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[post_content] => Pharmacists are asked to lead the shift from reliever-only inhalers to inhaled corticosteroid-containing regimens and to minimise short courses of oral corticosteroids.
Just under 3 million Australians live with asthma. The condition has the eighth-highest disease burden in the nation, and it is one of the most significant chronic conditions in children.
Guided by the results of large trials, recommendations for asthma management in adults and adolescents are changing, and pharmacists need to be aware of updated guidelines. The Australian Asthma Handbook was updated yesterday (16 September 2025) to reflect new thinking on asthma care and management.
What are the key updates?
Three key changes have been made to the Australian Asthma Handbook, including:
-
- All adults and adolescents with confirmed asthma should be taking inhaled corticosteroid-containing treatment and not as-needed short-acting beta2-agonists (SABAs) alone. Asthma can be well controlled with maintenance and reliever therapy, and a small proportion of patients with severe asthma may be eligible for biologics.
- An emphasis on the importance of limiting oral corticosteroids, which have been associated with a range of different harms, including damage to bone health, cataracts and type 2 diabetes.
- Health professionals should be aware the handbook has greater guidance for treating children aged 1–5 who are living with asthma and a recommendation that some older children should also be on low-dosage ICS maintenance therapy.
Why have the guidelines been updated?
Overuse of SABAs has been linked to poor asthma control and preventable hospitalisations.
‘The evidence is that the risks of SABA alone have become clearer and that we were overusing a not very effective and not very safe therapy,’ said Professor Nick Zwar, Executive Dean of Bond University’s Faculty of Health Sciences and Medicine, and Chair of the Australian Asthma Handbook Guidelines Committee.
‘Budesonide-formoterol, taken only as needed, is recommended in place of SABA. Maintenance and reliever therapy is now recommended as the next step up.’
The risks of SABA overuse include a lack of bronchodilator response over time, and the possibility that some people may have quite a severe asthma attack and end up in the hospital emergency department (ED), or hospitalised, when they don’t need to be.
There is very strong evidence to demonstrate that all adolescents and adults living with asthma should be treated with ICS, said pharmacist and Clinical Executive Lead at the National Asthma Council Australia, Debbie Rigby FPS.
‘Just having the SABA alone only treats one component of asthma, which is the bronchoconstriction, whereas having the low-dose ICS helps manage the inflammation and mucus production,’ she said. ‘I think that’s the biggest shift for us, pharmacists and doctors: helping patients to understand that asthma is a chronic inflammatory condition.’
What are the risks of poor asthma control?
Inadequately managed asthma can be a life-threatening condition, Ms Rigby stressed, noting there were 474 asthma-related deaths in Australia in 2023.
‘Those deaths shouldn’t be happening. Many of those people who did die from asthma or asthma-related causes would have been perceived as having mild, intermittent symptoms,’ she said. ‘Without wanting to scare patients, we should be really highlighting the consequences of not having good control of their asthma.’
Why is SABA still overused?
Despite access to long-acting beta2 agonists (ICS–LABAs), SABA use remains high for a range of reasons. These include cost, convenience and patient reluctance to medicate every day when they are accustomed to using a reliever-only when they have an asthma attack, Ms Rigby said.
Health professionals understand that many people are reluctant to use a preventer inhaler, but health professionals need to help them understand that they have a ‘chronic inflammatory condition, which may flare up from time to time’.
Effects of the cost-of-living crisis should not be underestimated either. However, the price gap between over-the-counter salbutamol and prescription asthma medicines is now narrowing, with 60-day dispensing for patients who are stable and, from January 2026, the co-payment for medicines being reduced from $31.60 to $25 per prescription.
The Australian uptake of Maintenance and Reliever Therapy (MART) has also been slow, despite strong evidence and subsidy on the Pharmaceutical Benefits Scheme. The evidence of large-scale trials has shown the importance of shifting patients with mild asthma onto anti-inflammatory reliever therapy on an as-needed basis, Ms Rigby said.
‘The evidence basically says it reduces the risk of severe exacerbations requiring ED or hospitalisation, or requiring oral corticosteroids,’ she said.
For practical guidance on discussing the guideline changes with patients, the role of prescribing pharmacists, and how biologics fit into care, don’t miss the October cover story in Australian Pharmacist.
[post_title] => New asthma guidelines released
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[post_content] => Case scenario
Ashley, a 23-year-old female, presents to your pharmacy with a prescription for a 7-day course of doxycycline 100 mg twice daily. She tells you she has had some mild vaginal discharge and that her STI screen has come back positive for vaginal chlamydia. You establish that she is currently taking ferrous sulfate 325 mg once daily as she is vegan, isotretinoin 30 mg once daily for acne, and has an etonogestrel implant in situ. She has no
known allergies.
Note: The authors recognise that gender identity is fluid. In this article, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Chlamydia and gonorrhoea are two of the most prevalent bacterial sexually transmitted infections (STIs) globally.1,2 They are preventable and curable infections that are usually transmitted through vaginal, oral or anal sex.1,2 Conjunctival infection can occur in neonates born to mothers carrying a chlamydia or gonorrhoea infection, or in adults via exposure to genital secretions.1–4 Both chlamydia and gonorrhoea can lead to serious health complications if left untreated, ranging from effects on fertility and pregnancy to blindness (in untreated ocular gonorrhoea infection).1,2
Chlamydia is caused by the gram-negative bacterium Chlamydia trachomatis.2 Gonorrhoea is caused by the gram-negative bacterium Neisseria gonorrhoeae.1
Chlamydia is relatively simple to treat, being susceptible to doxycycline and azithromycin.5 Gonorrhoea treatment may be more challenging due to emerging antimicrobial resistance to first-line treatments, particularly in urban Australia.6 All people diagnosed with chlamydia and gonorrhoea should be offered antibiotic treatment to resolve symptoms, prevent complications and to decrease transmission to others.1,2
Pharmacists can support patients by providing information on safe-sex practices, any prescribed medicines, in addition to providing advice or referring where appropriate.
The World Health Organization (WHO) estimates there were around 128.5 million new infections with C. trachomatis in 2020 among adults aged 15–49 years globally.2 In Australia, those under 30 years of age are at greatest risk of infection.5 There were 102,222* cases of chlamydia notified to the Australian government’s National Notifiable Diseases Surveillance System (NNDSS) in 2024, with an almost equal distribution of infection between males and females.7 This was an increase of almost 20% compared to the 86,810 case notifications in 2014.7 Across all ages, infections in females over this time period remained similar, however infections in males increased by approximately 40%.7
The WHO estimates that 82.4 million adults aged 15–49 years old acquired gonorrhoea worldwide in 2020.1 In Australia, gonorrhoea is most prevalent in men who have sex with men (MSM), remote Aboriginal and Torres Strait Islander communities, street-based sex workers, and returned travellers reporting sex overseas (in high prevalence countries).6,8 In recent years, there has been a rise in prevalence in the general population, especially in females of reproductive age.6 There were 44,547* cases of gonorrhoea notified to the NNDSS in 2024.7 This is almost triple the 15,674 cases notified in 2014.7
Co-infection with both chlamydia and gonorrhoea is relatively common.9 A study of high-prevalence Aboriginal communities in remote Australia found half of female and one-third of male participants aged 16–19 had one or more STIs.10 Chlamydia and gonorrhoea were the most common co-infections.10
*Figures correct as of May 2025.
Chlamydia
Chlamydia is often described as the “silent STI” because 85–90% of infections are asymptomatic.5 If symptoms do appear, they may not present until up to 3 weeks after sexual contact with an individual with chlamydia infection.2
Common chlamydia symptoms for males include2,5:
For females, symptoms include2,5:
Gonorrhoea
Gonorrhoea symptoms usually appear within 2 weeks of exposure.1 Infection is usually asymptomatic in females.1
If symptoms occur in females, they include1,4,6:
In contrast for males, penile urethral gonorrhoea is almost always symptomatic and symptoms may include1,6:
Complications
Untreated chlamydia and gonorrhoea can lead to various complications in both males and females, highlighting the need for prompt identification and treatment of infection.
Table 1 outlines some complications associated with untreated C. trachomatis and N. gonorrhoeae infection.
Diagnosis and differential diagnosis Molecular testing should be undertaken for those suspected of having chlamydia or gonorrhoea, or those at risk of infection. Certain groups (e.g. MSM, pregnant people, sex workers, Aboriginal and Torres Strait Islander people, gender diverse and transgender people) require special testing approaches due to increased risk of infection, adverse health outcomes or community prevalence.11 A full STI check-up including HIV and syphilis serology at initial presentation is recommended.11
Chlamydia is diagnosed via nucleic acid amplification tests (NAATs) (e.g. polymerase chain reaction [PCR]).5 NAATs are highly sensitive and the only recommended test for chlamydia.5 Microbiological culture of C. trachomatis is difficult and not routinely recommended.12
NAATs are also used to diagnose gonorrhoea.6 They are highly sensitive but do not provide any information on antibiotic susceptibility.6 Gonococcal microbiological culture has high specificity and allows for antibiotic susceptibility testing, but is less sensitive than NAATs.6
Some differential diagnoses for genital tract chlamydia infection may include lymphogranuloma venereum, gonorrhoea, bacterial vaginosis, vaginal candidiasis, trichomonas or Mycoplasma genitalium infection.13 For gonorrhoea, other conditions such as chlamydia, trichomonas, vaginal candidiasis, bacterial vaginosis or urinary tract infections may cause similar symptoms.14
Anatomical sites sampled for chlamydia and gonorrhoea testing will depend on the individual’s presentation, sexual history and risk factors.5,6 Self-collection of samples for testing by NAAT is common practice for asymptomatic patients.5 In symptomatic patients undergoing examination, a swab can be taken by the clinician (e.g. an endocervical swab if a speculum examination occurs).5,6 First-pass urine can be tested in people without a vagina (or if a vaginal swab cannot be taken) – it is less sensitive than a self-collected vaginal swab.5,6 An anorectal swab is recommended for all individuals who have anorectal symptoms, and for all MSM regardless of whether they are symptomatic.5,6 Similarly, a pharyngeal swab for NAAT is recommended for MSM for both gonorrhoea and chlamydia, even if asymptomatic.5,6
Gonococcal culture
Gonococcal cultures should be collected from all infected sites prior to commencing treatment to determine antibiotic susceptibility and to contribute to antimicrobial resistance surveillance.6 It is recommended that a culture is performed on a site if an individual is experiencing symptoms at that site.6 Pending culture results should not delay commencing treatment, and antibiotics can be administered prior to receiving the culture results.6
The goals of treatment for both chlamydia and gonorrhoea are to resolve symptoms, reduce complications and prevent transmission and reinfection. Sometimes a clinical diagnosis is made based on symptoms and risk factors. Certain presentations may warrant starting empiric treatment while awaiting confirmation of results. Examples include patients presenting with anorectal symptoms, symptoms of PID or epididymo-orchitis, where timely treatment is critical.15–17
Chlamydia
Doxycycline is the standard first-line therapy for chlamydia.5,18 Azithromycin is an alternative option if doxycycline is contraindicated (e.g. in pregnancy, if there are adherence or medicine interaction concerns).3,18
Previously, azithromycin was the first-line treatment, as it was a convenient single dose. However, a meta-analysis showed azithromycin 1 g orally may be up to 20% less efficacious than 7 days of doxycycline when treating anorectal chlamydia. A subsequent randomised trial of 625 Australian MSM with asymptomatic anorectal chlamydia demonstrated consistent findings.19,20 Azithromycin is also increasingly implicated in antimicrobial resistance for other STIs, therefore doxycycline is preferred.21
Gonorrhoea
The recommended treatment for gonorrhoea infection in Australia is ceftriaxone in combination with azithromycin.6 The recommended dose of oral azithromycin varies depending on the site of infection.4 The current combination treatment approach is highly effective and important in reducing the contribution to more widespread antimicrobial resistance.4,6 However, reduced susceptibility to these agents has been increasingly reported in urban Australia.6 Until recently, the combination of amoxicillin, probenecid and azithromycin was still recommended for gonorrhoea in some remote Australian areas. However, this changed to ceftriaxone with azithromycin, due to an increase in penicillin resistance in remote communities in the Northern Territory.22
Antimicrobial resistance is a growing problem in the treatment of gonorrhoea.1 Resistance to penicillin, tetracyclines, macrolides, sulphonamides and quinolones has been detected.23 Gonococcal surveillance programs are in place in some countries to track resistant strains.
Table 2 provides a summary of the current treatment approach for various presentations of chlamydia and gonorrhoea infection in Australia. Uncomplicated chlamydia or gonorrhoea infection refers to localised urogenital, anogenital, pharyngeal and ocular infections that are not associated with bacteraemia or ascending spread to other organs.24,25 Complicated infections and their treatment is beyond the scope of this article, as are other infections associated with C. trachomatis.
Prevention Consistent and correct condom use can prevent the transmission of chlamydia and gonorrhoea.1,2 There is currently no available vaccine to prevent either infection. The serogroup B meningococcal vaccine (4CMenB) is currently being investigated for its ability to provide cross-protection against N. gonorrhoeae.26
The use of doxycycline to prevent bacterial STIs (doxycycline post-exposure prophylaxis [doxy-PEP]) can offer protection against acquiring syphilis, chlamydia and, to a lesser extent, gonorrhoea, if taken within 72 hours of unprotected sexual intercourse.27 Controversy remains on whether the risk of changes to the microbiome and potential increased antimicrobial resistance as a result of using doxy-PEP outweighs the benefits of preventing these STIs, with research ongoing.27
Sexual contact should be avoided for 7 days after chlamydia and/or gonorrhoea treatment is commenced, or until the treatment course is completed and symptoms have resolved, whichever is later.5,6 Patients should be advised not to have sex with partners from the last 6 months for chlamydia, or the last 2 months for gonorrhoea, until partners have been tested and treated, if necessary.5,6 Notification of sexual partners is recommended and can be done anonymously by patients via websites such as Let Them Know (https://letthemknow.org.au/).5,6 With the consent of the patient, a clinician may support with contact tracing if necessary.
Reinfection with chlamydia and gonorrhoea is common.5,6 Retesting at 3 months is recommended to detect reinfection.5,6 A test of cure is not routinely recommended for chlamydia, except in specific circumstances (e.g. in pregnancy).5 A test of cure is recommended for gonorrhoea in cases where a culture was not collected before treatment, the culture indicated antimicrobial resistance or if a non-standard treatment regimen was used.6 Screening for other STIs should be performed if not done at the initial presentation.5,6
Patient-delivered partner therapy (PDPT) is where antibiotic treatment is prescribed or supplied for the sexual partner(s) of a patient diagnosed with chlamydia (index patient).5 The prescription or treatment is given directly to their partner(s) by the index patient.5 In jurisdictions where PDPT is approved, it can be considered for heterosexual index patients with anogenital or oropharyngeal chlamydia, whose partners are unlikely to seek chlamydia testing or treatment.5 PDPT can also be considered with cases of repeat infections where partners have not been treated.5 Guidance on PDPT for chlamydia is available in Victoria, New South Wales and the Northern Territory.5 The decision to use PDPT should be weighed against the potential to miss co-infections or complications in the partner(s) of the index patient.
Pharmacists may be among the first healthcare professionals that patients approach for guidance and treatment for STIs, particularly if presenting with symptoms of infection. Recognition of symptoms that may warrant onward referral to a medical practitioner is essential.
Pharmacists can support adherence to current recommended treatment regimens for STIs. This may include extended doxycycline courses, which ensures the resolution of infection and improves antibiotic efficacy.28 Pharmacists can also encourage patients to notify sexual partners regarding an STI diagnosis, enabling those partners to obtain timely treatment.
Doxy-PEP may be appropriate for some at-risk groups, providing an additional option to conventional STI prevention strategies. Evidence is building for doxy-PEP use and by following the Australasian Society for HIV, Viral Hepatitis & Sexual Health Medicine (ASHM) guidance, pharmacists can ensure they are providing evidence-based information to patients who wish to know more about this prevention strategy (see https://ashm.org.au/initiatives/doxy-pep-statement/).27
Chlamydia and gonorrhoea are two of the most prevalent bacterial STIs. Patients may be asymptomatic, and both can lead to serious complications if left untreated. Chlamydia is relatively easy to treat, however emerging antimicrobial resistance to first-line gonorrhoea treatments may complicate its management. Reinfection is common with both, and robust contact tracing of sexual partners is recommended.
Case scenario continuedAfter noting that doxycycline would need to be taken at least 2 hours before or after Ashley’s iron tablets, you also suspect an interaction with isotretinoin.28 You check the Australian Medicines Handbook (AMH), which highlights a risk of benign intracranial hypertension and that concurrent use should be avoided.29 You phone Ashley’s GP to recommend a safer, yet effective, alternative of azithromycin 1 g orally as a single dose. The GP and Ashley thank you for your help. |
Ivette Aguirre (she/her) BAppSc (MedLabSc), BPharm, GradCertPharmPrac, MClinPharm, FANZCAP (Inf Dis) is the senior clinical pharmacist at the Melbourne Sexual Health Centre (MSHC), a part of Alfred Health. She mentors pharmacists, technicians and pharmacy students during their rotations at MSHC, and is interested in the impact of pharmacist reviews in HIV clinics and emerging treatments for sexually transmissible infections such as Mycoplasma genitalium.
Kathryn (Kate) Mackie (she/her) BPharm, GradDipClinPharm, BCGP, FANZCAP (Inf Dis, Gen) is a senior clinical pharmacist at Alfred Health (including Melbourne Sexual Health Centre) and Barwon Health, working in infectious diseases, HIV, viral hepatitis and sexual health. With 20 years of experience in this area, she is engaged in clinical pharmacy research and contributes to undergraduate and health professional education.
Hana Numan (she/her) BPharm (NZ), PGDipClinPharm (NZ), MPS (NZ)
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[post_content] => Administered to the nasal mucosa, a spike-based formulation triggers rapid local defences that clear the COVID-19 virus where it enters.
In 2022, a year after Australia’s longest COVID-19 lockdowns, researchers from the Centenary Institute and the University of Sydney received a grant of almost $1 million from the NSW COVID-19 Vaccine Acceleration Research Grants Program to develop an intranasal COVID-19 vaccine.
Now, new research has been released by the team – finding that their formulation can stop infection in the nose before the virus spreads through the body, and to other people.
[caption id="attachment_30517" align="alignright" width="150"]
Dr Erica Stewart, Centenary Institute[/caption]
Australian Pharmacist sat down with Dr Erica Stewart, first author and researcher at the Centenary Institute when the work was undertaken, to discuss how the vaccine works, its applications and why it could be the key to stopping the spread.
What is the vaccine’s mechanism of action?
By acting where the virus first enters, the nasal vaccine prompts a rapid, effective immune response that eliminates the virus, Dr Stewart said.
‘The adjuvant we used was Pam2Cys, a Toll-like receptor 2 (TLR2), and we showed that it was able to stimulate the immune response in the nasal passages,’ she said.
‘We formulated the SARS-CoV-2 spike protein with this adjuvant, which emulates bacteria to alert the immune system that there is a danger and it should respond.’
When administered as a booster after a standard injection, the treatment also provided additional protection to vital organs, including the lungs and brain – pointing to the benefits of focusing immune responses within the upper airways.
Why target the nasal mucosa?
The nasal passage is an increasingly promising site for vaccine adjuvant formulation, Dr Stewart said.
‘It’s becoming more and more clear that the nasal passage is a very different immune environment to an injection in the muscle.’
Internationally, there are some other pre-clinical models of mucosal vaccines. ‘But most of those mucosal vaccines are viral vectors because there aren't a lot of vaccine adjuvants that have been found to be effective nasally, which is part of the novelty of this study,’ she said.
The team had previously looked at intranasal vaccination in mice, using a model where the vaccine entered both the lungs and the nose.
‘However, the main takeaway from this research was, when [administering] a very small volume to just the nose, we still got a really strong immune response in the blood,’ she said. ‘We also looked into the nose itself, and we could see that the immune cells were retained for long periods in the nasal passages, where they will be able to respond to infection quickly.’
There’s hope that these vaccines can potentially prevent infection and transmission by building immune defences directly in the upper airways where the virus first takes hold – a frontier that traditional vaccines have yet to reach.
‘We currently reduce disease severity really well, but we're still trying to block transmission,’ Dr Stewart said. ‘That's what nasal vaccines are aiming to address.’
Who would benefit most from a nasal COVID-19 vaccine?
Vulnerable populations who are more susceptible to severe disease, hospitalisations and death.
‘Sometimes you'll hear people say, “COVID-19 is over” – but people are still dying of it, including the elderly, immunocompromised people and those with other comorbidities,’ Dr Stewart said.
Similar to how younger, healthy patients are advised to get the flu vaccine to protect more vulnerable members of the community – this vaccine offers an additional layer of protection.
‘It would be the vulnerable people who are benefiting, but the vaccine would be for everyone to try to reduce the circulation of the virus in our community,’ she said.
How would the vaccine fit into the routine immunisation schedule?
With most people vaccinated against COVID-19 or exposed to the virus, the mucosal vaccines will likely be used as a booster.
‘In the mouse model, both the vaccine as a booster or as a primary vaccination induced nasal immunity,’ Dr Stewart said.
It’s assumed that the nasal vaccine will be used as an annual seasonal dose, similar to the flu vaccine or COVID-19 boosters for certain populations.
‘We do have some evidence that the vaccine can neutralise against other variants, but [we need to explore] how well it protects people and for how long, because that would indicate whether continuous boosters are needed,’ she said.
It’s also anticipated that the nasal vaccine will be self-administered.
‘There are studies looking into self-administration of nasal vaccines, which could really help with distribution and access to these vaccines in the community,’ she said.
This mode of administration could be particularly beneficial for those who are needlephobic, including children.
‘For people who cannot stand getting a needle, this is a less invasive method of vaccination,’ Dr Stewart said.
The researchers say that while more work is needed, the results show strong potential for nasal vaccines to complement existing COVID-19 vaccines and provide an extra layer of protection against the virus in the future.
[post_title] => Intranasal vaccine stops infection at the source
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[post_content] => For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way. AP meets guardians of medicine management who are highly involved.
Australian pharmacists are playing a vital role in one of the nation’s most important healthcare campaigns – the reduction and ultimate elimination of chemical restraint.
The final reports of the Royal Commission into Aged Care Quality and Safety1 (2021) and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability2 (2023) made strong recommendations to reduce and ultimately eliminate the use of chemical restraint, sharing a commitment to upholding the rights and dignity of older people and people with disability.
In a joint statement in 2022, the Australian Commission on Safety and Quality in Health Care, the Aged Care Quality and Safety Commission and the NDIS Safety and Quality Commission acknowledged that psychotropic medicines were being overprescribed and overused for managing behaviours of concern. The disability royal commission final report went even further, says Advanced Practice Pharmacist and University of Western Australia Adjunct Professor Manya Angley FPS.
‘It called for a national approach to reducing and eliminating restrictive practices, including chemical restraint, and emphasised the need for a coordinated framework with targets, data collection, evaluation, performance indicators, timeframes and independent oversight. It also focused,’ she notes, ‘on supported decision-making and workforce training in trauma-informed, person-centred care.’
Annual Positive Behaviour Support progress reports were specifically recommended, she says, with an independent evaluation of measures to determine if the use of psychotropic medicines as chemical restraint in people with cognitive disability was reducing.
‘I have been working in aged care as an RMMR and QUM pharmacist since 2018,’ says Dr Angley. ‘Before the aged care royal commission interim report, risperidone as chemical restraint, and psychotropic medicines generally, were used less “mindfully”. If a doctor prescribed a psychotropic medication at usual doses as chemical restraint, it was considered acceptable. Since 2020, GPs, nurses and care staff have greater awareness of the risks of antipsychotics (including falls, stroke and death), the value of bespoke Positive Behaviour Support plans containing a suite of person-centred non-pharmacological strategies, and the need to gain informed consent before using chemical restraint.’
Dr Angley believes ‘everyone is getting better at identifying triggers for changed behaviours’. These can include constipation, urinary retention, pain, boredom, hunger or thirst, infection and medicines.
‘There is improved understanding that chemical restraint should only be used as a last resort, for the shortest possible time and at the lowest dose possible.’
Dr Angley also registered as an NDIS Positive Behaviour Support (PBS) practitioner in 2023. She uses her medicines expertise to identify and deprescribe chemical restraint in NDIS participants.
Pharmacists, as highly trained clinicians, are able to identify if health issues are contributing to changed behaviour. She believes credentialed pharmacists need to play a bigger role in the development of PBS plans for NDIS participants who are prescribed chemical restraint.
There are, however, limited funding options for medicines review services by credentialed pharmacists. Aside from registering as a PBS practitioner, remuneration for services provided to NDIS participants in the community is only available through Home Medicines Reviews, which require a doctor’s referral – a significant barrier.
AP asked two credentialed pharmacists about their experiences with the reduction of chemical restraint.
Case 1
[caption id="attachment_30506" align="alignright" width="148"]
Chelsea Felkai, MPS[/caption]
Chelsea Felkai MPS, Disability and ACOP Pharmacist, Maroba Aged Care Facility, Waratah, Newcastle, NSW
I typically generate reports on residents who use psychotropic medicines. I talk with the resident, their family members, the RACF staff who know the resident, and the resident’s prescriber, to look at whether the medicine is the best option for the person, or if we need to explore alternatives.
Once we have established a resident would benefit from reductions, I work with the prescriber to put deprescribing or tapering plans in place to reduce (or cease) less appropriate medicines. Because I am on site 3 days a week, I am able to monitor this closely to ensure the resident is supported and safe through the process.
In early wins, we have been able to replace mostly tricyclic antidepressants (TCAs) with high anticholinergic burden to newer agent antidepressants (I tend to call this low-hanging fruit) with a lot of success.
Though it’s not strictly chemical restraint, it has brought about a large reduction in adverse outcomes across the facility. We have seen a complete cessation of antipsychotic medicines in only two residents so far (the facility has 150, with approximately 25 in the memory support unit), but we have been able to reduce chemical restraint in all residents to the lowest effective maintenance dose.
We have seen an increase in selective serotonin reuptake inhibitor (SSRI) medicines, and a reduction in TCAs. We have also seen an increase in duloxetine and mirtazapine. I have tried to use some of the newer evidence of duloxetine’s efficacy for chronic pain management and mirtazapine’s for sleep support, as options when switching antidepressants.
There has been some discomfort from residents and staff while we have trialled reduction in psychotropic medicines, to ensure the resident is on the lowest possible dose. Because education was provided to staff at the start, it was met with little resistance. And it helped that I was on site to provide support and monitor the outcomes.
Working with the nursing staff to understand when PRN (as required) chemical restraint might be used, and ensuring other options have been exhausted first, has shown the most reduction in how much psychotropic medications have been used so far. The numbers are relatively small, but to be honest, this is largely because the facility had great protocols to begin with.
The impact has been noticeable. Staff members say they feel more confident in the care they provide and the non-pharmacological options they now have at their disposal.
When they do move to a chemical restraint option, it is because other options have been exhausted, and it is in the best interest of the resident.
Case 2
[caption id="attachment_26803" align="alignleft" width="144"]
Dr Natalie Soulsby FPS[/caption]
Dr Natalie Soulsby FPS, Credentialed Pharmacist, South Australia
My role is Head of Clinical Governance and Quality Assurance for Embedded Health Solutions, which provides clinical pharmacy services to about 600 residential aged care facilities (RACFs).
One of my roles is to attend national medication advisory committee (MAC) meetings to provide information to head office on medication management, including the psychotropic register. I analyse the information on the register and provide a clinical lens, which is used to support staff to understand where these medicines may be being used as restraints.
The Aged Care Quality and Safety Commission responded to the Royal Commission into Aged Care Quality and Safety by creating a psychotropic register that needs to be updated monthly, so they can keep track of how many patients were prescribed a medicine that was used as a chemical restraint and how they were being managed.
In 2021, when the National Aged Care Quality Indicator Program included the use of antipsychotic medicines, the quarterly numbers showed 21.6% of residents were administered antipsychotic medicines during a 7-day time frame. That figure is now down to 17.3%.
The registers have been a good trigger to remind doctors to review their patients’ treatments. When it began, doctors were concerned about prescribing antipsychotic medicines, and unfortunately some GPs stopped their patients’ medicines, which caused a return of their symptoms. These medicines must be weaned slowly.
There is still a stigma with these medicines, and our focus is always on appropriateness. All the new red tape means staff at the facilities spend a lot more time collecting data.
Initially it was overwhelming and confusing. GPs were concerned about the impact on their patients. There was also a lack of communication and understanding. The staff are more confident now, but there is still confusion as to what constitutes a chemical restraint.
Now everyone in the care team, including the staff in the home, the GP and the family, are involved in the process. Staff members encourage GPs to look at the psychotropic medicines regularly (at least every 3 months), and the staff assess the effectiveness or otherwise of the medications and consider any adverse effects and update the Behaviour Support Plan. This is considered best practice.
And one of the roles of the credentialed pharmacist is to support the home in filling out the register.
One impact has been a shift to more person-centred care.
The patient is seen as an active participant in their care, which lines up with the new Aged Care Act coming into effect in November this year. The concept is good, but we are still trying to work out how that will work in the long term.
Reviewing the psychotropic register allows us to support our facilities in ensuring appropriate treatments are prescribed and reviewed regularly for the residents.
We can use the register as part of our reviews and for follow-ups.
Nursing staff are more aware of the role of medicines in treating responsive behaviours, and having the register supports their conversations with the GPs. Our role is to be the continuity-of-care person and why we allocate pharmacists to specific aged care facilities, which allows them to become part of the team and provide appropriate advice and support.
We are the second set of eyes. We put a clinical lens over what has gone on and can help the nursing staff.
Pharmacists are the guardians of medicines management and the advocates for the nursing staff and residents. We help support the residents’ care.
References
- Royal Commission into Aged Care Quality and Safety. Final Report. 2021. At: www.royalcommission.gov.au/aged-care/final-report
- Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability. Final Report. 2023. At: https://disability.royalcommission.gov.au/publications/final-report
[post_title] => How pharmacists are reducing chemical restraint
[post_excerpt] => For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way.
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[post_content] => Women of reproductive age using glucagon-like peptide-1 receptor agonists (GLP-1 RAs) could be at risk of unintended pregnancy, and may be unaware of associated risks to pregnancy and unborn babies.
A new study by Flinders University, which examined records from more than 1.6 million women aged 18–49 who attended general practice between 2011 and 2022, found that only one in five (21%) of those with first prescribing of GLP-1 RAs had documented contraceptive use.
The study also found that most prescriptions for GLP-1 RAs are now issued to women without diabetes. In 2022 alone, more than 6,000 women began treatment on GLP-1 RAs, and over 90% of those did not have a type 2 diabetes diagnosis.
[caption id="attachment_30483" align="alignright" width="300"]
Associate Professor Luke Grzeskowiak[/caption]
Participants were tracked at the initial stages of GLP-1 RA therapy, with the research team looking at documented evidence of pregnancies over a 6-month period, said lead author and pharmacist, Associate Professor Luke Grzeskowiak.
‘[While] limited to data from GP records, one in 25 women aged 18 to 34 years had a documented pregnancy at the time of prescribing,’ he said.
‘There will also be pregnancies that the GP might not be aware of, so if anything, what we're expecting is that this is an underestimate of what's truly happening.’
Those who were prescribed concurrent contraception were 50% less likely to have a documented pregnancy.
‘So we've got clear evidence that contraceptive use at the time of initiating these medicines reduces the risk of pregnancies occurring,’ A/Prof Grzeskowiak said.
Why does GLP-1 RA use increase pregnancy risk?
There are two key reasons: first, it is ‘well established’ that weight loss can improve fertility.
‘Because we know these medicines are very effective at promoting weight loss, it's highly plausible that they could improve fertility through that mechanism,’ A/Prof Grzeskowiak said.
There have also been concerns that GLP-1 RAs might impact absorption of the oral contraceptive pill.
In June 2025, the UK’s Medicines and Healthcare products Regulatory Agency issued a regulatory warning following case reports of unexpected pregnancies associated with GLP-1 RA use.
‘A detailed review [revealed] that the strongest evidence was around potential interaction between tirzepatide and reduced effectiveness of oral contraception,’ A/Prof Grzeskowiak said.
To date, evidence regarding interactions between GLP-1 RAs and the oral contraceptive pill is limited.
‘So the general recommendations around that regulatory warning were for those relying on oral contraceptive methods to also consider using a barrier method,’ he said.
What are the congenital risk factors?
The research also considered potential harms associated with GLP-1 RAs in pregnancy. Key concerns were taken from a University of Amsterdam review of animal studies, cited in the Flinders University study.
‘In animals, use of GLP-1 RAs [in pregnancy] led to reductions in foetal growth, impairments in bone development and impaired maternal weight gain,’ A/Prof Grzeskowiak said.
At this stage, the human data are more reassuring.
‘The studies that have been done have not shown an increased risk of birth defects,’ he said. ‘But they are still relatively limited in terms of numbers, and we don't have an examination of the full range of pregnancy outcomes yet,’ he said.
Due to this uncertainty, an abundance of caution is advised.
‘The recommendations are to not use these medicines during pregnancy, and to avoid the potential for them to be used during pregnancy accidentally,’ A/Prof Grzeskowiak said. ‘So it’s important to have a plan around concurrent contraception use, high-quality pre-conception care, and ensure that where pregnancies are planned, everything has been done to optimise pregnancy outcomes.’
What should pharmacists advise patients?
Dispensing GLP-1 RAs provides important opportunities for pharmacists to talk to patients about reproductive health.
For example, when dispensing tirzepatide, access to dispensing data on contraceptive methods enables pharmacists to raise awareness of the potential interaction by initiating an open and unassuming conversation, A/Prof Grzeskowiak said.
‘Having a conversation about how that might be addressed means patients can make an informed decision,’ he said. ‘It might mean changing contraceptive methods or [referring] them back to the GP for a conversation. Or it may be that they're using contraceptives for non-contraceptive purposes such as acne [management], so there’s a low risk of pregnancy.’
The initiation of therapy is the ideal time to discuss potential risks.
‘That way people know what to expect in terms of the medicines,’ he said.
When commencing GLP-1 RAs, patients may also experience profound gastrointestinal adverse effects, including vomiting or diarrhoea.
‘That in itself can reduce the effectiveness of oral contraception, regardless of any other interactions,’ A/Prof Grzeskowiak said. ‘So people should be aware of the side effects of what to expect when starting this and how it might impact on other treatments that they're using.’
Pharmacists have an important role in engaging patients in conversations about reproductive health, particularly contraception.
‘Not everyone feels comfortable asking those questions, but there are good training resources, particularly through PSA, around improving pharmacists’ comfort with having those conversations, including around the different types of contraceptive methods,’ he said.
‘It's one thing to start the conversation, but you also need to be armed with various information to be able to continue it, or at least identify when to refer patients back to their medical practitioner or another [healthcare practitioner] to provide that detailed advice.’
[post_title] => GLP-1 RAs found to pose pregnancy risks
[post_excerpt] => Women of reproductive age using GLP-1 RAs could be at risk of unintended pregnancy, and unaware of the risks to pregnancy and unborn babies.
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[post_content] => Pharmacists are asked to lead the shift from reliever-only inhalers to inhaled corticosteroid-containing regimens and to minimise short courses of oral corticosteroids.
Just under 3 million Australians live with asthma. The condition has the eighth-highest disease burden in the nation, and it is one of the most significant chronic conditions in children.
Guided by the results of large trials, recommendations for asthma management in adults and adolescents are changing, and pharmacists need to be aware of updated guidelines. The Australian Asthma Handbook was updated yesterday (16 September 2025) to reflect new thinking on asthma care and management.
What are the key updates?
Three key changes have been made to the Australian Asthma Handbook, including:
-
- All adults and adolescents with confirmed asthma should be taking inhaled corticosteroid-containing treatment and not as-needed short-acting beta2-agonists (SABAs) alone. Asthma can be well controlled with maintenance and reliever therapy, and a small proportion of patients with severe asthma may be eligible for biologics.
- An emphasis on the importance of limiting oral corticosteroids, which have been associated with a range of different harms, including damage to bone health, cataracts and type 2 diabetes.
- Health professionals should be aware the handbook has greater guidance for treating children aged 1–5 who are living with asthma and a recommendation that some older children should also be on low-dosage ICS maintenance therapy.
Why have the guidelines been updated?
Overuse of SABAs has been linked to poor asthma control and preventable hospitalisations.
‘The evidence is that the risks of SABA alone have become clearer and that we were overusing a not very effective and not very safe therapy,’ said Professor Nick Zwar, Executive Dean of Bond University’s Faculty of Health Sciences and Medicine, and Chair of the Australian Asthma Handbook Guidelines Committee.
‘Budesonide-formoterol, taken only as needed, is recommended in place of SABA. Maintenance and reliever therapy is now recommended as the next step up.’
The risks of SABA overuse include a lack of bronchodilator response over time, and the possibility that some people may have quite a severe asthma attack and end up in the hospital emergency department (ED), or hospitalised, when they don’t need to be.
There is very strong evidence to demonstrate that all adolescents and adults living with asthma should be treated with ICS, said pharmacist and Clinical Executive Lead at the National Asthma Council Australia, Debbie Rigby FPS.
‘Just having the SABA alone only treats one component of asthma, which is the bronchoconstriction, whereas having the low-dose ICS helps manage the inflammation and mucus production,’ she said. ‘I think that’s the biggest shift for us, pharmacists and doctors: helping patients to understand that asthma is a chronic inflammatory condition.’
What are the risks of poor asthma control?
Inadequately managed asthma can be a life-threatening condition, Ms Rigby stressed, noting there were 474 asthma-related deaths in Australia in 2023.
‘Those deaths shouldn’t be happening. Many of those people who did die from asthma or asthma-related causes would have been perceived as having mild, intermittent symptoms,’ she said. ‘Without wanting to scare patients, we should be really highlighting the consequences of not having good control of their asthma.’
Why is SABA still overused?
Despite access to long-acting beta2 agonists (ICS–LABAs), SABA use remains high for a range of reasons. These include cost, convenience and patient reluctance to medicate every day when they are accustomed to using a reliever-only when they have an asthma attack, Ms Rigby said.
Health professionals understand that many people are reluctant to use a preventer inhaler, but health professionals need to help them understand that they have a ‘chronic inflammatory condition, which may flare up from time to time’.
Effects of the cost-of-living crisis should not be underestimated either. However, the price gap between over-the-counter salbutamol and prescription asthma medicines is now narrowing, with 60-day dispensing for patients who are stable and, from January 2026, the co-payment for medicines being reduced from $31.60 to $25 per prescription.
The Australian uptake of Maintenance and Reliever Therapy (MART) has also been slow, despite strong evidence and subsidy on the Pharmaceutical Benefits Scheme. The evidence of large-scale trials has shown the importance of shifting patients with mild asthma onto anti-inflammatory reliever therapy on an as-needed basis, Ms Rigby said.
‘The evidence basically says it reduces the risk of severe exacerbations requiring ED or hospitalisation, or requiring oral corticosteroids,’ she said.
For practical guidance on discussing the guideline changes with patients, the role of prescribing pharmacists, and how biologics fit into care, don’t miss the October cover story in Australian Pharmacist.
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[post_content] => Case scenario
Ashley, a 23-year-old female, presents to your pharmacy with a prescription for a 7-day course of doxycycline 100 mg twice daily. She tells you she has had some mild vaginal discharge and that her STI screen has come back positive for vaginal chlamydia. You establish that she is currently taking ferrous sulfate 325 mg once daily as she is vegan, isotretinoin 30 mg once daily for acne, and has an etonogestrel implant in situ. She has no
known allergies.
Note: The authors recognise that gender identity is fluid. In this article, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Chlamydia and gonorrhoea are two of the most prevalent bacterial sexually transmitted infections (STIs) globally.1,2 They are preventable and curable infections that are usually transmitted through vaginal, oral or anal sex.1,2 Conjunctival infection can occur in neonates born to mothers carrying a chlamydia or gonorrhoea infection, or in adults via exposure to genital secretions.1–4 Both chlamydia and gonorrhoea can lead to serious health complications if left untreated, ranging from effects on fertility and pregnancy to blindness (in untreated ocular gonorrhoea infection).1,2
Chlamydia is caused by the gram-negative bacterium Chlamydia trachomatis.2 Gonorrhoea is caused by the gram-negative bacterium Neisseria gonorrhoeae.1
Chlamydia is relatively simple to treat, being susceptible to doxycycline and azithromycin.5 Gonorrhoea treatment may be more challenging due to emerging antimicrobial resistance to first-line treatments, particularly in urban Australia.6 All people diagnosed with chlamydia and gonorrhoea should be offered antibiotic treatment to resolve symptoms, prevent complications and to decrease transmission to others.1,2
Pharmacists can support patients by providing information on safe-sex practices, any prescribed medicines, in addition to providing advice or referring where appropriate.
The World Health Organization (WHO) estimates there were around 128.5 million new infections with C. trachomatis in 2020 among adults aged 15–49 years globally.2 In Australia, those under 30 years of age are at greatest risk of infection.5 There were 102,222* cases of chlamydia notified to the Australian government’s National Notifiable Diseases Surveillance System (NNDSS) in 2024, with an almost equal distribution of infection between males and females.7 This was an increase of almost 20% compared to the 86,810 case notifications in 2014.7 Across all ages, infections in females over this time period remained similar, however infections in males increased by approximately 40%.7
The WHO estimates that 82.4 million adults aged 15–49 years old acquired gonorrhoea worldwide in 2020.1 In Australia, gonorrhoea is most prevalent in men who have sex with men (MSM), remote Aboriginal and Torres Strait Islander communities, street-based sex workers, and returned travellers reporting sex overseas (in high prevalence countries).6,8 In recent years, there has been a rise in prevalence in the general population, especially in females of reproductive age.6 There were 44,547* cases of gonorrhoea notified to the NNDSS in 2024.7 This is almost triple the 15,674 cases notified in 2014.7
Co-infection with both chlamydia and gonorrhoea is relatively common.9 A study of high-prevalence Aboriginal communities in remote Australia found half of female and one-third of male participants aged 16–19 had one or more STIs.10 Chlamydia and gonorrhoea were the most common co-infections.10
*Figures correct as of May 2025.
Chlamydia
Chlamydia is often described as the “silent STI” because 85–90% of infections are asymptomatic.5 If symptoms do appear, they may not present until up to 3 weeks after sexual contact with an individual with chlamydia infection.2
Common chlamydia symptoms for males include2,5:
For females, symptoms include2,5:
Gonorrhoea
Gonorrhoea symptoms usually appear within 2 weeks of exposure.1 Infection is usually asymptomatic in females.1
If symptoms occur in females, they include1,4,6:
In contrast for males, penile urethral gonorrhoea is almost always symptomatic and symptoms may include1,6:
Complications
Untreated chlamydia and gonorrhoea can lead to various complications in both males and females, highlighting the need for prompt identification and treatment of infection.
Table 1 outlines some complications associated with untreated C. trachomatis and N. gonorrhoeae infection.
Diagnosis and differential diagnosis Molecular testing should be undertaken for those suspected of having chlamydia or gonorrhoea, or those at risk of infection. Certain groups (e.g. MSM, pregnant people, sex workers, Aboriginal and Torres Strait Islander people, gender diverse and transgender people) require special testing approaches due to increased risk of infection, adverse health outcomes or community prevalence.11 A full STI check-up including HIV and syphilis serology at initial presentation is recommended.11
Chlamydia is diagnosed via nucleic acid amplification tests (NAATs) (e.g. polymerase chain reaction [PCR]).5 NAATs are highly sensitive and the only recommended test for chlamydia.5 Microbiological culture of C. trachomatis is difficult and not routinely recommended.12
NAATs are also used to diagnose gonorrhoea.6 They are highly sensitive but do not provide any information on antibiotic susceptibility.6 Gonococcal microbiological culture has high specificity and allows for antibiotic susceptibility testing, but is less sensitive than NAATs.6
Some differential diagnoses for genital tract chlamydia infection may include lymphogranuloma venereum, gonorrhoea, bacterial vaginosis, vaginal candidiasis, trichomonas or Mycoplasma genitalium infection.13 For gonorrhoea, other conditions such as chlamydia, trichomonas, vaginal candidiasis, bacterial vaginosis or urinary tract infections may cause similar symptoms.14
Anatomical sites sampled for chlamydia and gonorrhoea testing will depend on the individual’s presentation, sexual history and risk factors.5,6 Self-collection of samples for testing by NAAT is common practice for asymptomatic patients.5 In symptomatic patients undergoing examination, a swab can be taken by the clinician (e.g. an endocervical swab if a speculum examination occurs).5,6 First-pass urine can be tested in people without a vagina (or if a vaginal swab cannot be taken) – it is less sensitive than a self-collected vaginal swab.5,6 An anorectal swab is recommended for all individuals who have anorectal symptoms, and for all MSM regardless of whether they are symptomatic.5,6 Similarly, a pharyngeal swab for NAAT is recommended for MSM for both gonorrhoea and chlamydia, even if asymptomatic.5,6
Gonococcal culture
Gonococcal cultures should be collected from all infected sites prior to commencing treatment to determine antibiotic susceptibility and to contribute to antimicrobial resistance surveillance.6 It is recommended that a culture is performed on a site if an individual is experiencing symptoms at that site.6 Pending culture results should not delay commencing treatment, and antibiotics can be administered prior to receiving the culture results.6
The goals of treatment for both chlamydia and gonorrhoea are to resolve symptoms, reduce complications and prevent transmission and reinfection. Sometimes a clinical diagnosis is made based on symptoms and risk factors. Certain presentations may warrant starting empiric treatment while awaiting confirmation of results. Examples include patients presenting with anorectal symptoms, symptoms of PID or epididymo-orchitis, where timely treatment is critical.15–17
Chlamydia
Doxycycline is the standard first-line therapy for chlamydia.5,18 Azithromycin is an alternative option if doxycycline is contraindicated (e.g. in pregnancy, if there are adherence or medicine interaction concerns).3,18
Previously, azithromycin was the first-line treatment, as it was a convenient single dose. However, a meta-analysis showed azithromycin 1 g orally may be up to 20% less efficacious than 7 days of doxycycline when treating anorectal chlamydia. A subsequent randomised trial of 625 Australian MSM with asymptomatic anorectal chlamydia demonstrated consistent findings.19,20 Azithromycin is also increasingly implicated in antimicrobial resistance for other STIs, therefore doxycycline is preferred.21
Gonorrhoea
The recommended treatment for gonorrhoea infection in Australia is ceftriaxone in combination with azithromycin.6 The recommended dose of oral azithromycin varies depending on the site of infection.4 The current combination treatment approach is highly effective and important in reducing the contribution to more widespread antimicrobial resistance.4,6 However, reduced susceptibility to these agents has been increasingly reported in urban Australia.6 Until recently, the combination of amoxicillin, probenecid and azithromycin was still recommended for gonorrhoea in some remote Australian areas. However, this changed to ceftriaxone with azithromycin, due to an increase in penicillin resistance in remote communities in the Northern Territory.22
Antimicrobial resistance is a growing problem in the treatment of gonorrhoea.1 Resistance to penicillin, tetracyclines, macrolides, sulphonamides and quinolones has been detected.23 Gonococcal surveillance programs are in place in some countries to track resistant strains.
Table 2 provides a summary of the current treatment approach for various presentations of chlamydia and gonorrhoea infection in Australia. Uncomplicated chlamydia or gonorrhoea infection refers to localised urogenital, anogenital, pharyngeal and ocular infections that are not associated with bacteraemia or ascending spread to other organs.24,25 Complicated infections and their treatment is beyond the scope of this article, as are other infections associated with C. trachomatis.
Prevention Consistent and correct condom use can prevent the transmission of chlamydia and gonorrhoea.1,2 There is currently no available vaccine to prevent either infection. The serogroup B meningococcal vaccine (4CMenB) is currently being investigated for its ability to provide cross-protection against N. gonorrhoeae.26
The use of doxycycline to prevent bacterial STIs (doxycycline post-exposure prophylaxis [doxy-PEP]) can offer protection against acquiring syphilis, chlamydia and, to a lesser extent, gonorrhoea, if taken within 72 hours of unprotected sexual intercourse.27 Controversy remains on whether the risk of changes to the microbiome and potential increased antimicrobial resistance as a result of using doxy-PEP outweighs the benefits of preventing these STIs, with research ongoing.27
Sexual contact should be avoided for 7 days after chlamydia and/or gonorrhoea treatment is commenced, or until the treatment course is completed and symptoms have resolved, whichever is later.5,6 Patients should be advised not to have sex with partners from the last 6 months for chlamydia, or the last 2 months for gonorrhoea, until partners have been tested and treated, if necessary.5,6 Notification of sexual partners is recommended and can be done anonymously by patients via websites such as Let Them Know (https://letthemknow.org.au/).5,6 With the consent of the patient, a clinician may support with contact tracing if necessary.
Reinfection with chlamydia and gonorrhoea is common.5,6 Retesting at 3 months is recommended to detect reinfection.5,6 A test of cure is not routinely recommended for chlamydia, except in specific circumstances (e.g. in pregnancy).5 A test of cure is recommended for gonorrhoea in cases where a culture was not collected before treatment, the culture indicated antimicrobial resistance or if a non-standard treatment regimen was used.6 Screening for other STIs should be performed if not done at the initial presentation.5,6
Patient-delivered partner therapy (PDPT) is where antibiotic treatment is prescribed or supplied for the sexual partner(s) of a patient diagnosed with chlamydia (index patient).5 The prescription or treatment is given directly to their partner(s) by the index patient.5 In jurisdictions where PDPT is approved, it can be considered for heterosexual index patients with anogenital or oropharyngeal chlamydia, whose partners are unlikely to seek chlamydia testing or treatment.5 PDPT can also be considered with cases of repeat infections where partners have not been treated.5 Guidance on PDPT for chlamydia is available in Victoria, New South Wales and the Northern Territory.5 The decision to use PDPT should be weighed against the potential to miss co-infections or complications in the partner(s) of the index patient.
Pharmacists may be among the first healthcare professionals that patients approach for guidance and treatment for STIs, particularly if presenting with symptoms of infection. Recognition of symptoms that may warrant onward referral to a medical practitioner is essential.
Pharmacists can support adherence to current recommended treatment regimens for STIs. This may include extended doxycycline courses, which ensures the resolution of infection and improves antibiotic efficacy.28 Pharmacists can also encourage patients to notify sexual partners regarding an STI diagnosis, enabling those partners to obtain timely treatment.
Doxy-PEP may be appropriate for some at-risk groups, providing an additional option to conventional STI prevention strategies. Evidence is building for doxy-PEP use and by following the Australasian Society for HIV, Viral Hepatitis & Sexual Health Medicine (ASHM) guidance, pharmacists can ensure they are providing evidence-based information to patients who wish to know more about this prevention strategy (see https://ashm.org.au/initiatives/doxy-pep-statement/).27
Chlamydia and gonorrhoea are two of the most prevalent bacterial STIs. Patients may be asymptomatic, and both can lead to serious complications if left untreated. Chlamydia is relatively easy to treat, however emerging antimicrobial resistance to first-line gonorrhoea treatments may complicate its management. Reinfection is common with both, and robust contact tracing of sexual partners is recommended.
Case scenario continuedAfter noting that doxycycline would need to be taken at least 2 hours before or after Ashley’s iron tablets, you also suspect an interaction with isotretinoin.28 You check the Australian Medicines Handbook (AMH), which highlights a risk of benign intracranial hypertension and that concurrent use should be avoided.29 You phone Ashley’s GP to recommend a safer, yet effective, alternative of azithromycin 1 g orally as a single dose. The GP and Ashley thank you for your help. |
Ivette Aguirre (she/her) BAppSc (MedLabSc), BPharm, GradCertPharmPrac, MClinPharm, FANZCAP (Inf Dis) is the senior clinical pharmacist at the Melbourne Sexual Health Centre (MSHC), a part of Alfred Health. She mentors pharmacists, technicians and pharmacy students during their rotations at MSHC, and is interested in the impact of pharmacist reviews in HIV clinics and emerging treatments for sexually transmissible infections such as Mycoplasma genitalium.
Kathryn (Kate) Mackie (she/her) BPharm, GradDipClinPharm, BCGP, FANZCAP (Inf Dis, Gen) is a senior clinical pharmacist at Alfred Health (including Melbourne Sexual Health Centre) and Barwon Health, working in infectious diseases, HIV, viral hepatitis and sexual health. With 20 years of experience in this area, she is engaged in clinical pharmacy research and contributes to undergraduate and health professional education.
Hana Numan (she/her) BPharm (NZ), PGDipClinPharm (NZ), MPS (NZ)
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[post_content] => Administered to the nasal mucosa, a spike-based formulation triggers rapid local defences that clear the COVID-19 virus where it enters.
In 2022, a year after Australia’s longest COVID-19 lockdowns, researchers from the Centenary Institute and the University of Sydney received a grant of almost $1 million from the NSW COVID-19 Vaccine Acceleration Research Grants Program to develop an intranasal COVID-19 vaccine.
Now, new research has been released by the team – finding that their formulation can stop infection in the nose before the virus spreads through the body, and to other people.
[caption id="attachment_30517" align="alignright" width="150"] Dr Erica Stewart, Centenary Institute[/caption]
Australian Pharmacist sat down with Dr Erica Stewart, first author and researcher at the Centenary Institute when the work was undertaken, to discuss how the vaccine works, its applications and why it could be the key to stopping the spread.
What is the vaccine’s mechanism of action?
By acting where the virus first enters, the nasal vaccine prompts a rapid, effective immune response that eliminates the virus, Dr Stewart said.
‘The adjuvant we used was Pam2Cys, a Toll-like receptor 2 (TLR2), and we showed that it was able to stimulate the immune response in the nasal passages,’ she said.
‘We formulated the SARS-CoV-2 spike protein with this adjuvant, which emulates bacteria to alert the immune system that there is a danger and it should respond.’
When administered as a booster after a standard injection, the treatment also provided additional protection to vital organs, including the lungs and brain – pointing to the benefits of focusing immune responses within the upper airways.
Why target the nasal mucosa?
The nasal passage is an increasingly promising site for vaccine adjuvant formulation, Dr Stewart said.
‘It’s becoming more and more clear that the nasal passage is a very different immune environment to an injection in the muscle.’
Internationally, there are some other pre-clinical models of mucosal vaccines. ‘But most of those mucosal vaccines are viral vectors because there aren't a lot of vaccine adjuvants that have been found to be effective nasally, which is part of the novelty of this study,’ she said.
The team had previously looked at intranasal vaccination in mice, using a model where the vaccine entered both the lungs and the nose.
‘However, the main takeaway from this research was, when [administering] a very small volume to just the nose, we still got a really strong immune response in the blood,’ she said. ‘We also looked into the nose itself, and we could see that the immune cells were retained for long periods in the nasal passages, where they will be able to respond to infection quickly.’
There’s hope that these vaccines can potentially prevent infection and transmission by building immune defences directly in the upper airways where the virus first takes hold – a frontier that traditional vaccines have yet to reach.
‘We currently reduce disease severity really well, but we're still trying to block transmission,’ Dr Stewart said. ‘That's what nasal vaccines are aiming to address.’
Who would benefit most from a nasal COVID-19 vaccine?
Vulnerable populations who are more susceptible to severe disease, hospitalisations and death.
‘Sometimes you'll hear people say, “COVID-19 is over” – but people are still dying of it, including the elderly, immunocompromised people and those with other comorbidities,’ Dr Stewart said.
Similar to how younger, healthy patients are advised to get the flu vaccine to protect more vulnerable members of the community – this vaccine offers an additional layer of protection.
‘It would be the vulnerable people who are benefiting, but the vaccine would be for everyone to try to reduce the circulation of the virus in our community,’ she said.
How would the vaccine fit into the routine immunisation schedule?
With most people vaccinated against COVID-19 or exposed to the virus, the mucosal vaccines will likely be used as a booster.
‘In the mouse model, both the vaccine as a booster or as a primary vaccination induced nasal immunity,’ Dr Stewart said.
It’s assumed that the nasal vaccine will be used as an annual seasonal dose, similar to the flu vaccine or COVID-19 boosters for certain populations.
‘We do have some evidence that the vaccine can neutralise against other variants, but [we need to explore] how well it protects people and for how long, because that would indicate whether continuous boosters are needed,’ she said.
It’s also anticipated that the nasal vaccine will be self-administered.
‘There are studies looking into self-administration of nasal vaccines, which could really help with distribution and access to these vaccines in the community,’ she said.
This mode of administration could be particularly beneficial for those who are needlephobic, including children.
‘For people who cannot stand getting a needle, this is a less invasive method of vaccination,’ Dr Stewart said.
The researchers say that while more work is needed, the results show strong potential for nasal vaccines to complement existing COVID-19 vaccines and provide an extra layer of protection against the virus in the future.
[post_title] => Intranasal vaccine stops infection at the source
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[post_content] => For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way. AP meets guardians of medicine management who are highly involved.
Australian pharmacists are playing a vital role in one of the nation’s most important healthcare campaigns – the reduction and ultimate elimination of chemical restraint.
The final reports of the Royal Commission into Aged Care Quality and Safety1 (2021) and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability2 (2023) made strong recommendations to reduce and ultimately eliminate the use of chemical restraint, sharing a commitment to upholding the rights and dignity of older people and people with disability.
In a joint statement in 2022, the Australian Commission on Safety and Quality in Health Care, the Aged Care Quality and Safety Commission and the NDIS Safety and Quality Commission acknowledged that psychotropic medicines were being overprescribed and overused for managing behaviours of concern. The disability royal commission final report went even further, says Advanced Practice Pharmacist and University of Western Australia Adjunct Professor Manya Angley FPS.
‘It called for a national approach to reducing and eliminating restrictive practices, including chemical restraint, and emphasised the need for a coordinated framework with targets, data collection, evaluation, performance indicators, timeframes and independent oversight. It also focused,’ she notes, ‘on supported decision-making and workforce training in trauma-informed, person-centred care.’
Annual Positive Behaviour Support progress reports were specifically recommended, she says, with an independent evaluation of measures to determine if the use of psychotropic medicines as chemical restraint in people with cognitive disability was reducing.
‘I have been working in aged care as an RMMR and QUM pharmacist since 2018,’ says Dr Angley. ‘Before the aged care royal commission interim report, risperidone as chemical restraint, and psychotropic medicines generally, were used less “mindfully”. If a doctor prescribed a psychotropic medication at usual doses as chemical restraint, it was considered acceptable. Since 2020, GPs, nurses and care staff have greater awareness of the risks of antipsychotics (including falls, stroke and death), the value of bespoke Positive Behaviour Support plans containing a suite of person-centred non-pharmacological strategies, and the need to gain informed consent before using chemical restraint.’
Dr Angley believes ‘everyone is getting better at identifying triggers for changed behaviours’. These can include constipation, urinary retention, pain, boredom, hunger or thirst, infection and medicines.
‘There is improved understanding that chemical restraint should only be used as a last resort, for the shortest possible time and at the lowest dose possible.’
Dr Angley also registered as an NDIS Positive Behaviour Support (PBS) practitioner in 2023. She uses her medicines expertise to identify and deprescribe chemical restraint in NDIS participants.
Pharmacists, as highly trained clinicians, are able to identify if health issues are contributing to changed behaviour. She believes credentialed pharmacists need to play a bigger role in the development of PBS plans for NDIS participants who are prescribed chemical restraint.
There are, however, limited funding options for medicines review services by credentialed pharmacists. Aside from registering as a PBS practitioner, remuneration for services provided to NDIS participants in the community is only available through Home Medicines Reviews, which require a doctor’s referral – a significant barrier.
AP asked two credentialed pharmacists about their experiences with the reduction of chemical restraint.
Case 1
[caption id="attachment_30506" align="alignright" width="148"] Chelsea Felkai, MPS[/caption]
Chelsea Felkai MPS, Disability and ACOP Pharmacist, Maroba Aged Care Facility, Waratah, Newcastle, NSW
I typically generate reports on residents who use psychotropic medicines. I talk with the resident, their family members, the RACF staff who know the resident, and the resident’s prescriber, to look at whether the medicine is the best option for the person, or if we need to explore alternatives.
Once we have established a resident would benefit from reductions, I work with the prescriber to put deprescribing or tapering plans in place to reduce (or cease) less appropriate medicines. Because I am on site 3 days a week, I am able to monitor this closely to ensure the resident is supported and safe through the process.
In early wins, we have been able to replace mostly tricyclic antidepressants (TCAs) with high anticholinergic burden to newer agent antidepressants (I tend to call this low-hanging fruit) with a lot of success.
Though it’s not strictly chemical restraint, it has brought about a large reduction in adverse outcomes across the facility. We have seen a complete cessation of antipsychotic medicines in only two residents so far (the facility has 150, with approximately 25 in the memory support unit), but we have been able to reduce chemical restraint in all residents to the lowest effective maintenance dose.
We have seen an increase in selective serotonin reuptake inhibitor (SSRI) medicines, and a reduction in TCAs. We have also seen an increase in duloxetine and mirtazapine. I have tried to use some of the newer evidence of duloxetine’s efficacy for chronic pain management and mirtazapine’s for sleep support, as options when switching antidepressants.
There has been some discomfort from residents and staff while we have trialled reduction in psychotropic medicines, to ensure the resident is on the lowest possible dose. Because education was provided to staff at the start, it was met with little resistance. And it helped that I was on site to provide support and monitor the outcomes.
Working with the nursing staff to understand when PRN (as required) chemical restraint might be used, and ensuring other options have been exhausted first, has shown the most reduction in how much psychotropic medications have been used so far. The numbers are relatively small, but to be honest, this is largely because the facility had great protocols to begin with.
The impact has been noticeable. Staff members say they feel more confident in the care they provide and the non-pharmacological options they now have at their disposal.
When they do move to a chemical restraint option, it is because other options have been exhausted, and it is in the best interest of the resident.
Case 2
[caption id="attachment_26803" align="alignleft" width="144"] Dr Natalie Soulsby FPS[/caption]
Dr Natalie Soulsby FPS, Credentialed Pharmacist, South Australia
My role is Head of Clinical Governance and Quality Assurance for Embedded Health Solutions, which provides clinical pharmacy services to about 600 residential aged care facilities (RACFs).
One of my roles is to attend national medication advisory committee (MAC) meetings to provide information to head office on medication management, including the psychotropic register. I analyse the information on the register and provide a clinical lens, which is used to support staff to understand where these medicines may be being used as restraints.
The Aged Care Quality and Safety Commission responded to the Royal Commission into Aged Care Quality and Safety by creating a psychotropic register that needs to be updated monthly, so they can keep track of how many patients were prescribed a medicine that was used as a chemical restraint and how they were being managed.
In 2021, when the National Aged Care Quality Indicator Program included the use of antipsychotic medicines, the quarterly numbers showed 21.6% of residents were administered antipsychotic medicines during a 7-day time frame. That figure is now down to 17.3%.
The registers have been a good trigger to remind doctors to review their patients’ treatments. When it began, doctors were concerned about prescribing antipsychotic medicines, and unfortunately some GPs stopped their patients’ medicines, which caused a return of their symptoms. These medicines must be weaned slowly.
There is still a stigma with these medicines, and our focus is always on appropriateness. All the new red tape means staff at the facilities spend a lot more time collecting data.
Initially it was overwhelming and confusing. GPs were concerned about the impact on their patients. There was also a lack of communication and understanding. The staff are more confident now, but there is still confusion as to what constitutes a chemical restraint.
Now everyone in the care team, including the staff in the home, the GP and the family, are involved in the process. Staff members encourage GPs to look at the psychotropic medicines regularly (at least every 3 months), and the staff assess the effectiveness or otherwise of the medications and consider any adverse effects and update the Behaviour Support Plan. This is considered best practice.
And one of the roles of the credentialed pharmacist is to support the home in filling out the register.
One impact has been a shift to more person-centred care.
The patient is seen as an active participant in their care, which lines up with the new Aged Care Act coming into effect in November this year. The concept is good, but we are still trying to work out how that will work in the long term.
Reviewing the psychotropic register allows us to support our facilities in ensuring appropriate treatments are prescribed and reviewed regularly for the residents.
We can use the register as part of our reviews and for follow-ups.
Nursing staff are more aware of the role of medicines in treating responsive behaviours, and having the register supports their conversations with the GPs. Our role is to be the continuity-of-care person and why we allocate pharmacists to specific aged care facilities, which allows them to become part of the team and provide appropriate advice and support.
We are the second set of eyes. We put a clinical lens over what has gone on and can help the nursing staff.
Pharmacists are the guardians of medicines management and the advocates for the nursing staff and residents. We help support the residents’ care.
References
- Royal Commission into Aged Care Quality and Safety. Final Report. 2021. At: www.royalcommission.gov.au/aged-care/final-report
- Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability. Final Report. 2023. At: https://disability.royalcommission.gov.au/publications/final-report
[post_title] => How pharmacists are reducing chemical restraint
[post_excerpt] => For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way.
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[post_content] => Women of reproductive age using glucagon-like peptide-1 receptor agonists (GLP-1 RAs) could be at risk of unintended pregnancy, and may be unaware of associated risks to pregnancy and unborn babies.
A new study by Flinders University, which examined records from more than 1.6 million women aged 18–49 who attended general practice between 2011 and 2022, found that only one in five (21%) of those with first prescribing of GLP-1 RAs had documented contraceptive use.
The study also found that most prescriptions for GLP-1 RAs are now issued to women without diabetes. In 2022 alone, more than 6,000 women began treatment on GLP-1 RAs, and over 90% of those did not have a type 2 diabetes diagnosis.
[caption id="attachment_30483" align="alignright" width="300"] Associate Professor Luke Grzeskowiak[/caption]
Participants were tracked at the initial stages of GLP-1 RA therapy, with the research team looking at documented evidence of pregnancies over a 6-month period, said lead author and pharmacist, Associate Professor Luke Grzeskowiak.
‘[While] limited to data from GP records, one in 25 women aged 18 to 34 years had a documented pregnancy at the time of prescribing,’ he said.
‘There will also be pregnancies that the GP might not be aware of, so if anything, what we're expecting is that this is an underestimate of what's truly happening.’
Those who were prescribed concurrent contraception were 50% less likely to have a documented pregnancy.
‘So we've got clear evidence that contraceptive use at the time of initiating these medicines reduces the risk of pregnancies occurring,’ A/Prof Grzeskowiak said.
Why does GLP-1 RA use increase pregnancy risk?
There are two key reasons: first, it is ‘well established’ that weight loss can improve fertility.
‘Because we know these medicines are very effective at promoting weight loss, it's highly plausible that they could improve fertility through that mechanism,’ A/Prof Grzeskowiak said.
There have also been concerns that GLP-1 RAs might impact absorption of the oral contraceptive pill.
In June 2025, the UK’s Medicines and Healthcare products Regulatory Agency issued a regulatory warning following case reports of unexpected pregnancies associated with GLP-1 RA use.
‘A detailed review [revealed] that the strongest evidence was around potential interaction between tirzepatide and reduced effectiveness of oral contraception,’ A/Prof Grzeskowiak said.
To date, evidence regarding interactions between GLP-1 RAs and the oral contraceptive pill is limited.
‘So the general recommendations around that regulatory warning were for those relying on oral contraceptive methods to also consider using a barrier method,’ he said.
What are the congenital risk factors?
The research also considered potential harms associated with GLP-1 RAs in pregnancy. Key concerns were taken from a University of Amsterdam review of animal studies, cited in the Flinders University study.
‘In animals, use of GLP-1 RAs [in pregnancy] led to reductions in foetal growth, impairments in bone development and impaired maternal weight gain,’ A/Prof Grzeskowiak said.
At this stage, the human data are more reassuring.
‘The studies that have been done have not shown an increased risk of birth defects,’ he said. ‘But they are still relatively limited in terms of numbers, and we don't have an examination of the full range of pregnancy outcomes yet,’ he said.
Due to this uncertainty, an abundance of caution is advised.
‘The recommendations are to not use these medicines during pregnancy, and to avoid the potential for them to be used during pregnancy accidentally,’ A/Prof Grzeskowiak said. ‘So it’s important to have a plan around concurrent contraception use, high-quality pre-conception care, and ensure that where pregnancies are planned, everything has been done to optimise pregnancy outcomes.’
What should pharmacists advise patients?
Dispensing GLP-1 RAs provides important opportunities for pharmacists to talk to patients about reproductive health.
For example, when dispensing tirzepatide, access to dispensing data on contraceptive methods enables pharmacists to raise awareness of the potential interaction by initiating an open and unassuming conversation, A/Prof Grzeskowiak said.
‘Having a conversation about how that might be addressed means patients can make an informed decision,’ he said. ‘It might mean changing contraceptive methods or [referring] them back to the GP for a conversation. Or it may be that they're using contraceptives for non-contraceptive purposes such as acne [management], so there’s a low risk of pregnancy.’
The initiation of therapy is the ideal time to discuss potential risks.
‘That way people know what to expect in terms of the medicines,’ he said.
When commencing GLP-1 RAs, patients may also experience profound gastrointestinal adverse effects, including vomiting or diarrhoea.
‘That in itself can reduce the effectiveness of oral contraception, regardless of any other interactions,’ A/Prof Grzeskowiak said. ‘So people should be aware of the side effects of what to expect when starting this and how it might impact on other treatments that they're using.’
Pharmacists have an important role in engaging patients in conversations about reproductive health, particularly contraception.
‘Not everyone feels comfortable asking those questions, but there are good training resources, particularly through PSA, around improving pharmacists’ comfort with having those conversations, including around the different types of contraceptive methods,’ he said.
‘It's one thing to start the conversation, but you also need to be armed with various information to be able to continue it, or at least identify when to refer patients back to their medical practitioner or another [healthcare practitioner] to provide that detailed advice.’
[post_title] => GLP-1 RAs found to pose pregnancy risks
[post_excerpt] => Women of reproductive age using GLP-1 RAs could be at risk of unintended pregnancy, and unaware of the risks to pregnancy and unborn babies.
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[post_content] => Pharmacists are asked to lead the shift from reliever-only inhalers to inhaled corticosteroid-containing regimens and to minimise short courses of oral corticosteroids.
Just under 3 million Australians live with asthma. The condition has the eighth-highest disease burden in the nation, and it is one of the most significant chronic conditions in children.
Guided by the results of large trials, recommendations for asthma management in adults and adolescents are changing, and pharmacists need to be aware of updated guidelines. The Australian Asthma Handbook was updated yesterday (16 September 2025) to reflect new thinking on asthma care and management.
What are the key updates?
Three key changes have been made to the Australian Asthma Handbook, including:
-
- All adults and adolescents with confirmed asthma should be taking inhaled corticosteroid-containing treatment and not as-needed short-acting beta2-agonists (SABAs) alone. Asthma can be well controlled with maintenance and reliever therapy, and a small proportion of patients with severe asthma may be eligible for biologics.
- An emphasis on the importance of limiting oral corticosteroids, which have been associated with a range of different harms, including damage to bone health, cataracts and type 2 diabetes.
- Health professionals should be aware the handbook has greater guidance for treating children aged 1–5 who are living with asthma and a recommendation that some older children should also be on low-dosage ICS maintenance therapy.
Why have the guidelines been updated?
Overuse of SABAs has been linked to poor asthma control and preventable hospitalisations.
‘The evidence is that the risks of SABA alone have become clearer and that we were overusing a not very effective and not very safe therapy,’ said Professor Nick Zwar, Executive Dean of Bond University’s Faculty of Health Sciences and Medicine, and Chair of the Australian Asthma Handbook Guidelines Committee.
‘Budesonide-formoterol, taken only as needed, is recommended in place of SABA. Maintenance and reliever therapy is now recommended as the next step up.’
The risks of SABA overuse include a lack of bronchodilator response over time, and the possibility that some people may have quite a severe asthma attack and end up in the hospital emergency department (ED), or hospitalised, when they don’t need to be.
There is very strong evidence to demonstrate that all adolescents and adults living with asthma should be treated with ICS, said pharmacist and Clinical Executive Lead at the National Asthma Council Australia, Debbie Rigby FPS.
‘Just having the SABA alone only treats one component of asthma, which is the bronchoconstriction, whereas having the low-dose ICS helps manage the inflammation and mucus production,’ she said. ‘I think that’s the biggest shift for us, pharmacists and doctors: helping patients to understand that asthma is a chronic inflammatory condition.’
What are the risks of poor asthma control?
Inadequately managed asthma can be a life-threatening condition, Ms Rigby stressed, noting there were 474 asthma-related deaths in Australia in 2023.
‘Those deaths shouldn’t be happening. Many of those people who did die from asthma or asthma-related causes would have been perceived as having mild, intermittent symptoms,’ she said. ‘Without wanting to scare patients, we should be really highlighting the consequences of not having good control of their asthma.’
Why is SABA still overused?
Despite access to long-acting beta2 agonists (ICS–LABAs), SABA use remains high for a range of reasons. These include cost, convenience and patient reluctance to medicate every day when they are accustomed to using a reliever-only when they have an asthma attack, Ms Rigby said.
Health professionals understand that many people are reluctant to use a preventer inhaler, but health professionals need to help them understand that they have a ‘chronic inflammatory condition, which may flare up from time to time’.
Effects of the cost-of-living crisis should not be underestimated either. However, the price gap between over-the-counter salbutamol and prescription asthma medicines is now narrowing, with 60-day dispensing for patients who are stable and, from January 2026, the co-payment for medicines being reduced from $31.60 to $25 per prescription.
The Australian uptake of Maintenance and Reliever Therapy (MART) has also been slow, despite strong evidence and subsidy on the Pharmaceutical Benefits Scheme. The evidence of large-scale trials has shown the importance of shifting patients with mild asthma onto anti-inflammatory reliever therapy on an as-needed basis, Ms Rigby said.
‘The evidence basically says it reduces the risk of severe exacerbations requiring ED or hospitalisation, or requiring oral corticosteroids,’ she said.
For practical guidance on discussing the guideline changes with patients, the role of prescribing pharmacists, and how biologics fit into care, don’t miss the October cover story in Australian Pharmacist.
[post_title] => New asthma guidelines released
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[title_attribute] => New asthma guidelines released
[title] => New asthma guidelines released
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[post_content] => Case scenario
Ashley, a 23-year-old female, presents to your pharmacy with a prescription for a 7-day course of doxycycline 100 mg twice daily. She tells you she has had some mild vaginal discharge and that her STI screen has come back positive for vaginal chlamydia. You establish that she is currently taking ferrous sulfate 325 mg once daily as she is vegan, isotretinoin 30 mg once daily for acne, and has an etonogestrel implant in situ. She has no
known allergies.
Note: The authors recognise that gender identity is fluid. In this article, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Chlamydia and gonorrhoea are two of the most prevalent bacterial sexually transmitted infections (STIs) globally.1,2 They are preventable and curable infections that are usually transmitted through vaginal, oral or anal sex.1,2 Conjunctival infection can occur in neonates born to mothers carrying a chlamydia or gonorrhoea infection, or in adults via exposure to genital secretions.1–4 Both chlamydia and gonorrhoea can lead to serious health complications if left untreated, ranging from effects on fertility and pregnancy to blindness (in untreated ocular gonorrhoea infection).1,2
Chlamydia is caused by the gram-negative bacterium Chlamydia trachomatis.2 Gonorrhoea is caused by the gram-negative bacterium Neisseria gonorrhoeae.1
Chlamydia is relatively simple to treat, being susceptible to doxycycline and azithromycin.5 Gonorrhoea treatment may be more challenging due to emerging antimicrobial resistance to first-line treatments, particularly in urban Australia.6 All people diagnosed with chlamydia and gonorrhoea should be offered antibiotic treatment to resolve symptoms, prevent complications and to decrease transmission to others.1,2
Pharmacists can support patients by providing information on safe-sex practices, any prescribed medicines, in addition to providing advice or referring where appropriate.
The World Health Organization (WHO) estimates there were around 128.5 million new infections with C. trachomatis in 2020 among adults aged 15–49 years globally.2 In Australia, those under 30 years of age are at greatest risk of infection.5 There were 102,222* cases of chlamydia notified to the Australian government’s National Notifiable Diseases Surveillance System (NNDSS) in 2024, with an almost equal distribution of infection between males and females.7 This was an increase of almost 20% compared to the 86,810 case notifications in 2014.7 Across all ages, infections in females over this time period remained similar, however infections in males increased by approximately 40%.7
The WHO estimates that 82.4 million adults aged 15–49 years old acquired gonorrhoea worldwide in 2020.1 In Australia, gonorrhoea is most prevalent in men who have sex with men (MSM), remote Aboriginal and Torres Strait Islander communities, street-based sex workers, and returned travellers reporting sex overseas (in high prevalence countries).6,8 In recent years, there has been a rise in prevalence in the general population, especially in females of reproductive age.6 There were 44,547* cases of gonorrhoea notified to the NNDSS in 2024.7 This is almost triple the 15,674 cases notified in 2014.7
Co-infection with both chlamydia and gonorrhoea is relatively common.9 A study of high-prevalence Aboriginal communities in remote Australia found half of female and one-third of male participants aged 16–19 had one or more STIs.10 Chlamydia and gonorrhoea were the most common co-infections.10
*Figures correct as of May 2025.
Chlamydia
Chlamydia is often described as the “silent STI” because 85–90% of infections are asymptomatic.5 If symptoms do appear, they may not present until up to 3 weeks after sexual contact with an individual with chlamydia infection.2
Common chlamydia symptoms for males include2,5:
For females, symptoms include2,5:
Gonorrhoea
Gonorrhoea symptoms usually appear within 2 weeks of exposure.1 Infection is usually asymptomatic in females.1
If symptoms occur in females, they include1,4,6:
In contrast for males, penile urethral gonorrhoea is almost always symptomatic and symptoms may include1,6:
Complications
Untreated chlamydia and gonorrhoea can lead to various complications in both males and females, highlighting the need for prompt identification and treatment of infection.
Table 1 outlines some complications associated with untreated C. trachomatis and N. gonorrhoeae infection.
Diagnosis and differential diagnosis Molecular testing should be undertaken for those suspected of having chlamydia or gonorrhoea, or those at risk of infection. Certain groups (e.g. MSM, pregnant people, sex workers, Aboriginal and Torres Strait Islander people, gender diverse and transgender people) require special testing approaches due to increased risk of infection, adverse health outcomes or community prevalence.11 A full STI check-up including HIV and syphilis serology at initial presentation is recommended.11
Chlamydia is diagnosed via nucleic acid amplification tests (NAATs) (e.g. polymerase chain reaction [PCR]).5 NAATs are highly sensitive and the only recommended test for chlamydia.5 Microbiological culture of C. trachomatis is difficult and not routinely recommended.12
NAATs are also used to diagnose gonorrhoea.6 They are highly sensitive but do not provide any information on antibiotic susceptibility.6 Gonococcal microbiological culture has high specificity and allows for antibiotic susceptibility testing, but is less sensitive than NAATs.6
Some differential diagnoses for genital tract chlamydia infection may include lymphogranuloma venereum, gonorrhoea, bacterial vaginosis, vaginal candidiasis, trichomonas or Mycoplasma genitalium infection.13 For gonorrhoea, other conditions such as chlamydia, trichomonas, vaginal candidiasis, bacterial vaginosis or urinary tract infections may cause similar symptoms.14
Anatomical sites sampled for chlamydia and gonorrhoea testing will depend on the individual’s presentation, sexual history and risk factors.5,6 Self-collection of samples for testing by NAAT is common practice for asymptomatic patients.5 In symptomatic patients undergoing examination, a swab can be taken by the clinician (e.g. an endocervical swab if a speculum examination occurs).5,6 First-pass urine can be tested in people without a vagina (or if a vaginal swab cannot be taken) – it is less sensitive than a self-collected vaginal swab.5,6 An anorectal swab is recommended for all individuals who have anorectal symptoms, and for all MSM regardless of whether they are symptomatic.5,6 Similarly, a pharyngeal swab for NAAT is recommended for MSM for both gonorrhoea and chlamydia, even if asymptomatic.5,6
Gonococcal culture
Gonococcal cultures should be collected from all infected sites prior to commencing treatment to determine antibiotic susceptibility and to contribute to antimicrobial resistance surveillance.6 It is recommended that a culture is performed on a site if an individual is experiencing symptoms at that site.6 Pending culture results should not delay commencing treatment, and antibiotics can be administered prior to receiving the culture results.6
The goals of treatment for both chlamydia and gonorrhoea are to resolve symptoms, reduce complications and prevent transmission and reinfection. Sometimes a clinical diagnosis is made based on symptoms and risk factors. Certain presentations may warrant starting empiric treatment while awaiting confirmation of results. Examples include patients presenting with anorectal symptoms, symptoms of PID or epididymo-orchitis, where timely treatment is critical.15–17
Chlamydia
Doxycycline is the standard first-line therapy for chlamydia.5,18 Azithromycin is an alternative option if doxycycline is contraindicated (e.g. in pregnancy, if there are adherence or medicine interaction concerns).3,18
Previously, azithromycin was the first-line treatment, as it was a convenient single dose. However, a meta-analysis showed azithromycin 1 g orally may be up to 20% less efficacious than 7 days of doxycycline when treating anorectal chlamydia. A subsequent randomised trial of 625 Australian MSM with asymptomatic anorectal chlamydia demonstrated consistent findings.19,20 Azithromycin is also increasingly implicated in antimicrobial resistance for other STIs, therefore doxycycline is preferred.21
Gonorrhoea
The recommended treatment for gonorrhoea infection in Australia is ceftriaxone in combination with azithromycin.6 The recommended dose of oral azithromycin varies depending on the site of infection.4 The current combination treatment approach is highly effective and important in reducing the contribution to more widespread antimicrobial resistance.4,6 However, reduced susceptibility to these agents has been increasingly reported in urban Australia.6 Until recently, the combination of amoxicillin, probenecid and azithromycin was still recommended for gonorrhoea in some remote Australian areas. However, this changed to ceftriaxone with azithromycin, due to an increase in penicillin resistance in remote communities in the Northern Territory.22
Antimicrobial resistance is a growing problem in the treatment of gonorrhoea.1 Resistance to penicillin, tetracyclines, macrolides, sulphonamides and quinolones has been detected.23 Gonococcal surveillance programs are in place in some countries to track resistant strains.
Table 2 provides a summary of the current treatment approach for various presentations of chlamydia and gonorrhoea infection in Australia. Uncomplicated chlamydia or gonorrhoea infection refers to localised urogenital, anogenital, pharyngeal and ocular infections that are not associated with bacteraemia or ascending spread to other organs.24,25 Complicated infections and their treatment is beyond the scope of this article, as are other infections associated with C. trachomatis.
Prevention Consistent and correct condom use can prevent the transmission of chlamydia and gonorrhoea.1,2 There is currently no available vaccine to prevent either infection. The serogroup B meningococcal vaccine (4CMenB) is currently being investigated for its ability to provide cross-protection against N. gonorrhoeae.26
The use of doxycycline to prevent bacterial STIs (doxycycline post-exposure prophylaxis [doxy-PEP]) can offer protection against acquiring syphilis, chlamydia and, to a lesser extent, gonorrhoea, if taken within 72 hours of unprotected sexual intercourse.27 Controversy remains on whether the risk of changes to the microbiome and potential increased antimicrobial resistance as a result of using doxy-PEP outweighs the benefits of preventing these STIs, with research ongoing.27
Sexual contact should be avoided for 7 days after chlamydia and/or gonorrhoea treatment is commenced, or until the treatment course is completed and symptoms have resolved, whichever is later.5,6 Patients should be advised not to have sex with partners from the last 6 months for chlamydia, or the last 2 months for gonorrhoea, until partners have been tested and treated, if necessary.5,6 Notification of sexual partners is recommended and can be done anonymously by patients via websites such as Let Them Know (https://letthemknow.org.au/).5,6 With the consent of the patient, a clinician may support with contact tracing if necessary.
Reinfection with chlamydia and gonorrhoea is common.5,6 Retesting at 3 months is recommended to detect reinfection.5,6 A test of cure is not routinely recommended for chlamydia, except in specific circumstances (e.g. in pregnancy).5 A test of cure is recommended for gonorrhoea in cases where a culture was not collected before treatment, the culture indicated antimicrobial resistance or if a non-standard treatment regimen was used.6 Screening for other STIs should be performed if not done at the initial presentation.5,6
Patient-delivered partner therapy (PDPT) is where antibiotic treatment is prescribed or supplied for the sexual partner(s) of a patient diagnosed with chlamydia (index patient).5 The prescription or treatment is given directly to their partner(s) by the index patient.5 In jurisdictions where PDPT is approved, it can be considered for heterosexual index patients with anogenital or oropharyngeal chlamydia, whose partners are unlikely to seek chlamydia testing or treatment.5 PDPT can also be considered with cases of repeat infections where partners have not been treated.5 Guidance on PDPT for chlamydia is available in Victoria, New South Wales and the Northern Territory.5 The decision to use PDPT should be weighed against the potential to miss co-infections or complications in the partner(s) of the index patient.
Pharmacists may be among the first healthcare professionals that patients approach for guidance and treatment for STIs, particularly if presenting with symptoms of infection. Recognition of symptoms that may warrant onward referral to a medical practitioner is essential.
Pharmacists can support adherence to current recommended treatment regimens for STIs. This may include extended doxycycline courses, which ensures the resolution of infection and improves antibiotic efficacy.28 Pharmacists can also encourage patients to notify sexual partners regarding an STI diagnosis, enabling those partners to obtain timely treatment.
Doxy-PEP may be appropriate for some at-risk groups, providing an additional option to conventional STI prevention strategies. Evidence is building for doxy-PEP use and by following the Australasian Society for HIV, Viral Hepatitis & Sexual Health Medicine (ASHM) guidance, pharmacists can ensure they are providing evidence-based information to patients who wish to know more about this prevention strategy (see https://ashm.org.au/initiatives/doxy-pep-statement/).27
Chlamydia and gonorrhoea are two of the most prevalent bacterial STIs. Patients may be asymptomatic, and both can lead to serious complications if left untreated. Chlamydia is relatively easy to treat, however emerging antimicrobial resistance to first-line gonorrhoea treatments may complicate its management. Reinfection is common with both, and robust contact tracing of sexual partners is recommended.
Case scenario continuedAfter noting that doxycycline would need to be taken at least 2 hours before or after Ashley’s iron tablets, you also suspect an interaction with isotretinoin.28 You check the Australian Medicines Handbook (AMH), which highlights a risk of benign intracranial hypertension and that concurrent use should be avoided.29 You phone Ashley’s GP to recommend a safer, yet effective, alternative of azithromycin 1 g orally as a single dose. The GP and Ashley thank you for your help. |
Ivette Aguirre (she/her) BAppSc (MedLabSc), BPharm, GradCertPharmPrac, MClinPharm, FANZCAP (Inf Dis) is the senior clinical pharmacist at the Melbourne Sexual Health Centre (MSHC), a part of Alfred Health. She mentors pharmacists, technicians and pharmacy students during their rotations at MSHC, and is interested in the impact of pharmacist reviews in HIV clinics and emerging treatments for sexually transmissible infections such as Mycoplasma genitalium.
Kathryn (Kate) Mackie (she/her) BPharm, GradDipClinPharm, BCGP, FANZCAP (Inf Dis, Gen) is a senior clinical pharmacist at Alfred Health (including Melbourne Sexual Health Centre) and Barwon Health, working in infectious diseases, HIV, viral hepatitis and sexual health. With 20 years of experience in this area, she is engaged in clinical pharmacy research and contributes to undergraduate and health professional education.
Hana Numan (she/her) BPharm (NZ), PGDipClinPharm (NZ), MPS (NZ)
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[post_content] => Administered to the nasal mucosa, a spike-based formulation triggers rapid local defences that clear the COVID-19 virus where it enters.
In 2022, a year after Australia’s longest COVID-19 lockdowns, researchers from the Centenary Institute and the University of Sydney received a grant of almost $1 million from the NSW COVID-19 Vaccine Acceleration Research Grants Program to develop an intranasal COVID-19 vaccine.
Now, new research has been released by the team – finding that their formulation can stop infection in the nose before the virus spreads through the body, and to other people.
[caption id="attachment_30517" align="alignright" width="150"] Dr Erica Stewart, Centenary Institute[/caption]
Australian Pharmacist sat down with Dr Erica Stewart, first author and researcher at the Centenary Institute when the work was undertaken, to discuss how the vaccine works, its applications and why it could be the key to stopping the spread.
What is the vaccine’s mechanism of action?
By acting where the virus first enters, the nasal vaccine prompts a rapid, effective immune response that eliminates the virus, Dr Stewart said.
‘The adjuvant we used was Pam2Cys, a Toll-like receptor 2 (TLR2), and we showed that it was able to stimulate the immune response in the nasal passages,’ she said.
‘We formulated the SARS-CoV-2 spike protein with this adjuvant, which emulates bacteria to alert the immune system that there is a danger and it should respond.’
When administered as a booster after a standard injection, the treatment also provided additional protection to vital organs, including the lungs and brain – pointing to the benefits of focusing immune responses within the upper airways.
Why target the nasal mucosa?
The nasal passage is an increasingly promising site for vaccine adjuvant formulation, Dr Stewart said.
‘It’s becoming more and more clear that the nasal passage is a very different immune environment to an injection in the muscle.’
Internationally, there are some other pre-clinical models of mucosal vaccines. ‘But most of those mucosal vaccines are viral vectors because there aren't a lot of vaccine adjuvants that have been found to be effective nasally, which is part of the novelty of this study,’ she said.
The team had previously looked at intranasal vaccination in mice, using a model where the vaccine entered both the lungs and the nose.
‘However, the main takeaway from this research was, when [administering] a very small volume to just the nose, we still got a really strong immune response in the blood,’ she said. ‘We also looked into the nose itself, and we could see that the immune cells were retained for long periods in the nasal passages, where they will be able to respond to infection quickly.’
There’s hope that these vaccines can potentially prevent infection and transmission by building immune defences directly in the upper airways where the virus first takes hold – a frontier that traditional vaccines have yet to reach.
‘We currently reduce disease severity really well, but we're still trying to block transmission,’ Dr Stewart said. ‘That's what nasal vaccines are aiming to address.’
Who would benefit most from a nasal COVID-19 vaccine?
Vulnerable populations who are more susceptible to severe disease, hospitalisations and death.
‘Sometimes you'll hear people say, “COVID-19 is over” – but people are still dying of it, including the elderly, immunocompromised people and those with other comorbidities,’ Dr Stewart said.
Similar to how younger, healthy patients are advised to get the flu vaccine to protect more vulnerable members of the community – this vaccine offers an additional layer of protection.
‘It would be the vulnerable people who are benefiting, but the vaccine would be for everyone to try to reduce the circulation of the virus in our community,’ she said.
How would the vaccine fit into the routine immunisation schedule?
With most people vaccinated against COVID-19 or exposed to the virus, the mucosal vaccines will likely be used as a booster.
‘In the mouse model, both the vaccine as a booster or as a primary vaccination induced nasal immunity,’ Dr Stewart said.
It’s assumed that the nasal vaccine will be used as an annual seasonal dose, similar to the flu vaccine or COVID-19 boosters for certain populations.
‘We do have some evidence that the vaccine can neutralise against other variants, but [we need to explore] how well it protects people and for how long, because that would indicate whether continuous boosters are needed,’ she said.
It’s also anticipated that the nasal vaccine will be self-administered.
‘There are studies looking into self-administration of nasal vaccines, which could really help with distribution and access to these vaccines in the community,’ she said.
This mode of administration could be particularly beneficial for those who are needlephobic, including children.
‘For people who cannot stand getting a needle, this is a less invasive method of vaccination,’ Dr Stewart said.
The researchers say that while more work is needed, the results show strong potential for nasal vaccines to complement existing COVID-19 vaccines and provide an extra layer of protection against the virus in the future.
[post_title] => Intranasal vaccine stops infection at the source
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[post_content] => For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way. AP meets guardians of medicine management who are highly involved.
Australian pharmacists are playing a vital role in one of the nation’s most important healthcare campaigns – the reduction and ultimate elimination of chemical restraint.
The final reports of the Royal Commission into Aged Care Quality and Safety1 (2021) and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability2 (2023) made strong recommendations to reduce and ultimately eliminate the use of chemical restraint, sharing a commitment to upholding the rights and dignity of older people and people with disability.
In a joint statement in 2022, the Australian Commission on Safety and Quality in Health Care, the Aged Care Quality and Safety Commission and the NDIS Safety and Quality Commission acknowledged that psychotropic medicines were being overprescribed and overused for managing behaviours of concern. The disability royal commission final report went even further, says Advanced Practice Pharmacist and University of Western Australia Adjunct Professor Manya Angley FPS.
‘It called for a national approach to reducing and eliminating restrictive practices, including chemical restraint, and emphasised the need for a coordinated framework with targets, data collection, evaluation, performance indicators, timeframes and independent oversight. It also focused,’ she notes, ‘on supported decision-making and workforce training in trauma-informed, person-centred care.’
Annual Positive Behaviour Support progress reports were specifically recommended, she says, with an independent evaluation of measures to determine if the use of psychotropic medicines as chemical restraint in people with cognitive disability was reducing.
‘I have been working in aged care as an RMMR and QUM pharmacist since 2018,’ says Dr Angley. ‘Before the aged care royal commission interim report, risperidone as chemical restraint, and psychotropic medicines generally, were used less “mindfully”. If a doctor prescribed a psychotropic medication at usual doses as chemical restraint, it was considered acceptable. Since 2020, GPs, nurses and care staff have greater awareness of the risks of antipsychotics (including falls, stroke and death), the value of bespoke Positive Behaviour Support plans containing a suite of person-centred non-pharmacological strategies, and the need to gain informed consent before using chemical restraint.’
Dr Angley believes ‘everyone is getting better at identifying triggers for changed behaviours’. These can include constipation, urinary retention, pain, boredom, hunger or thirst, infection and medicines.
‘There is improved understanding that chemical restraint should only be used as a last resort, for the shortest possible time and at the lowest dose possible.’
Dr Angley also registered as an NDIS Positive Behaviour Support (PBS) practitioner in 2023. She uses her medicines expertise to identify and deprescribe chemical restraint in NDIS participants.
Pharmacists, as highly trained clinicians, are able to identify if health issues are contributing to changed behaviour. She believes credentialed pharmacists need to play a bigger role in the development of PBS plans for NDIS participants who are prescribed chemical restraint.
There are, however, limited funding options for medicines review services by credentialed pharmacists. Aside from registering as a PBS practitioner, remuneration for services provided to NDIS participants in the community is only available through Home Medicines Reviews, which require a doctor’s referral – a significant barrier.
AP asked two credentialed pharmacists about their experiences with the reduction of chemical restraint.
Case 1
[caption id="attachment_30506" align="alignright" width="148"] Chelsea Felkai, MPS[/caption]
Chelsea Felkai MPS, Disability and ACOP Pharmacist, Maroba Aged Care Facility, Waratah, Newcastle, NSW
I typically generate reports on residents who use psychotropic medicines. I talk with the resident, their family members, the RACF staff who know the resident, and the resident’s prescriber, to look at whether the medicine is the best option for the person, or if we need to explore alternatives.
Once we have established a resident would benefit from reductions, I work with the prescriber to put deprescribing or tapering plans in place to reduce (or cease) less appropriate medicines. Because I am on site 3 days a week, I am able to monitor this closely to ensure the resident is supported and safe through the process.
In early wins, we have been able to replace mostly tricyclic antidepressants (TCAs) with high anticholinergic burden to newer agent antidepressants (I tend to call this low-hanging fruit) with a lot of success.
Though it’s not strictly chemical restraint, it has brought about a large reduction in adverse outcomes across the facility. We have seen a complete cessation of antipsychotic medicines in only two residents so far (the facility has 150, with approximately 25 in the memory support unit), but we have been able to reduce chemical restraint in all residents to the lowest effective maintenance dose.
We have seen an increase in selective serotonin reuptake inhibitor (SSRI) medicines, and a reduction in TCAs. We have also seen an increase in duloxetine and mirtazapine. I have tried to use some of the newer evidence of duloxetine’s efficacy for chronic pain management and mirtazapine’s for sleep support, as options when switching antidepressants.
There has been some discomfort from residents and staff while we have trialled reduction in psychotropic medicines, to ensure the resident is on the lowest possible dose. Because education was provided to staff at the start, it was met with little resistance. And it helped that I was on site to provide support and monitor the outcomes.
Working with the nursing staff to understand when PRN (as required) chemical restraint might be used, and ensuring other options have been exhausted first, has shown the most reduction in how much psychotropic medications have been used so far. The numbers are relatively small, but to be honest, this is largely because the facility had great protocols to begin with.
The impact has been noticeable. Staff members say they feel more confident in the care they provide and the non-pharmacological options they now have at their disposal.
When they do move to a chemical restraint option, it is because other options have been exhausted, and it is in the best interest of the resident.
Case 2
[caption id="attachment_26803" align="alignleft" width="144"] Dr Natalie Soulsby FPS[/caption]
Dr Natalie Soulsby FPS, Credentialed Pharmacist, South Australia
My role is Head of Clinical Governance and Quality Assurance for Embedded Health Solutions, which provides clinical pharmacy services to about 600 residential aged care facilities (RACFs).
One of my roles is to attend national medication advisory committee (MAC) meetings to provide information to head office on medication management, including the psychotropic register. I analyse the information on the register and provide a clinical lens, which is used to support staff to understand where these medicines may be being used as restraints.
The Aged Care Quality and Safety Commission responded to the Royal Commission into Aged Care Quality and Safety by creating a psychotropic register that needs to be updated monthly, so they can keep track of how many patients were prescribed a medicine that was used as a chemical restraint and how they were being managed.
In 2021, when the National Aged Care Quality Indicator Program included the use of antipsychotic medicines, the quarterly numbers showed 21.6% of residents were administered antipsychotic medicines during a 7-day time frame. That figure is now down to 17.3%.
The registers have been a good trigger to remind doctors to review their patients’ treatments. When it began, doctors were concerned about prescribing antipsychotic medicines, and unfortunately some GPs stopped their patients’ medicines, which caused a return of their symptoms. These medicines must be weaned slowly.
There is still a stigma with these medicines, and our focus is always on appropriateness. All the new red tape means staff at the facilities spend a lot more time collecting data.
Initially it was overwhelming and confusing. GPs were concerned about the impact on their patients. There was also a lack of communication and understanding. The staff are more confident now, but there is still confusion as to what constitutes a chemical restraint.
Now everyone in the care team, including the staff in the home, the GP and the family, are involved in the process. Staff members encourage GPs to look at the psychotropic medicines regularly (at least every 3 months), and the staff assess the effectiveness or otherwise of the medications and consider any adverse effects and update the Behaviour Support Plan. This is considered best practice.
And one of the roles of the credentialed pharmacist is to support the home in filling out the register.
One impact has been a shift to more person-centred care.
The patient is seen as an active participant in their care, which lines up with the new Aged Care Act coming into effect in November this year. The concept is good, but we are still trying to work out how that will work in the long term.
Reviewing the psychotropic register allows us to support our facilities in ensuring appropriate treatments are prescribed and reviewed regularly for the residents.
We can use the register as part of our reviews and for follow-ups.
Nursing staff are more aware of the role of medicines in treating responsive behaviours, and having the register supports their conversations with the GPs. Our role is to be the continuity-of-care person and why we allocate pharmacists to specific aged care facilities, which allows them to become part of the team and provide appropriate advice and support.
We are the second set of eyes. We put a clinical lens over what has gone on and can help the nursing staff.
Pharmacists are the guardians of medicines management and the advocates for the nursing staff and residents. We help support the residents’ care.
References
- Royal Commission into Aged Care Quality and Safety. Final Report. 2021. At: www.royalcommission.gov.au/aged-care/final-report
- Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability. Final Report. 2023. At: https://disability.royalcommission.gov.au/publications/final-report
[post_title] => How pharmacists are reducing chemical restraint
[post_excerpt] => For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way.
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[post_content] => Women of reproductive age using glucagon-like peptide-1 receptor agonists (GLP-1 RAs) could be at risk of unintended pregnancy, and may be unaware of associated risks to pregnancy and unborn babies.
A new study by Flinders University, which examined records from more than 1.6 million women aged 18–49 who attended general practice between 2011 and 2022, found that only one in five (21%) of those with first prescribing of GLP-1 RAs had documented contraceptive use.
The study also found that most prescriptions for GLP-1 RAs are now issued to women without diabetes. In 2022 alone, more than 6,000 women began treatment on GLP-1 RAs, and over 90% of those did not have a type 2 diabetes diagnosis.
[caption id="attachment_30483" align="alignright" width="300"] Associate Professor Luke Grzeskowiak[/caption]
Participants were tracked at the initial stages of GLP-1 RA therapy, with the research team looking at documented evidence of pregnancies over a 6-month period, said lead author and pharmacist, Associate Professor Luke Grzeskowiak.
‘[While] limited to data from GP records, one in 25 women aged 18 to 34 years had a documented pregnancy at the time of prescribing,’ he said.
‘There will also be pregnancies that the GP might not be aware of, so if anything, what we're expecting is that this is an underestimate of what's truly happening.’
Those who were prescribed concurrent contraception were 50% less likely to have a documented pregnancy.
‘So we've got clear evidence that contraceptive use at the time of initiating these medicines reduces the risk of pregnancies occurring,’ A/Prof Grzeskowiak said.
Why does GLP-1 RA use increase pregnancy risk?
There are two key reasons: first, it is ‘well established’ that weight loss can improve fertility.
‘Because we know these medicines are very effective at promoting weight loss, it's highly plausible that they could improve fertility through that mechanism,’ A/Prof Grzeskowiak said.
There have also been concerns that GLP-1 RAs might impact absorption of the oral contraceptive pill.
In June 2025, the UK’s Medicines and Healthcare products Regulatory Agency issued a regulatory warning following case reports of unexpected pregnancies associated with GLP-1 RA use.
‘A detailed review [revealed] that the strongest evidence was around potential interaction between tirzepatide and reduced effectiveness of oral contraception,’ A/Prof Grzeskowiak said.
To date, evidence regarding interactions between GLP-1 RAs and the oral contraceptive pill is limited.
‘So the general recommendations around that regulatory warning were for those relying on oral contraceptive methods to also consider using a barrier method,’ he said.
What are the congenital risk factors?
The research also considered potential harms associated with GLP-1 RAs in pregnancy. Key concerns were taken from a University of Amsterdam review of animal studies, cited in the Flinders University study.
‘In animals, use of GLP-1 RAs [in pregnancy] led to reductions in foetal growth, impairments in bone development and impaired maternal weight gain,’ A/Prof Grzeskowiak said.
At this stage, the human data are more reassuring.
‘The studies that have been done have not shown an increased risk of birth defects,’ he said. ‘But they are still relatively limited in terms of numbers, and we don't have an examination of the full range of pregnancy outcomes yet,’ he said.
Due to this uncertainty, an abundance of caution is advised.
‘The recommendations are to not use these medicines during pregnancy, and to avoid the potential for them to be used during pregnancy accidentally,’ A/Prof Grzeskowiak said. ‘So it’s important to have a plan around concurrent contraception use, high-quality pre-conception care, and ensure that where pregnancies are planned, everything has been done to optimise pregnancy outcomes.’
What should pharmacists advise patients?
Dispensing GLP-1 RAs provides important opportunities for pharmacists to talk to patients about reproductive health.
For example, when dispensing tirzepatide, access to dispensing data on contraceptive methods enables pharmacists to raise awareness of the potential interaction by initiating an open and unassuming conversation, A/Prof Grzeskowiak said.
‘Having a conversation about how that might be addressed means patients can make an informed decision,’ he said. ‘It might mean changing contraceptive methods or [referring] them back to the GP for a conversation. Or it may be that they're using contraceptives for non-contraceptive purposes such as acne [management], so there’s a low risk of pregnancy.’
The initiation of therapy is the ideal time to discuss potential risks.
‘That way people know what to expect in terms of the medicines,’ he said.
When commencing GLP-1 RAs, patients may also experience profound gastrointestinal adverse effects, including vomiting or diarrhoea.
‘That in itself can reduce the effectiveness of oral contraception, regardless of any other interactions,’ A/Prof Grzeskowiak said. ‘So people should be aware of the side effects of what to expect when starting this and how it might impact on other treatments that they're using.’
Pharmacists have an important role in engaging patients in conversations about reproductive health, particularly contraception.
‘Not everyone feels comfortable asking those questions, but there are good training resources, particularly through PSA, around improving pharmacists’ comfort with having those conversations, including around the different types of contraceptive methods,’ he said.
‘It's one thing to start the conversation, but you also need to be armed with various information to be able to continue it, or at least identify when to refer patients back to their medical practitioner or another [healthcare practitioner] to provide that detailed advice.’
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[post_excerpt] => Women of reproductive age using GLP-1 RAs could be at risk of unintended pregnancy, and unaware of the risks to pregnancy and unborn babies.
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[post_content] => Pharmacists are asked to lead the shift from reliever-only inhalers to inhaled corticosteroid-containing regimens and to minimise short courses of oral corticosteroids.
Just under 3 million Australians live with asthma. The condition has the eighth-highest disease burden in the nation, and it is one of the most significant chronic conditions in children.
Guided by the results of large trials, recommendations for asthma management in adults and adolescents are changing, and pharmacists need to be aware of updated guidelines. The Australian Asthma Handbook was updated yesterday (16 September 2025) to reflect new thinking on asthma care and management.
What are the key updates?
Three key changes have been made to the Australian Asthma Handbook, including:
-
- All adults and adolescents with confirmed asthma should be taking inhaled corticosteroid-containing treatment and not as-needed short-acting beta2-agonists (SABAs) alone. Asthma can be well controlled with maintenance and reliever therapy, and a small proportion of patients with severe asthma may be eligible for biologics.
- An emphasis on the importance of limiting oral corticosteroids, which have been associated with a range of different harms, including damage to bone health, cataracts and type 2 diabetes.
- Health professionals should be aware the handbook has greater guidance for treating children aged 1–5 who are living with asthma and a recommendation that some older children should also be on low-dosage ICS maintenance therapy.
Why have the guidelines been updated?
Overuse of SABAs has been linked to poor asthma control and preventable hospitalisations.
‘The evidence is that the risks of SABA alone have become clearer and that we were overusing a not very effective and not very safe therapy,’ said Professor Nick Zwar, Executive Dean of Bond University’s Faculty of Health Sciences and Medicine, and Chair of the Australian Asthma Handbook Guidelines Committee.
‘Budesonide-formoterol, taken only as needed, is recommended in place of SABA. Maintenance and reliever therapy is now recommended as the next step up.’
The risks of SABA overuse include a lack of bronchodilator response over time, and the possibility that some people may have quite a severe asthma attack and end up in the hospital emergency department (ED), or hospitalised, when they don’t need to be.
There is very strong evidence to demonstrate that all adolescents and adults living with asthma should be treated with ICS, said pharmacist and Clinical Executive Lead at the National Asthma Council Australia, Debbie Rigby FPS.
‘Just having the SABA alone only treats one component of asthma, which is the bronchoconstriction, whereas having the low-dose ICS helps manage the inflammation and mucus production,’ she said. ‘I think that’s the biggest shift for us, pharmacists and doctors: helping patients to understand that asthma is a chronic inflammatory condition.’
What are the risks of poor asthma control?
Inadequately managed asthma can be a life-threatening condition, Ms Rigby stressed, noting there were 474 asthma-related deaths in Australia in 2023.
‘Those deaths shouldn’t be happening. Many of those people who did die from asthma or asthma-related causes would have been perceived as having mild, intermittent symptoms,’ she said. ‘Without wanting to scare patients, we should be really highlighting the consequences of not having good control of their asthma.’
Why is SABA still overused?
Despite access to long-acting beta2 agonists (ICS–LABAs), SABA use remains high for a range of reasons. These include cost, convenience and patient reluctance to medicate every day when they are accustomed to using a reliever-only when they have an asthma attack, Ms Rigby said.
Health professionals understand that many people are reluctant to use a preventer inhaler, but health professionals need to help them understand that they have a ‘chronic inflammatory condition, which may flare up from time to time’.
Effects of the cost-of-living crisis should not be underestimated either. However, the price gap between over-the-counter salbutamol and prescription asthma medicines is now narrowing, with 60-day dispensing for patients who are stable and, from January 2026, the co-payment for medicines being reduced from $31.60 to $25 per prescription.
The Australian uptake of Maintenance and Reliever Therapy (MART) has also been slow, despite strong evidence and subsidy on the Pharmaceutical Benefits Scheme. The evidence of large-scale trials has shown the importance of shifting patients with mild asthma onto anti-inflammatory reliever therapy on an as-needed basis, Ms Rigby said.
‘The evidence basically says it reduces the risk of severe exacerbations requiring ED or hospitalisation, or requiring oral corticosteroids,’ she said.
For practical guidance on discussing the guideline changes with patients, the role of prescribing pharmacists, and how biologics fit into care, don’t miss the October cover story in Australian Pharmacist.
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[post_content] => Case scenario
Ashley, a 23-year-old female, presents to your pharmacy with a prescription for a 7-day course of doxycycline 100 mg twice daily. She tells you she has had some mild vaginal discharge and that her STI screen has come back positive for vaginal chlamydia. You establish that she is currently taking ferrous sulfate 325 mg once daily as she is vegan, isotretinoin 30 mg once daily for acne, and has an etonogestrel implant in situ. She has no
known allergies.
Note: The authors recognise that gender identity is fluid. In this article, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Chlamydia and gonorrhoea are two of the most prevalent bacterial sexually transmitted infections (STIs) globally.1,2 They are preventable and curable infections that are usually transmitted through vaginal, oral or anal sex.1,2 Conjunctival infection can occur in neonates born to mothers carrying a chlamydia or gonorrhoea infection, or in adults via exposure to genital secretions.1–4 Both chlamydia and gonorrhoea can lead to serious health complications if left untreated, ranging from effects on fertility and pregnancy to blindness (in untreated ocular gonorrhoea infection).1,2
Chlamydia is caused by the gram-negative bacterium Chlamydia trachomatis.2 Gonorrhoea is caused by the gram-negative bacterium Neisseria gonorrhoeae.1
Chlamydia is relatively simple to treat, being susceptible to doxycycline and azithromycin.5 Gonorrhoea treatment may be more challenging due to emerging antimicrobial resistance to first-line treatments, particularly in urban Australia.6 All people diagnosed with chlamydia and gonorrhoea should be offered antibiotic treatment to resolve symptoms, prevent complications and to decrease transmission to others.1,2
Pharmacists can support patients by providing information on safe-sex practices, any prescribed medicines, in addition to providing advice or referring where appropriate.
The World Health Organization (WHO) estimates there were around 128.5 million new infections with C. trachomatis in 2020 among adults aged 15–49 years globally.2 In Australia, those under 30 years of age are at greatest risk of infection.5 There were 102,222* cases of chlamydia notified to the Australian government’s National Notifiable Diseases Surveillance System (NNDSS) in 2024, with an almost equal distribution of infection between males and females.7 This was an increase of almost 20% compared to the 86,810 case notifications in 2014.7 Across all ages, infections in females over this time period remained similar, however infections in males increased by approximately 40%.7
The WHO estimates that 82.4 million adults aged 15–49 years old acquired gonorrhoea worldwide in 2020.1 In Australia, gonorrhoea is most prevalent in men who have sex with men (MSM), remote Aboriginal and Torres Strait Islander communities, street-based sex workers, and returned travellers reporting sex overseas (in high prevalence countries).6,8 In recent years, there has been a rise in prevalence in the general population, especially in females of reproductive age.6 There were 44,547* cases of gonorrhoea notified to the NNDSS in 2024.7 This is almost triple the 15,674 cases notified in 2014.7
Co-infection with both chlamydia and gonorrhoea is relatively common.9 A study of high-prevalence Aboriginal communities in remote Australia found half of female and one-third of male participants aged 16–19 had one or more STIs.10 Chlamydia and gonorrhoea were the most common co-infections.10
*Figures correct as of May 2025.
Chlamydia
Chlamydia is often described as the “silent STI” because 85–90% of infections are asymptomatic.5 If symptoms do appear, they may not present until up to 3 weeks after sexual contact with an individual with chlamydia infection.2
Common chlamydia symptoms for males include2,5:
For females, symptoms include2,5:
Gonorrhoea
Gonorrhoea symptoms usually appear within 2 weeks of exposure.1 Infection is usually asymptomatic in females.1
If symptoms occur in females, they include1,4,6:
In contrast for males, penile urethral gonorrhoea is almost always symptomatic and symptoms may include1,6:
Complications
Untreated chlamydia and gonorrhoea can lead to various complications in both males and females, highlighting the need for prompt identification and treatment of infection.
Table 1 outlines some complications associated with untreated C. trachomatis and N. gonorrhoeae infection.
Diagnosis and differential diagnosis Molecular testing should be undertaken for those suspected of having chlamydia or gonorrhoea, or those at risk of infection. Certain groups (e.g. MSM, pregnant people, sex workers, Aboriginal and Torres Strait Islander people, gender diverse and transgender people) require special testing approaches due to increased risk of infection, adverse health outcomes or community prevalence.11 A full STI check-up including HIV and syphilis serology at initial presentation is recommended.11
Chlamydia is diagnosed via nucleic acid amplification tests (NAATs) (e.g. polymerase chain reaction [PCR]).5 NAATs are highly sensitive and the only recommended test for chlamydia.5 Microbiological culture of C. trachomatis is difficult and not routinely recommended.12
NAATs are also used to diagnose gonorrhoea.6 They are highly sensitive but do not provide any information on antibiotic susceptibility.6 Gonococcal microbiological culture has high specificity and allows for antibiotic susceptibility testing, but is less sensitive than NAATs.6
Some differential diagnoses for genital tract chlamydia infection may include lymphogranuloma venereum, gonorrhoea, bacterial vaginosis, vaginal candidiasis, trichomonas or Mycoplasma genitalium infection.13 For gonorrhoea, other conditions such as chlamydia, trichomonas, vaginal candidiasis, bacterial vaginosis or urinary tract infections may cause similar symptoms.14
Anatomical sites sampled for chlamydia and gonorrhoea testing will depend on the individual’s presentation, sexual history and risk factors.5,6 Self-collection of samples for testing by NAAT is common practice for asymptomatic patients.5 In symptomatic patients undergoing examination, a swab can be taken by the clinician (e.g. an endocervical swab if a speculum examination occurs).5,6 First-pass urine can be tested in people without a vagina (or if a vaginal swab cannot be taken) – it is less sensitive than a self-collected vaginal swab.5,6 An anorectal swab is recommended for all individuals who have anorectal symptoms, and for all MSM regardless of whether they are symptomatic.5,6 Similarly, a pharyngeal swab for NAAT is recommended for MSM for both gonorrhoea and chlamydia, even if asymptomatic.5,6
Gonococcal culture
Gonococcal cultures should be collected from all infected sites prior to commencing treatment to determine antibiotic susceptibility and to contribute to antimicrobial resistance surveillance.6 It is recommended that a culture is performed on a site if an individual is experiencing symptoms at that site.6 Pending culture results should not delay commencing treatment, and antibiotics can be administered prior to receiving the culture results.6
The goals of treatment for both chlamydia and gonorrhoea are to resolve symptoms, reduce complications and prevent transmission and reinfection. Sometimes a clinical diagnosis is made based on symptoms and risk factors. Certain presentations may warrant starting empiric treatment while awaiting confirmation of results. Examples include patients presenting with anorectal symptoms, symptoms of PID or epididymo-orchitis, where timely treatment is critical.15–17
Chlamydia
Doxycycline is the standard first-line therapy for chlamydia.5,18 Azithromycin is an alternative option if doxycycline is contraindicated (e.g. in pregnancy, if there are adherence or medicine interaction concerns).3,18
Previously, azithromycin was the first-line treatment, as it was a convenient single dose. However, a meta-analysis showed azithromycin 1 g orally may be up to 20% less efficacious than 7 days of doxycycline when treating anorectal chlamydia. A subsequent randomised trial of 625 Australian MSM with asymptomatic anorectal chlamydia demonstrated consistent findings.19,20 Azithromycin is also increasingly implicated in antimicrobial resistance for other STIs, therefore doxycycline is preferred.21
Gonorrhoea
The recommended treatment for gonorrhoea infection in Australia is ceftriaxone in combination with azithromycin.6 The recommended dose of oral azithromycin varies depending on the site of infection.4 The current combination treatment approach is highly effective and important in reducing the contribution to more widespread antimicrobial resistance.4,6 However, reduced susceptibility to these agents has been increasingly reported in urban Australia.6 Until recently, the combination of amoxicillin, probenecid and azithromycin was still recommended for gonorrhoea in some remote Australian areas. However, this changed to ceftriaxone with azithromycin, due to an increase in penicillin resistance in remote communities in the Northern Territory.22
Antimicrobial resistance is a growing problem in the treatment of gonorrhoea.1 Resistance to penicillin, tetracyclines, macrolides, sulphonamides and quinolones has been detected.23 Gonococcal surveillance programs are in place in some countries to track resistant strains.
Table 2 provides a summary of the current treatment approach for various presentations of chlamydia and gonorrhoea infection in Australia. Uncomplicated chlamydia or gonorrhoea infection refers to localised urogenital, anogenital, pharyngeal and ocular infections that are not associated with bacteraemia or ascending spread to other organs.24,25 Complicated infections and their treatment is beyond the scope of this article, as are other infections associated with C. trachomatis.
Prevention Consistent and correct condom use can prevent the transmission of chlamydia and gonorrhoea.1,2 There is currently no available vaccine to prevent either infection. The serogroup B meningococcal vaccine (4CMenB) is currently being investigated for its ability to provide cross-protection against N. gonorrhoeae.26
The use of doxycycline to prevent bacterial STIs (doxycycline post-exposure prophylaxis [doxy-PEP]) can offer protection against acquiring syphilis, chlamydia and, to a lesser extent, gonorrhoea, if taken within 72 hours of unprotected sexual intercourse.27 Controversy remains on whether the risk of changes to the microbiome and potential increased antimicrobial resistance as a result of using doxy-PEP outweighs the benefits of preventing these STIs, with research ongoing.27
Sexual contact should be avoided for 7 days after chlamydia and/or gonorrhoea treatment is commenced, or until the treatment course is completed and symptoms have resolved, whichever is later.5,6 Patients should be advised not to have sex with partners from the last 6 months for chlamydia, or the last 2 months for gonorrhoea, until partners have been tested and treated, if necessary.5,6 Notification of sexual partners is recommended and can be done anonymously by patients via websites such as Let Them Know (https://letthemknow.org.au/).5,6 With the consent of the patient, a clinician may support with contact tracing if necessary.
Reinfection with chlamydia and gonorrhoea is common.5,6 Retesting at 3 months is recommended to detect reinfection.5,6 A test of cure is not routinely recommended for chlamydia, except in specific circumstances (e.g. in pregnancy).5 A test of cure is recommended for gonorrhoea in cases where a culture was not collected before treatment, the culture indicated antimicrobial resistance or if a non-standard treatment regimen was used.6 Screening for other STIs should be performed if not done at the initial presentation.5,6
Patient-delivered partner therapy (PDPT) is where antibiotic treatment is prescribed or supplied for the sexual partner(s) of a patient diagnosed with chlamydia (index patient).5 The prescription or treatment is given directly to their partner(s) by the index patient.5 In jurisdictions where PDPT is approved, it can be considered for heterosexual index patients with anogenital or oropharyngeal chlamydia, whose partners are unlikely to seek chlamydia testing or treatment.5 PDPT can also be considered with cases of repeat infections where partners have not been treated.5 Guidance on PDPT for chlamydia is available in Victoria, New South Wales and the Northern Territory.5 The decision to use PDPT should be weighed against the potential to miss co-infections or complications in the partner(s) of the index patient.
Pharmacists may be among the first healthcare professionals that patients approach for guidance and treatment for STIs, particularly if presenting with symptoms of infection. Recognition of symptoms that may warrant onward referral to a medical practitioner is essential.
Pharmacists can support adherence to current recommended treatment regimens for STIs. This may include extended doxycycline courses, which ensures the resolution of infection and improves antibiotic efficacy.28 Pharmacists can also encourage patients to notify sexual partners regarding an STI diagnosis, enabling those partners to obtain timely treatment.
Doxy-PEP may be appropriate for some at-risk groups, providing an additional option to conventional STI prevention strategies. Evidence is building for doxy-PEP use and by following the Australasian Society for HIV, Viral Hepatitis & Sexual Health Medicine (ASHM) guidance, pharmacists can ensure they are providing evidence-based information to patients who wish to know more about this prevention strategy (see https://ashm.org.au/initiatives/doxy-pep-statement/).27
Chlamydia and gonorrhoea are two of the most prevalent bacterial STIs. Patients may be asymptomatic, and both can lead to serious complications if left untreated. Chlamydia is relatively easy to treat, however emerging antimicrobial resistance to first-line gonorrhoea treatments may complicate its management. Reinfection is common with both, and robust contact tracing of sexual partners is recommended.
Case scenario continuedAfter noting that doxycycline would need to be taken at least 2 hours before or after Ashley’s iron tablets, you also suspect an interaction with isotretinoin.28 You check the Australian Medicines Handbook (AMH), which highlights a risk of benign intracranial hypertension and that concurrent use should be avoided.29 You phone Ashley’s GP to recommend a safer, yet effective, alternative of azithromycin 1 g orally as a single dose. The GP and Ashley thank you for your help. |
Ivette Aguirre (she/her) BAppSc (MedLabSc), BPharm, GradCertPharmPrac, MClinPharm, FANZCAP (Inf Dis) is the senior clinical pharmacist at the Melbourne Sexual Health Centre (MSHC), a part of Alfred Health. She mentors pharmacists, technicians and pharmacy students during their rotations at MSHC, and is interested in the impact of pharmacist reviews in HIV clinics and emerging treatments for sexually transmissible infections such as Mycoplasma genitalium.
Kathryn (Kate) Mackie (she/her) BPharm, GradDipClinPharm, BCGP, FANZCAP (Inf Dis, Gen) is a senior clinical pharmacist at Alfred Health (including Melbourne Sexual Health Centre) and Barwon Health, working in infectious diseases, HIV, viral hepatitis and sexual health. With 20 years of experience in this area, she is engaged in clinical pharmacy research and contributes to undergraduate and health professional education.
Hana Numan (she/her) BPharm (NZ), PGDipClinPharm (NZ), MPS (NZ)
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[post_content] => Administered to the nasal mucosa, a spike-based formulation triggers rapid local defences that clear the COVID-19 virus where it enters.
In 2022, a year after Australia’s longest COVID-19 lockdowns, researchers from the Centenary Institute and the University of Sydney received a grant of almost $1 million from the NSW COVID-19 Vaccine Acceleration Research Grants Program to develop an intranasal COVID-19 vaccine.
Now, new research has been released by the team – finding that their formulation can stop infection in the nose before the virus spreads through the body, and to other people.
[caption id="attachment_30517" align="alignright" width="150"] Dr Erica Stewart, Centenary Institute[/caption]
Australian Pharmacist sat down with Dr Erica Stewart, first author and researcher at the Centenary Institute when the work was undertaken, to discuss how the vaccine works, its applications and why it could be the key to stopping the spread.
What is the vaccine’s mechanism of action?
By acting where the virus first enters, the nasal vaccine prompts a rapid, effective immune response that eliminates the virus, Dr Stewart said.
‘The adjuvant we used was Pam2Cys, a Toll-like receptor 2 (TLR2), and we showed that it was able to stimulate the immune response in the nasal passages,’ she said.
‘We formulated the SARS-CoV-2 spike protein with this adjuvant, which emulates bacteria to alert the immune system that there is a danger and it should respond.’
When administered as a booster after a standard injection, the treatment also provided additional protection to vital organs, including the lungs and brain – pointing to the benefits of focusing immune responses within the upper airways.
Why target the nasal mucosa?
The nasal passage is an increasingly promising site for vaccine adjuvant formulation, Dr Stewart said.
‘It’s becoming more and more clear that the nasal passage is a very different immune environment to an injection in the muscle.’
Internationally, there are some other pre-clinical models of mucosal vaccines. ‘But most of those mucosal vaccines are viral vectors because there aren't a lot of vaccine adjuvants that have been found to be effective nasally, which is part of the novelty of this study,’ she said.
The team had previously looked at intranasal vaccination in mice, using a model where the vaccine entered both the lungs and the nose.
‘However, the main takeaway from this research was, when [administering] a very small volume to just the nose, we still got a really strong immune response in the blood,’ she said. ‘We also looked into the nose itself, and we could see that the immune cells were retained for long periods in the nasal passages, where they will be able to respond to infection quickly.’
There’s hope that these vaccines can potentially prevent infection and transmission by building immune defences directly in the upper airways where the virus first takes hold – a frontier that traditional vaccines have yet to reach.
‘We currently reduce disease severity really well, but we're still trying to block transmission,’ Dr Stewart said. ‘That's what nasal vaccines are aiming to address.’
Who would benefit most from a nasal COVID-19 vaccine?
Vulnerable populations who are more susceptible to severe disease, hospitalisations and death.
‘Sometimes you'll hear people say, “COVID-19 is over” – but people are still dying of it, including the elderly, immunocompromised people and those with other comorbidities,’ Dr Stewart said.
Similar to how younger, healthy patients are advised to get the flu vaccine to protect more vulnerable members of the community – this vaccine offers an additional layer of protection.
‘It would be the vulnerable people who are benefiting, but the vaccine would be for everyone to try to reduce the circulation of the virus in our community,’ she said.
How would the vaccine fit into the routine immunisation schedule?
With most people vaccinated against COVID-19 or exposed to the virus, the mucosal vaccines will likely be used as a booster.
‘In the mouse model, both the vaccine as a booster or as a primary vaccination induced nasal immunity,’ Dr Stewart said.
It’s assumed that the nasal vaccine will be used as an annual seasonal dose, similar to the flu vaccine or COVID-19 boosters for certain populations.
‘We do have some evidence that the vaccine can neutralise against other variants, but [we need to explore] how well it protects people and for how long, because that would indicate whether continuous boosters are needed,’ she said.
It’s also anticipated that the nasal vaccine will be self-administered.
‘There are studies looking into self-administration of nasal vaccines, which could really help with distribution and access to these vaccines in the community,’ she said.
This mode of administration could be particularly beneficial for those who are needlephobic, including children.
‘For people who cannot stand getting a needle, this is a less invasive method of vaccination,’ Dr Stewart said.
The researchers say that while more work is needed, the results show strong potential for nasal vaccines to complement existing COVID-19 vaccines and provide an extra layer of protection against the virus in the future.
[post_title] => Intranasal vaccine stops infection at the source
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[post_content] => For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way. AP meets guardians of medicine management who are highly involved.
Australian pharmacists are playing a vital role in one of the nation’s most important healthcare campaigns – the reduction and ultimate elimination of chemical restraint.
The final reports of the Royal Commission into Aged Care Quality and Safety1 (2021) and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability2 (2023) made strong recommendations to reduce and ultimately eliminate the use of chemical restraint, sharing a commitment to upholding the rights and dignity of older people and people with disability.
In a joint statement in 2022, the Australian Commission on Safety and Quality in Health Care, the Aged Care Quality and Safety Commission and the NDIS Safety and Quality Commission acknowledged that psychotropic medicines were being overprescribed and overused for managing behaviours of concern. The disability royal commission final report went even further, says Advanced Practice Pharmacist and University of Western Australia Adjunct Professor Manya Angley FPS.
‘It called for a national approach to reducing and eliminating restrictive practices, including chemical restraint, and emphasised the need for a coordinated framework with targets, data collection, evaluation, performance indicators, timeframes and independent oversight. It also focused,’ she notes, ‘on supported decision-making and workforce training in trauma-informed, person-centred care.’
Annual Positive Behaviour Support progress reports were specifically recommended, she says, with an independent evaluation of measures to determine if the use of psychotropic medicines as chemical restraint in people with cognitive disability was reducing.
‘I have been working in aged care as an RMMR and QUM pharmacist since 2018,’ says Dr Angley. ‘Before the aged care royal commission interim report, risperidone as chemical restraint, and psychotropic medicines generally, were used less “mindfully”. If a doctor prescribed a psychotropic medication at usual doses as chemical restraint, it was considered acceptable. Since 2020, GPs, nurses and care staff have greater awareness of the risks of antipsychotics (including falls, stroke and death), the value of bespoke Positive Behaviour Support plans containing a suite of person-centred non-pharmacological strategies, and the need to gain informed consent before using chemical restraint.’
Dr Angley believes ‘everyone is getting better at identifying triggers for changed behaviours’. These can include constipation, urinary retention, pain, boredom, hunger or thirst, infection and medicines.
‘There is improved understanding that chemical restraint should only be used as a last resort, for the shortest possible time and at the lowest dose possible.’
Dr Angley also registered as an NDIS Positive Behaviour Support (PBS) practitioner in 2023. She uses her medicines expertise to identify and deprescribe chemical restraint in NDIS participants.
Pharmacists, as highly trained clinicians, are able to identify if health issues are contributing to changed behaviour. She believes credentialed pharmacists need to play a bigger role in the development of PBS plans for NDIS participants who are prescribed chemical restraint.
There are, however, limited funding options for medicines review services by credentialed pharmacists. Aside from registering as a PBS practitioner, remuneration for services provided to NDIS participants in the community is only available through Home Medicines Reviews, which require a doctor’s referral – a significant barrier.
AP asked two credentialed pharmacists about their experiences with the reduction of chemical restraint.
Case 1
[caption id="attachment_30506" align="alignright" width="148"] Chelsea Felkai, MPS[/caption]
Chelsea Felkai MPS, Disability and ACOP Pharmacist, Maroba Aged Care Facility, Waratah, Newcastle, NSW
I typically generate reports on residents who use psychotropic medicines. I talk with the resident, their family members, the RACF staff who know the resident, and the resident’s prescriber, to look at whether the medicine is the best option for the person, or if we need to explore alternatives.
Once we have established a resident would benefit from reductions, I work with the prescriber to put deprescribing or tapering plans in place to reduce (or cease) less appropriate medicines. Because I am on site 3 days a week, I am able to monitor this closely to ensure the resident is supported and safe through the process.
In early wins, we have been able to replace mostly tricyclic antidepressants (TCAs) with high anticholinergic burden to newer agent antidepressants (I tend to call this low-hanging fruit) with a lot of success.
Though it’s not strictly chemical restraint, it has brought about a large reduction in adverse outcomes across the facility. We have seen a complete cessation of antipsychotic medicines in only two residents so far (the facility has 150, with approximately 25 in the memory support unit), but we have been able to reduce chemical restraint in all residents to the lowest effective maintenance dose.
We have seen an increase in selective serotonin reuptake inhibitor (SSRI) medicines, and a reduction in TCAs. We have also seen an increase in duloxetine and mirtazapine. I have tried to use some of the newer evidence of duloxetine’s efficacy for chronic pain management and mirtazapine’s for sleep support, as options when switching antidepressants.
There has been some discomfort from residents and staff while we have trialled reduction in psychotropic medicines, to ensure the resident is on the lowest possible dose. Because education was provided to staff at the start, it was met with little resistance. And it helped that I was on site to provide support and monitor the outcomes.
Working with the nursing staff to understand when PRN (as required) chemical restraint might be used, and ensuring other options have been exhausted first, has shown the most reduction in how much psychotropic medications have been used so far. The numbers are relatively small, but to be honest, this is largely because the facility had great protocols to begin with.
The impact has been noticeable. Staff members say they feel more confident in the care they provide and the non-pharmacological options they now have at their disposal.
When they do move to a chemical restraint option, it is because other options have been exhausted, and it is in the best interest of the resident.
Case 2
[caption id="attachment_26803" align="alignleft" width="144"] Dr Natalie Soulsby FPS[/caption]
Dr Natalie Soulsby FPS, Credentialed Pharmacist, South Australia
My role is Head of Clinical Governance and Quality Assurance for Embedded Health Solutions, which provides clinical pharmacy services to about 600 residential aged care facilities (RACFs).
One of my roles is to attend national medication advisory committee (MAC) meetings to provide information to head office on medication management, including the psychotropic register. I analyse the information on the register and provide a clinical lens, which is used to support staff to understand where these medicines may be being used as restraints.
The Aged Care Quality and Safety Commission responded to the Royal Commission into Aged Care Quality and Safety by creating a psychotropic register that needs to be updated monthly, so they can keep track of how many patients were prescribed a medicine that was used as a chemical restraint and how they were being managed.
In 2021, when the National Aged Care Quality Indicator Program included the use of antipsychotic medicines, the quarterly numbers showed 21.6% of residents were administered antipsychotic medicines during a 7-day time frame. That figure is now down to 17.3%.
The registers have been a good trigger to remind doctors to review their patients’ treatments. When it began, doctors were concerned about prescribing antipsychotic medicines, and unfortunately some GPs stopped their patients’ medicines, which caused a return of their symptoms. These medicines must be weaned slowly.
There is still a stigma with these medicines, and our focus is always on appropriateness. All the new red tape means staff at the facilities spend a lot more time collecting data.
Initially it was overwhelming and confusing. GPs were concerned about the impact on their patients. There was also a lack of communication and understanding. The staff are more confident now, but there is still confusion as to what constitutes a chemical restraint.
Now everyone in the care team, including the staff in the home, the GP and the family, are involved in the process. Staff members encourage GPs to look at the psychotropic medicines regularly (at least every 3 months), and the staff assess the effectiveness or otherwise of the medications and consider any adverse effects and update the Behaviour Support Plan. This is considered best practice.
And one of the roles of the credentialed pharmacist is to support the home in filling out the register.
One impact has been a shift to more person-centred care.
The patient is seen as an active participant in their care, which lines up with the new Aged Care Act coming into effect in November this year. The concept is good, but we are still trying to work out how that will work in the long term.
Reviewing the psychotropic register allows us to support our facilities in ensuring appropriate treatments are prescribed and reviewed regularly for the residents.
We can use the register as part of our reviews and for follow-ups.
Nursing staff are more aware of the role of medicines in treating responsive behaviours, and having the register supports their conversations with the GPs. Our role is to be the continuity-of-care person and why we allocate pharmacists to specific aged care facilities, which allows them to become part of the team and provide appropriate advice and support.
We are the second set of eyes. We put a clinical lens over what has gone on and can help the nursing staff.
Pharmacists are the guardians of medicines management and the advocates for the nursing staff and residents. We help support the residents’ care.
References
- Royal Commission into Aged Care Quality and Safety. Final Report. 2021. At: www.royalcommission.gov.au/aged-care/final-report
- Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability. Final Report. 2023. At: https://disability.royalcommission.gov.au/publications/final-report
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[post_content] => Women of reproductive age using glucagon-like peptide-1 receptor agonists (GLP-1 RAs) could be at risk of unintended pregnancy, and may be unaware of associated risks to pregnancy and unborn babies.
A new study by Flinders University, which examined records from more than 1.6 million women aged 18–49 who attended general practice between 2011 and 2022, found that only one in five (21%) of those with first prescribing of GLP-1 RAs had documented contraceptive use.
The study also found that most prescriptions for GLP-1 RAs are now issued to women without diabetes. In 2022 alone, more than 6,000 women began treatment on GLP-1 RAs, and over 90% of those did not have a type 2 diabetes diagnosis.
[caption id="attachment_30483" align="alignright" width="300"] Associate Professor Luke Grzeskowiak[/caption]
Participants were tracked at the initial stages of GLP-1 RA therapy, with the research team looking at documented evidence of pregnancies over a 6-month period, said lead author and pharmacist, Associate Professor Luke Grzeskowiak.
‘[While] limited to data from GP records, one in 25 women aged 18 to 34 years had a documented pregnancy at the time of prescribing,’ he said.
‘There will also be pregnancies that the GP might not be aware of, so if anything, what we're expecting is that this is an underestimate of what's truly happening.’
Those who were prescribed concurrent contraception were 50% less likely to have a documented pregnancy.
‘So we've got clear evidence that contraceptive use at the time of initiating these medicines reduces the risk of pregnancies occurring,’ A/Prof Grzeskowiak said.
Why does GLP-1 RA use increase pregnancy risk?
There are two key reasons: first, it is ‘well established’ that weight loss can improve fertility.
‘Because we know these medicines are very effective at promoting weight loss, it's highly plausible that they could improve fertility through that mechanism,’ A/Prof Grzeskowiak said.
There have also been concerns that GLP-1 RAs might impact absorption of the oral contraceptive pill.
In June 2025, the UK’s Medicines and Healthcare products Regulatory Agency issued a regulatory warning following case reports of unexpected pregnancies associated with GLP-1 RA use.
‘A detailed review [revealed] that the strongest evidence was around potential interaction between tirzepatide and reduced effectiveness of oral contraception,’ A/Prof Grzeskowiak said.
To date, evidence regarding interactions between GLP-1 RAs and the oral contraceptive pill is limited.
‘So the general recommendations around that regulatory warning were for those relying on oral contraceptive methods to also consider using a barrier method,’ he said.
What are the congenital risk factors?
The research also considered potential harms associated with GLP-1 RAs in pregnancy. Key concerns were taken from a University of Amsterdam review of animal studies, cited in the Flinders University study.
‘In animals, use of GLP-1 RAs [in pregnancy] led to reductions in foetal growth, impairments in bone development and impaired maternal weight gain,’ A/Prof Grzeskowiak said.
At this stage, the human data are more reassuring.
‘The studies that have been done have not shown an increased risk of birth defects,’ he said. ‘But they are still relatively limited in terms of numbers, and we don't have an examination of the full range of pregnancy outcomes yet,’ he said.
Due to this uncertainty, an abundance of caution is advised.
‘The recommendations are to not use these medicines during pregnancy, and to avoid the potential for them to be used during pregnancy accidentally,’ A/Prof Grzeskowiak said. ‘So it’s important to have a plan around concurrent contraception use, high-quality pre-conception care, and ensure that where pregnancies are planned, everything has been done to optimise pregnancy outcomes.’
What should pharmacists advise patients?
Dispensing GLP-1 RAs provides important opportunities for pharmacists to talk to patients about reproductive health.
For example, when dispensing tirzepatide, access to dispensing data on contraceptive methods enables pharmacists to raise awareness of the potential interaction by initiating an open and unassuming conversation, A/Prof Grzeskowiak said.
‘Having a conversation about how that might be addressed means patients can make an informed decision,’ he said. ‘It might mean changing contraceptive methods or [referring] them back to the GP for a conversation. Or it may be that they're using contraceptives for non-contraceptive purposes such as acne [management], so there’s a low risk of pregnancy.’
The initiation of therapy is the ideal time to discuss potential risks.
‘That way people know what to expect in terms of the medicines,’ he said.
When commencing GLP-1 RAs, patients may also experience profound gastrointestinal adverse effects, including vomiting or diarrhoea.
‘That in itself can reduce the effectiveness of oral contraception, regardless of any other interactions,’ A/Prof Grzeskowiak said. ‘So people should be aware of the side effects of what to expect when starting this and how it might impact on other treatments that they're using.’
Pharmacists have an important role in engaging patients in conversations about reproductive health, particularly contraception.
‘Not everyone feels comfortable asking those questions, but there are good training resources, particularly through PSA, around improving pharmacists’ comfort with having those conversations, including around the different types of contraceptive methods,’ he said.
‘It's one thing to start the conversation, but you also need to be armed with various information to be able to continue it, or at least identify when to refer patients back to their medical practitioner or another [healthcare practitioner] to provide that detailed advice.’
[post_title] => GLP-1 RAs found to pose pregnancy risks
[post_excerpt] => Women of reproductive age using GLP-1 RAs could be at risk of unintended pregnancy, and unaware of the risks to pregnancy and unborn babies.
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