone not eating due to chemotherapy – which obviously prompts a very different and comprehensive discussion.

These open‑ended questions encourage people to share more without slowing workflow, and they help prevent anchoring on a self‑diagnosis that may not reflect the real issue.

[caption id="attachment_31745" align="alignright" width="256"] Gauri Godbole FPS[/caption]

      ‘What’s your strongest painkiller’
      
People often reveal more than they realise. A request for a ‘strong painkiller’ could just be the tip of the iceberg.

For example, peripheral neuropathy is more common than most people realise. It’s also caused by vitamin B6 toxicity from multiple B6‑containing products more often than considered.

So a conversation where you discuss how a painkiller request could actually signal neuropathy from long‑term use of multiple high‑dose multivitamins, energy supplements, or ‘nerve support’ products is critical. Without gentle questioning, the true cause can be easily missed.

There are plenty of other examples that frequently appear, including requests for:

        
 	
      • ‘Something stronger for pain’, which may reflect chronic pain escalation or medicines overuse.
        • 
 	
      • Medicines for diarrhoea, where ongoing or recurrent symptoms can suggest medicine-related adverse effects, infection, malabsorption, or laxative overuse.
        • 

      

        
 	
      • Sleep aids, which could be a sign of stress, grief, burnout or caregiver fatigue.
        • 

      
These small clues are easy to overlook. A simple, empathic, ‘That sounds uncomfortable; let’s take a closer look together’, will usually open the door to a more meaningful conversation.

      Normalising and reframing
      
Normalising language helps people feel safe discussing sensitive issues and reduces defensiveness when the requested product isn’t appropriate. For example:

        
 	
      • ‘Many people don’t realise that too much vitamin B6 can actually cause nerve pain symptoms. Let’s check what you’re already taking.’
        • 
 	
      • ‘A lot of rashes look similar; before choosing a cream, it’s worth making sure we’re treating the right thing.’
        • 

      
This reframes the interaction from a quick sale to a collaborative assessment.
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      Case scenario
      

      During peak hour, 19-year-old Enzo and his mother arrive to collect a new prescription for melatonin MR 2 mg. The pharmacy is highly stimulating: background music blares, customers converse loudly nearby, staff assist others in a cramped space, and general noise amplifies the chaos. While processing Enzo’s prescription and attempting to deliver verbal instructions, you observe Enzo avoiding eye contact, fidgeting intensely, and appearing overwhelmed, with reduced capacity to process verbal or non-verbal cues due to sensory overload.
      


      


      


      Learning objectives
      
After reading this article, pharmacists should be able to:

        
 	
      • Describe the current prevalence of autism in Australia 
        • 
 	
      • Describe current challenges and opportunities in supporting autistic people in pharmacy practice
        • 
 	
      • Discuss practice adjustments pharmacists can make and/or supports that can improve accessibility for autistic individuals 
        • 
 	
      • Address common myths and misinformation relating to autism that may be encountered in a pharmacy setting.
        • 

      
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.1, 2.2, 2.3, 3.1, 3.5, 3.6, 4.3

Accreditation number:  PSAAP2604YA

Accreditation expiry: 31/03/2028      		

      
      

      
 

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

      Introduction
      
[caption id="attachment_31687" align="alignright" width="300"] Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism[/caption]

      Neurodevelopmental disorders (NDDs) arise from differences in brain development and typically affect cognition, communication, behaviour and occupational functioning. Common NDDs include attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), referred to as autism in this article, and intellectual developmental disorder (IDD).1 Autism is characterised by persistent social interaction and communication difficulties and restricted behavioural patterns.2 Symptoms begin in early childhood; however, diagnosis can occur at any age.3 Autism affects how the brain processes information, shaping how autistic people see, understand and respond to the world around them, with marked variability in presentation, day-to-day functioning and support needs.3,4 
      

      In Australia, autism prevalence has increased due to evolving diagnostic practices and awareness,5 meaning pharmacists now routinely engage with autistic individuals as part of everyday practice. 
      

      The challenge and opportunity for pharmacy is to shift from a medical model of crisis response, treatments and cures to a neuro-affirming social model that helps autistic individuals thrive, not just survive. 
      

      A neuro-affirming social model conceptualises neurodevelopmental differences as natural variations within human diversity and rejects deficit-based assumptions that frame these differences as disorders.6 Rather than ‘correcting’ individual traits, this approach provides reasonable adjustments while supporting autonomy, community participation and wellbeing, alongside awareness of diagnostic criteria, comorbidities, communication styles, lived realities and the impact of misinformation.6 The shift to a neuro-affirming social model calls for reducing systemic and environmental barriers, while still addressing health needs.6,7 
      

      For pharmacists, it means making practice adjustments in the way that the profession engages with and provides support for autistic individuals. 
      


      Epidemiology 
      

      According to the Australian Bureau of Statistics, approximately 290,900 Australians (1.1%) are reported to have had an autism diagnosis in 2022.5 A recent estimate by Autism Spectrum Australia (Aspect) suggested at least 1 in 40 Australians are autistic.7
      

      Rising prevalence reflects improved awareness and diagnostic practices rather than a true increase in incidence, including better recognition in historically underdiagnosed groups such as females and older adults.7 Autism prevalence peaks in children and adolescents, particularly those aged 10–14 years, and is markedly lower in adults, acknowledging limited adult data.5,8,9 
      

      Autism prevalence rates may appear to vary among ethnic and cultural
groups, reflecting inequities such as access to healthcare, effective communication, diagnostic practices and cultural perceptions.10 
      

      Prevalence remains higher in males than females, with 1.6% of males identified compared with 0.7% of females, and the greatest disparity is seen in children aged 5–9 years.5 Autism in females is frequently underdiagnosed, as characteristics may manifest differently, be masked (e.g. forced eye contact, rehearsed social scripts, suppressing stimming or copying peers), or fail to align with historically male-centred diagnostic criteria, leading to misdiagnosis as mood or personality disorders.11,12 Masking may occur due to a desire to fit in, fear of stigma or bullying, previous negative reactions to autistic behaviours, and expectations of how females are ‘supposed’ to behave.12 Increasing awareness of the under-recognition of autism in females and gender-diverse individuals, and the social drivers of masking, is anticipated to influence future prevalence estimates.4,5,11
      


      Aetiology
      

      There is no single cause of autism, and despite extensive research, aetiology remains incompletely understood. Current evidence indicates autism arises from a complex interaction between genetic susceptibility and environmental influences on neurodevelopment.13
      

      Family history is one of the strongest predictors of autism.13,14 Researchers have identified hundreds of genes, with approximately 10–20% of cases associated with rare genetic variants arising from mutations in sperm or egg cells.14 Autism is considered polygenic, meaning overall risk typically reflects the cumulative effect of multiple inherited variants, each contributing a small effect.14 
      

      The expression of genetic susceptibility is known to be influenced by prenatal, perinatal and postnatal environmental factors.13 Environmental factors appear most relevant during the prenatal period.14 Modest associations have been reported between autism likelihood and maternal factors such as hypertension, gestational diabetes, obesity, alcohol and substance use, poor antenatal care, and infection or fever during pregnancy.15
      

      Imprecise and inconsistent associations have been reported for folate status, exposure to some air pollutants, and the use of some medicines.15–17 Importantly, these findings are largely derived from observational studies and are subject to confounding. While some prenatal medicine exposures show more consistent associations with autism, there is no clear   evidence that associations between autism and other environmental and medicine exposures represent a causal relationship, and any contribution to autism risk remains limited and uncertain.14,17  
      


      

      Diagnosis
      

      Autism is diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria: ‘persistent deficits in social communication and social interaction across multiple contexts’, with the presence of ‘restricted, repetitive patterns of behaviour, interests or activities’.2 
      

      ‘Symptoms must be present in the early development period’, although they may only become fully apparent later in life. 
      

      ‘Symptoms cause clinically significant impairment in social, occupational or other important areas of functioning’ and ‘these disturbances are not better explained by IDD’ although both can co-occur.2 The DSM-5-TR also specifies severity levels (1–3) to indicate the degree of support required.2
      

      In Australia, individuals may pursue an autism diagnosis through public or private pathways.18 Both are typically lengthy and necessitate a degree of health literacy and English proficiency. Diagnostic assessments may be conducted by a multidisciplinary team, including paediatricians, psychiatrists, psychologists, speech pathologists and occupational therapists.4 Multiple appointments may be needed, drawing on input from family, carers or teachers.18,19 
      

      Barriers to diagnosis include limited awareness of early signs among caregivers and clinicians, long wait times and out-of-pocket costs for specialist assessment, socioeconomic and geographic disparities, and bias in recognising diverse presentations.11,20,21 Limited health literacy and the complexity of navigating multidisciplinary assessments and National Disability Insurance Scheme requirements further impede access.21 In some communities, stigma, fear of labelling, and differing cultural interpretations of behaviour may delay help-seeking.22 
      

      A best-practice diagnostic approach should promote cultural safety and sensitivity, acknowledge variations in health literacy, address socioeconomic barriers, and be grounded in person-centred care.
      

      Autism is a spectrum, with each individual having a unique mix of strengths, challenges, interests, needs and way of interacting with the world. Autism advocate Dr Stephen Shore states, ‘If you have met one autistic person, you have met one autistic person’.23 
      


      Beyond the core features
      

      Comorbid NDDs, and psychiatric and medical conditions can create significant challenges for autistic individuals in relation to diagnosis, selection of appropriate interventions, medicines and support services.1,24 
      

      Comorbid NDDs among autistic individuals include ADHD, developmental coordination disorder (dyspraxia), IDD, and specific learning disorders such as dyslexia, dysgraphia and dyscalculia.25 Psychiatric comorbidities are also prevalent, including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder.26 These conditions can intensify social and sensory challenges, increase vulnerability to stress, and impair emotional regulation and executive functioning. 
      

      Autistic individuals experience higher rates and severity of mental and physical health comorbidities than neurotypical individuals. Neurodivergent mental health outcomes are influenced by the interaction between individual differences and environmental and societal factors.25–28 Diagnostic overshadowing, whereby mental health symptoms are erroneously attributed to autism, should be avoided.29 Comorbid conditions warrant assessment and treatment according to the same clinical standards applied to neurotypical individuals, with adaptations made to accommodate the communication, sensory and support needs of autistic people. Neurodivergent individuals experience the full range of medical comorbidities seen in the general population; however, research indicates higher prevalence of certain conditions, including gastrointestinal disorders (e.g. irritable bowel syndrome, chronic constipation), sleep disturbances, epilepsy, and immune or metabolic disorders.30 These conditions may worsen fatigue, concentration and mood regulation, while motor difficulties may contribute to musculoskeletal pain, reduced physical activity and secondary health issues.31 
      

      Physical health conditions may be underdiagnosed when the clinical focus is limited to behavioural or psychological symptoms.29 
      

      Recognising the complex interconnections between physical, psychiatric and NDD health is paramount. Pharmacists can play a vital role in this process. Effective care relies on health professionals working collaboratively to identify how comorbid conditions, treatment burden and medicines may influence behaviour, cognition and developmental outcomes. 
      


      Support and interventions   
      

      Autism is a lifelong NDD for which there is no curative treatment.4 Clinical care focuses on supporting health, functioning and community participation, addressing comorbidities, and optimising quality of life, while recognising and respecting the individual strengths, capabilities and perspectives of autistic individuals.3
      


      Non-pharmacological support
      

      Supports and interventions are individualised and typically involve a multidisciplinary team to address evolving needs.10 Allied health professionals may include speech pathologists to support communication, occupational therapists to address sensory processing and daily living skills, and psychologists to support emotional regulation and mental health. Physiotherapists may support gross motor skills, while dietitians support feeding and nutritional adequacy, alongside specialist educational support and therapy (e.g. play therapy, art therapy).3 Effective management relies on coordinated care, regular goal review and clear communication between the autistic individual, families and carers, and the multidisciplinary team.24
      


      Pharmacological support 
      

      There is no evidence to support the use of medicines, exclusion diets or other biological treatment for the core features of autism.32,33 To support comorbidities, psychotropic medicines, antiepileptics and sleep agents may be used short term and under specific circumstances. Off-label use is common and requires careful assessment of risk-benefit balance, adverse effects, formulation choice, monitoring, cumulative treatment
burden, and very careful consideration if the medicine is being prescribed as a
chemical restraint.4
      


      

      Myths and misconceptions
      

      Autism is subject to persistent myths that pharmacists may encounter. The most damaging is the long-debunked claim that vaccines cause autism.14 The retracted 1998 Lancet study by Andrew Wakefield that claimed a link between the measles, mumps, rubella (MMR) vaccine and autism was a small, flawed study (with only 12 participants) and was exposed for unethical processes, methodological misconduct, and undisclosed conflicts of interest.14 Despite retraction, its claims were (and continue to be) amplified, eroding trust in public health and fuelling vaccine hesitancy. A Cochrane review published in 2021 found no credible evidence of an association between MMR and MMRV vaccines and autism.34 
      

      Two medicines made headlines in 2025: paracetamol and leucovorin (folinic acid or calcium folinate) claimed as a cause and treatment of autism respectively. Antenatal paracetamol exposure was alleged to increase autism and ADHD risk; however, major studies have not demonstrated a causal relationship.9 Stronger evidence from a large Swedish population-based cohort of 2,480,797 children born between 1995 and 2019 found no association between paracetamol use during pregnancy and autism, ADHD or IDD in sibling-controlled analysis.16 Cerebral folate deficiency (CFD) has been reported in a subset of autistic individuals, related to impaired folate transport into the brain, and may be associated with symptoms of speech difficulties, seizures and IDD, often within early childhood.35,36 Leucovorin, a folinic acid derivative, has been investigated as a potential treatment for autistic children with CFD. Leucovorin can bypass impaired folate transport, increasing central nervous system folate availability.36 Although some small-scale trials indicate potential minor behavioural improvements, supporting evidence remains limited, inconsistent, and not independently replicated.15,37
      

      As medicines experts, pharmacists are well placed to counter common myths. Responses should prioritise empathetic, respectful communication and the provision of clear, evidence-based information and resources. 
      


      Knowledge to practice 
      

      Accessibility, strong communication skills, medicines expertise, understanding of health system navigation and ability to synthesise information, position pharmacists to provide continuity of care for autistic individuals. Pharmacists can serve as an integrative link within multidisciplinary teams, supporting autistic individuals and their families across the healthcare continuum. 
      


      Communication tips 
      

      Effective communication underpins person-centred pharmacy practice. Pharmacists supporting autistic individuals should adapt both verbal and non-verbal communication to meet diverse needs.38 Autism can influence communication and sensory processing in unique ways, with some individuals experiencing sensory sensitivities to sound, light, smell, touch and visual stimuli.3,4,33 Some autistic individuals regulate sensory input through stimming (self-stimulatory behaviour), which may present as repetitive movements or sounds such as fidgeting, rocking or hand-flapping.39 Flexibility, empathy and understanding of sensory needs ensure equitable access to healthcare and fosters the relationship between patient and pharmacist. Verbal communication with autistic individuals should be clear and structured. Pharmacists should use straightforward, unambiguous language and present information in small, logical steps, allowing time for processing and response. Offering a calm, quiet space can both minimise sensory overload and facilitate a more comfortable environment for communication.38,40 
      

      Non-verbal communication requires equal attention. Eye contact, facial expressions and gestures can carry unintended meaning for autistic individuals. Some avoid eye contact
as a coping mechanism, not as disinterest.38 Pharmacists should avoid assumptions and focus on open, calm body language and a reassuring tone. Visual supports can reinforce verbal explanations to provide ongoing reference, especially for individuals who process visual information more effectively than spoken language.40
      

      A person-centred approach requires pharmacists to recognise, respond and adapt to the communication preferences of each autistic individual. If a caregiver or support worker is present, collaboration should occur while directing communication towards the patient whenever possible.40 Empathy, flexibility and inclusive communication techniques ensure care that is respectful and accessible and upholds an individual’s dignity and autonomy.
      


      Conclusion
      

      By adopting inclusive, neuro-affirming approaches, pharmacists strengthen equity, accessibility and person-centredness within healthcare. In doing so, they uphold the profession’s commitment to compassionate, evidence-based practice and help ensure autistic Australians receive the respect, understanding and tailored support needed to achieve optimal health and wellbeing.
      


      


      


      Case scenario continued
      
Enzo’s mother discloses Enzo’s autism diagnosis and requests a quiet area and slower, step-by-step instructions. You offer a consultation room with dimmed lights, minimal visual clutter and no background noise. Enzo settles, visibly calmer.

In this adapted space, you employ person-centred strategies: a soft, steady voice; paced delivery; short, simple sentences; pauses after each point for processing; confirming understanding via yes/no questions or thumbs-up signals; and a clear, written handout with bullet points, icons (e.g. clock for bedtime), and appropriate font. Enzo engages, maintaining partial eye contact and nodding, while his mother clarifies. These modifications demonstrate empathy, flexibility and equitable care, minimising distress, enhancing information access and supporting Enzo’s autonomy.      		

      
      

      
[cpd_submit_answer_button]

      Key points
      

        
 	
      • Shift to a neuro-affirming social model – pharmacists must transition to a social model that fosters neuro-affirming environments and services.
        • 
 	
      • Use clear and visual communication – use straightforward, unambiguous language, present information in small, logical steps, and utilise visual supports to reinforce verbal explanations.
        • 
 	
      • Ensure environmental accessibility – acknowledge sensory differences and offer calm, quiet spaces to reduce sensory overload.
        • 
 	
      • Pharmacists should act as an integrative care link within multidisciplinary teams – bridging care gaps for individuals and families.
        • 
 	
      • Manage comorbidity holistically – apply pharmacological expertise to manage physical, psychiatric and neurodevelopmental health.
        • 
 	
      • Correct misinformation – deliver evidence-based information, empathetically, compassionately and respectfully.
        • 

      

      Our author
      

      Yvette Anderson (she/her) BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism is an accredited clinical pharmacist with over 20 years’ experience across aged care, consultancy, community pharmacy and hospital pharmacy. In 2020, she launched The Spectrum Pharmacist to increase awareness, promote inclusion, and provide education and support for neurodevelopmental disorders.
      


      Our Reviewer
      

      Victor Senescall (he/him) BPharm (Hons)
      


      References
      

        
 	
      1. 

        Merck Manual Professional Version. Overview of learning disorders. 2024. Available from: www.merckmanuals.com/professional/pediatrics/learning-and-developmental-disorders/overview-of-learning-disorders?query=neurodevelopment%20disorders
        

        2. 
 	
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        American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington (DC): American Psychiatric Publishing; 2022.
        

        3. 
 	
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        Merck Manual Professional Version. Autism spectrum disorder. 2025. Available from: www.merckmanuals.com/professional/pediatrics/learning-and-developmental-disorders/autism-spectrum-disorder
        

        4. 
 	
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        Therapeutic Guidelines. Autism spectrum disorder. Melbourne: Therapeutic Guidelines; 2021.
        

        5. 
 	
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        Australian Bureau of Statistics. Autism in Australia 2022. 2024. Available from: www.abs.gov.au/articles/autism-australia-2022
        

        6. 
 	
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        Bertilsdotter Rosqvist H, Pearson A, Pavlopoulou G, et al. The social model in autism research. Autism. 2025;29(9):2201–2204.
        

        7. 
 	
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        Autism Spectrum Australia. At least 1 in 40 Australians are autistic: new estimate by Aspect on World Autism Understanding Day. 2024. Available from: www.aspect.org.au/news/at-least-1-in-40-australians-are-autistic
        

        8. 
 	
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        Therapeutic Guidelines. Autism spectrum disorder. eTG complete. Melbourne: Therapeutic Guidelines; 2021.
        

        9. 
 	
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        Trollor J, Arnold S, Walker SE. Australian Longitudinal Study of Autism in Adulthood (ALSAA): final report. Brisbane: Autism CRC; 2022.
        

        10. 
 	
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        Rasheed Z. Autism in Australia: understanding, challenges, and support. Int J Health Sci. 2023;17(5):1–4.
        

        11. 
 	
      11. 

        Lai M-C, Amestoy A, Bishop S, et al. Improving autism identification and support for individuals assigned female at birth: clinical suggestions and research priorities. Lancet Child Adolesc Health. 2023;7(12):897–908.
        

        12. 
 	
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        National Autistic Society. Masking. 2026. Available from: www.autism.org.uk/advice-and-guidance/topics/behaviour/masking
        

        13. 
 	
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        Ostrowski J, Religioni U, Gellert B, et al. Autism spectrum disorders: etiology, epidemiology, and challenges for public health. Med Sci Monit. 2024;30.
        

        14. 
 	
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        Australian Academy of Health and Medical Sciences. Autism: an evidence brief. 2025. Available from: https://aahms.org/policy/evidence-brief-on-autism
        

        15. 
 	
      15. 

        Love C, Sominsky L, O'Hely M, et al. Prenatal environmental risk factors for autism spectrum disorder and their potential mechanisms. BMC Med. 2024;22.
        

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            [post_excerpt] => By adopting neuro-affirming approaches pharmacists can reduce barriers to deliver more personalised care to autistic individuals.
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      Pharmacy’s neuro-affirming approach to autism

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            [post_content] => As fuel costs climb and shortages loom, community pharmacies are facing mounting uncertainty on supply chains, workforce mobility, and equitable patient access.

Fuel shortages and escalating petrol costs are emerging as a significant disruptor for Australian workforces – including pharmacists, with exposure to the downstream impacts  potentially affecting medicines delivery, patient access to care and workforce logistics.

      


      
Addressing the national fuel crisis

        
 	
      • A National Cabinet was held on Monday (30 March), with Prime Minister Anthony Albanese announcing a four-step National Security Plan. We are currently at stage two, which involves localised fuel disruptions.
        • 
 	
      • Fuel excise will be halved for 3 months to address this, which will lower the cost of petrol by $0.26/L.
        • 
 	
      • The heavy vehicle road user charge will also be removed for 3 months.
        • 
 	
      • Stage three of the plan will incorporate collective fuel reduction through measures such as working from home, while stage four will involve a stricter set of rules to protect crucial services. 
        • 

      
      		

      
      

      
Ongoing geopolitical tensions in the Middle East stemming from the US-Israel war with Iran have taken the shape of catastrophic implications, driving global energy instability, including exacerbated cost-of-living effects, leaving essential sectors in vulnerable positions.

AP looks at the potential impacts on pharmacists and patients.

      Workforce pain and travel relief
      
Workforce mobility may be constrained as rising fuel shortages complicate staff travel. While some jurisdictions are offering relief, others are holding firm. 

Tasmania has announced that public transport will be free for the next 3 months, saving commuters between $20 and $88 per week. 

In Victoria, all public transport will be free until after April. ‘This is a temporary measure to help with the cost of living; it will take pressure off the pump and help you save,’ Premier Jacinta Allan stated.

However, public transport is usually not a straightforward option for much of the pharmacy workforce due to after-hours shifts, indirect public transport options or family commitments. And in regional and remote areas, commuter public transport is usually non-existent.

      

      Supply and delivery of medicines
      
Vital delivery providers, including Australia Post and StarTrack, have already increased surcharges – signaling the beginning of broader cost increases. For community pharmacies, this is likely to increase the price of medicines delivery and postage costs for consumers.

Liz de Somer, CEO of Medicines Australia said, ‘The fact that Australia is in a difficult geographical location presents some challenges. As we know, medicines are part of our national security, so it is having an impact on the industry’s costs and an ability to bring medicines to Australia, however … they’re doing everything in their power to ensure the supplies are available.’ 

Ryan Collins, Operations Manager at OTC distributor Be Med told AP, reflecting that wholesalers are, ‘already feeling the pressure through higher freight charges and fuel levies, which are starting to squeeze margins’.

‘If oil prices keep climbing, we expect suppliers to pass on cost increases, meaning higher landed costs for us. There’s also concern around longer lead times if transport capacity tightens,’ he said.

Price increases are also significantly impacting delivery schedules, meaning pharmacists might need to consider how and when they order medicines.

‘Although deliveries are still running, we're seeing less flexibility from carriers,’ Mr Collins  told AP.

‘Some routes are being consolidated, and delivery windows are getting tighter. We’re preparing for potential reductions in frequency if costs continue to rise. 

‘We’re [also] starting to notice more cautious ordering from customers, with some stocking up earlier to avoid future price increases. We expect availability to become less predictable if conditions worsen.’

In terms of equity, Mr Collins said that regional areas are more exposed. 

‘Freight costs are higher, and service levels are more likely to be affected. We’re managing this by planning orders more carefully, encouraging earlier ordering, and trying to consolidate deliveries where possible to keep costs down,’ he said.

‘We’re already having to pass on freight costs from 1 April, as they’ve become impossible for us to absorb. Beyond that, we’re looking at increasing safety stock on key lines, reviewing supplier options, and prioritising essential products.’

      Impacts on medicines review services
      
Fuel pressures are also placing stress on Home Medicines Review (HMR) services, potentially placing vulnerable patients at risk, which would flow directly down the line to pressures on our hospital system.

These challenges are felt acutely in regional areas where long travel distances are commonplace, and staff-mobility is restricted for essential at-home services, which poses challenges for  equity and continuity of care. 

The PSA has called for greater access to services to ensure patients receive care and pharmacists are able to deliver services to patients who are unable to travel, enhancing access for those in a compromised position.

‘We need to see some [changes] in service delivery, such as bringing back telehealth,’ PSA’s Head of Policy and Strategy Chris Campbell FPS said.

PSA National President Professor Mark Naunton MPS agreed, emphasising that patients need and deserve timely, trusted care. ‘That is our highest priority. We can’t have patients languishing or, worst case, dying on waiting lists. Telehealth solves this instantly,’ he said.

‘Telehealth is one of the most equitable measures we have to deliver HMRs to Australians no matter where they live. It ensures that someone in a regional or remote community or even in a metropolitan area is not penalised simply because of their postcode.

Telehealth also keeps pharmacists safe by eliminating the need for them to drive long distances, especially during the current petrol crisis, Prof Naunton said.

‘Pharmacists in regional areas know this better than most, we have real workforce issues to contend with and telehealth is an excellent option that does not compromise patient wellbeing,’ he said.

‘We are clearly in a petrol-related crisis now that is bringing its own immediate pressures but as pharmacists we are regularly dealing with problems accessing patients, be it natural disasters like flooding or bushfires to questions of road access and safety.’

PSA’s 2026–27 Federal Budget Submission, released 25 February 2026, identifies reform of HMRs, including telehealth flexibility, as a priority under the First Pharmacy Programs Reform Package.
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      Fuel shortages pose emerging risks for pharmacy

AUSTRALIAN PHARMACIST Australian Pharmacist
Home People Pharmacists shine at the PSA19 Gala Dinner

Pharmacists shine at the PSA19 Gala Dinner

People
By
Ruth Cooper
-
29 July 2019
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Gala Dinner

The social highlight of the annual PSA conference is the Gala Dinner, and this year certainly did not disappoint.

  • Gala Dinner
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