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[post_content] => From 1 July 2025, pharmacists will see a range of adjustments to how they deliver and bill for vaccination.
Here, Australian Pharmacist outlines the changes in vaccination services and fees pharmacists can expect from early next month.
1. NIPVIP vaccine administration fees will (slightly) increase
In 2025, the Consumer Price Index (CPI) rose by 2.4%. So from next month, there will be a CPI increase applied to all National Immunisation Program Vaccinations in Pharmacy (NIPVIP) vaccines administered. Pharmacists will receive $20.05 per vaccine administered, up from $19.60.
2. The COVID-19 vaccination payment will (significantly) drop
In less than a week, community pharmacists will see a significant reduction in the COVID-19 vaccine administration fee. The new rate will be $20.05 per vaccine administration in all Australian locations.
This is a significant decrease from the previous rates per dose, which were:
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[post_content] => As investigations reveal many popular high-SPF sunscreens don’t live up to their labels, both pharmacists and pharmacy assistants have a greater role to play in promoting a holistic sun protection routine.
On 12 June 2025, consumer advocacy group CHOICE released findings of a review on 20 popular SPF50 and SPF50+ brands – revealing that many don’t stack up as claimed.
According to the findings, only 20% (4) sunscreens met their SPF claims – with one Australian brand, Ultra Violette Lean Screen SPF 50+ Matifying Zinc Skinscreen, measuring only SPF 4.
Last week, the Therapeutic Goods Administration (TGA) vowed to investigate the matter.
With confidence in sunscreen already undermined via social media claims that its ingredients are toxic, how should pharmacists promote sun safety?
How do SPF numbers translate into real-world UV protection?
Australia has the highest incidence of melanoma in the world. So when the UV Index is 3 or above, it’s advisable to use a broad-spectrum, water-resistant sunscreen with an SPF30 or higher to protect against both UVA and UVB rays.
Despite the CHOICE findings, the difference in SPF ratings is not as stark as it seems. For example, Sunscreens with SPF 50 block around 98% of ultraviolet radiation (UVR), whereas SPF 30 formulations block roughly 96.7%.
So if unprotected skin begins to redden after 5 minutes in the sun, using an SPF50 formulation should, in theory, delay that reaction by fifty times – equating to roughly 250 minutes of protection. Likewise, an SPF30 product would ideally extend safe exposure to about 150 minutes. But by that rationale, an SPF4 sunscreen would only provide 20 minutes of protection – proving very limited benefit.
Application thickness also matters, Professor Rachel Neale, Senior Group Leader at the QIMR Berghofer Medical Research Institute told Australian Pharmacist.
‘The amount of sunscreen people apply will make a substantial difference to the SPF.’
What advice should pharmacists provide?
Even if the sunscreens don't meet their marketed claims, pharmacists should remind patients that they likely still offer a reasonable level of protection if used according to reapplication instructions.
Since pharmacy assistants often field questions about over-the-counter products such as sunscreen, pharmacists must ensure they’re fully across this messaging, including:
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[post_content] => Case scenario
Mrs Alvarez, an 82-year-old woman, presents to your pharmacy with a new prescription for apixaban 5 mg twice daily and some discharge paperwork, following a recent hospital admission after a fall at home. You notice that she was diagnosed with AF during her stay. Her medical history includes a myocardial infarction (MI) 2 years ago, for which she has been taking metoprolol, atorvastatin and aspirin.
Sponsorship statement
Funded by the Australian Government through the Quality Use of Diagnostics, Therapeutics and Pathology Program
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Atrial fibrillation (AF) is the most common recurrent arrhythmia worldwide,1 characterised by uncoordinated atrial activity and irregular ventricular contractions. While its causes and contributors are many, all share a common sequela – an increased risk of ischaemic stroke that can be mitigated by anticoagulation.1 While the use of anticoagulants since the emergence of direct-acting oral anticoagulants has increased, the prevalence of AF has grown.1 This has been accompanied by a rise in hospitalisations both directly due to AF, and indirectly due to stroke and its complications.1 Pharmacists can significantly enhance AF care through direct patient engagement and collaboration with other healthcare professionals across all practice settings. Understanding key aspects of AF, its clinical features and evidence-based treatment strategies allows pharmacists to contribute positively to the overall management of individuals living with the condition.
The prevalence of AF is rising, with over 500,000 Australians estimated to have the condition in 2020,1 and over 600,000 projected by 2034.2 Although this is likely to be an underestimate of the true prevalence of AF in Australia.2
Complications arising from AF pose a substantial health burden, with a fivefold increase in the risk of stroke.3 In 2017–18 there were over 72,000 hospitalisations for AF in Australia, with the condition contributing to 9% of deaths in 2018.1 In 2015–16, AF-related healthcare expenditure in Australia was $881 million, with 69% attributed to hospital costs.1
AF results from electrophysiological abnormalities that underlie impulse generation in the heart, and/or structural irregularities that impair rapid and uniform impulse conduction.4 AF often arises from abnormal electrical activity triggered by ectopic action potentials originating in the pulmonary veins of the left atrium.4 Ongoing clinically meaningful AF requires underlying structural or electrical changes in the heart that continue to disrupt normal conduction and contraction.5 An interactive animation demonstrating cardiac activity in AF from the American Heart Association is available at https://watchlearnlive.heart.org/CVML_Mobile.php?moduleSelect=atrfib.
AF arises from a combination of genetic, metabolic, and environmental factors.4 Contributors include oxidative stress (such as alcohol intake or sleep-disordered breathing), pro-inflammatory states (diabetes and obesity), structural atrial changes (heart failure), genetics and aging.4 These conditions are interlinked, reinforcing the concept that “AF begets AF”.4 In other words, the conditions that cause AF can worsen AF, and AF can also worsen these conditions. The main sequela to this is increased stroke risk. This is caused due to the irregular contractions of the left atria leading to stasis of blood, predisposing to thrombus formation. If the thrombus embolises, it can shift into the ventricle and enter systemic circulation and subsequently the carotid arteries, leading to the embolus becoming lodged in the cerebral arteries.
Beyond the arrhythmia, AF often signals broader pathological processes that impair cardiac function and reduce quality of life and life expectancy.5 Many of these conditions are closely linked to social determinants of health, disproportionately affecting populations with socioeconomic disadvantage. Effective AF management requires addressing both the arrhythmia and its underlying contributors.4
Symptoms
Like many cardiac conditions, AF symptoms can vary between individuals and overlap with other conditions, including coronary syndromes, heart failure, COPD and asthma. Common symptoms include5:
In addition, some individuals with AF may be completely asymptomatic.4
AF is also linked to higher rates of dementia and depression compared to the general population.5 Several tools are available to assess symptom burden and stratify the impact of symptoms, such as the modified European Heart Rhythm Association Score.5 Understanding the burden of AF and its associated comorbidities is essential for providing a holistic approach to patient care.
Stroke risk
The first sign of AF can be a stroke. The Australian Institute of Health and Welfare reported that in 2017–18, AF was present in 15.5% of patients hospitalised for stroke.1
Stroke risk varies, and the CHA2DS2-VA calculator is widely used in clinical practice to estimate the risk of stroke in AF.6 Points are assigned based on the following parameters7:
Scores range from 0 (ischaemic stroke incidence rate of 0.5 per 100 patient years) through to 8 (19.5 per 100 patient years).7 Scores may be used to inform decisions around initiating anticoagulation. There are other tools available, such as the GARFIELD-AF calculator, which offer more precise risk prediction, including bleeding and mortality, but require more detailed data.4
AF is diagnosed with the use of a 12-lead electrocardiogram (ECG). The ECG typically demonstrates an absence of discernible P waves and an irregularly irregular rhythm.5
Most recent international guidelines recommend further investigation for episodes lasting 30 seconds or more, with many anticoagulant trials requiring at least two separate ECGs demonstrating AF.5 Ambulatory monitors (e.g. Holter monitor) can be used for periods of 24 hours to a week and should not be confused with personal wearable devices.5
It is considered good practice to opportunistically screen for AF in patients ≥65 years of age or Aboriginal and Torres Strait Islander patients ≥50 years of age.8,9 Pharmacists may have the opportunity to do so when performing a blood pressure check, however it should be noted that automatic blood pressure machines may not always reliably detect the presence of AF.9
Wearable devices
TGA-approved wearable smart watches and devices are appropriate tools to assist in screening for AF,10 although diagnosis needs to be confirmed by an ECG that has been interpreted by a physician.5
Atrial flutter versus atrial fibrillation
Atrial flutter, a separate diagnosis to AF, is characterised as an atrial tachyarrhythmia but with regular atrial and ventricular activity. Nearly half of those diagnosed with atrial flutter will progress to atrial fibrillation.5 While stroke risk is elevated, it is not always elevated to the extent of AF.5
To address underlying causes or factors contributing to AF, tests recommended at diagnosis include5:
Further tests (e.g. for obstructive sleep apnoea and coronary artery disease) may be required for some patients to optimise management and improve outcomes.5
Treatments
The latest European Society of Cardiology (ESC) guidelines introduced the AF-CARE pathway, which emphasises treating contributing comorbidities and adopting a holistic person-centred approach to AF management.5 This replaces the previous ABC approach (Anticoagulation, Better symptom control, and Comorbidity management).5
C – Comorbidity and risk factor management
As outlined, many comorbidities increase the risk of developing AF, and contribute to increased risk of stroke (e.g. diabetes, hypertension, heart failure). Monitoring and managing these conditions is a priority in AF. Class 1 recommendations include5:
A – Avoid stroke and thromboembolism
Stroke risk assessment is important for determining anticoagulation needs. Across all guidelines there is consensus supporting anticoagulation for CHA2DS2-VA ≥2.4,5,11,12 There is less evidence for anticoagulant use in lower risk scores. In all cases, ongoing risk assessment and shared decision-making in balancing modifiable and non-modifiable risks for stroke and bleeding are key for successful management.5
R – Reduce symptoms by rate and rhythm control
Many patients with AF require interventions or treatments that control heart rate, revert to sinus rhythm or maintain sinus rhythm, leading to improved symptoms and outcomes.5 Treatment options include5:
E – Evaluation and dynamic reassessment
The ‘newest’ addition to previous treatment pathways ensures management adapts to changes in stroke risk, symptoms, comorbidities and other individual needs.5 Generally, a 6–12 monthly follow-up is recommended.5 Further guidance is available from the Quality Use of Medicines Alliance clinical guidance at https://go.medcast.com.au/anticoagulant-management-atrial-fibrillation-clinical-guide.
The role of anticoagulant therapy
AF significantly increases the risk of stroke, making timely assessment and anticoagulation critical. Oral anticoagulants reduce the risk of stroke by 64% and all-cause mortality by 26% in patients with AF.13,14
Direct-acting oral anticoagulants (DOACs)
DOACs have transformed ischaemic stroke prevention in AF (excluding patients with moderate/severe mitral stenosis or mechanical heart valves).5
Landmark trials (RE-LY, Rocket AF, and Aristotle) demonstrated their non-inferiority to warfarin in reducing the risk of stroke and systemic embolism, while halving the risk of intracranial haemorrhage.5
While DOACs offer advantages, no direct comparisons exist between apixaban, rivaroxaban and dabigatran. Choice of agent relies heavily on patient-specific factors such as age, renal function, comorbidities and bleeding risk, as well as practical considerations like accessibility and practicality of dosing regimens.
While stroke prevention benefits are well-established, prescribers must also address potential harms, including bleeding risk. Guidelines recommend addressing bleeding risk factors such as: discontinuing NSAIDs, reducing alcohol intake, lowering falls risk, and ceasing concomitant antiplatelets >12 months post-MI.4,5
However, limitations in the current DOAC evidence base warrant careful consideration. For instance, challenges remain for patients with extremes of bodyweight (BMI) above 40 kg/m² or >120 kg, where data on safety and efficacy remain sparse.4 Additionally, DOACs’ short half-lives mean anticoagulation will be compromised with any missed doses or therapy interruptions.15 Table 1 provides information on currently available oral anticoagulants.16
Warfarin
While DOACs are recommended over vitamin K antagonists (VKA) to prevent ischaemic stroke and thromboembolism in AF, patients with mechanical heart valves or moderate-to-severe mitral stenosis and AF should be anticoagulated with a VKA such as warfarin.5 Pharmacists may support patients prescribed warfarin by taking time to discuss their INR target range, the importance of consistent INR recording, and by providing strategies to improve INR control.
Role of the electrophysiologists
Electrophysiologists are cardiologists specialising in arrhythmias and rhythm control procedures such as catheter ablations. They practise in both public and private settings, and are often consulted for difficult-to-treat AF. While cardiologist referral is important for follow-up and treatment escalation, it should not delay assessing risk and commencing anticoagulation or arrhythmia treatments.
Role of the GP
GPs are integral to diagnosis and commencing the initial management of AF, as well as commencing appropriate therapies and specialist referral. Importantly, comorbidity diagnosis and ongoing management are also central to the GP role.
Role of the pharmacist
Stroke and bleeding risk change over time and may be influenced by new medical conditions or medicines that increase or decrease anticoagulant activity. Pharmacists play a pivotal role in addressing these issues by providing advice on day-to-day medicine use, reducing risks such as bleeding, medicine interactions and ongoing monitoring. Like all chronic conditions, adherence to risk-reducing therapies is an ongoing challenge, and there are a range of mitigating strategies pharmacists can use.17 Pharmacists may consider offering tailored solutions to suit individual needs – this might be in the form of dose administration aids or dose reminders. Encouraging Home Medicines Reviews and supporting patients to keep an up-to-date medicines list can all encourage patients’ self-advocacy and clinicians’ decision-making. Tools like the PSA’s Quick Reference Guide can further aid pharmacists in optimising medicine use. See www.psa.org.au/career-and-support/qum/qum-alliance/oral-anticoagulants/
All patients with recent presentations for AF may be eligible for publicly funded cardiac rehabilitation, which combines education, exercise assessments and ongoing planning by a multidisciplinary team. These programs improve exercise tolerance, support weight loss and promote physical activity – all key AF management strategies.5 Many centres also offer ongoing exercise therapy or referral to tailored programs. All health professionals can refer patients, and the Heart Foundation provides an Australia-wide cardiac rehabilitation directory. Further information on these centres is available at: www.heartfoundation.org.au/your-heart/cardiac-services-directory.
Pharmacists have an essential role in providing medicines education to individuals who are prescribed anticoagulant medicines. Education should be patient-centred, culturally appropriate and include details on the importance of adherence, expected side effects and potential drug interactions. Pharmacists can offer personalised education on minimising bleeding risk by recommending reduced alcohol consumption, avoiding NSAIDs and addressing fall prevention strategies. Incorporating broader cardiovascular risk advice, like smoking cessation, weight management, and promoting blood pressure and diabetes control, may improve AF outcomes. Patients with AF can be offered further support in the form of an anticoagulation plan. A sample anticoagulation plan is available at https://go.medcast.com.au/anticoagulant-care-plan. It is essential that anticoagulants are dosed in accordance with patient characteristics. Pharmacists should flag patients who may benefit from dose adjustment based on weight, renal function or age. When appropriate, patients can be referred to their local cardiac rehabilitation centres.
Given the increasing prevalence of AF, the importance of individualised anticoagulant treatment plans cannot be overstated. Pharmacists can support early detection of AF in at-risk patients and optimise use of oral anticoagulants through medication management services, patient education and ongoing monitoring. By working collaboratively as part of the multidisciplinary team, pharmacists can significantly impact the care of patients with AF.
| Case scenario continued Prior to dispensing Mrs Alvarez her apixaban, you assess the prescribed dose. You ask her if she would mind being weighed and record her weight as 57 kg. Given her age (≥80 years) and low weight (<60 kg), you identify that she meets the criteria for a dose reduction of apixaban to 2.5 mg twice daily, regardless of her renal function. You contact the prescriber, who agrees to the dose reduction. During the conversation, you also raise your concern about the elevated bleeding risk with the concurrent use of aspirin. The prescriber confirms the intention was to discontinue aspirin before starting apixaban. You then counsel Mrs Alvarez on her updated medication regimen. You discuss the importance of adherence, signs of bleeding and stroke, and strategies for fall prevention to ensure safe and effective anticoagulation therapy. |
Adam Livori BAppSci(NucMed), BPharm(Hons), MClinPharm, FSCANZ, FAdPha, FANZCAP(Cardiol, Research) is a cardiology pharmacist and the Lead Pharmacist for Medicine and Continuing Care at Grampians Health.
Jarrah Anderson BPharm is a Clinical Lead at Medcast.
Rawa Osman MPharm, MClinTria(Res), FSHPA, FANZCAP (MedsMgmt, PublicHlth) is a Director at QUM Connect, and Research and Design Lead for the Quality Use of Medicines Alliance.
Julie Briggs MPS (she/her) B Pharm, CredPharm (MMR), FANZCAP (Generalist, PublicHlth)
Rawa Osman is currently Design Lead for the Quality Use of Medicines Alliance, which is leading a national program focused on oral anticoagulants used in AF.
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[post_content] => In a significant advancement for patient-centred care, a team of pharmacists from the University of Tasmania is reshaping the landscape of antidepressant deprescribing.
Their latest research aims to close a long-standing clinical gap by making easy-to-prepare, cost-effective oral liquid formulations of commonly prescribed antidepressants accessible to every Australian pharmacist.
[caption id="attachment_29732" align="alignright" width="263"]
Natalie Cooper[/caption]
These new formulas will help to ensure that patients have options to access safe and effective medications when deprescribing antidepressants, said Natalie Cooper, Research Project Lead at the University of Tasmania’s School of Pharmacy and Pharmacology.
‘Prescribers can also have confidence that when they are prescribing these formulas and suggesting a deprescribing regime, the patient is going to receive an accurate and effective dose,’ she said.
Long-term use with limited tapering options
Each year, over 3.5 million Australians are prescribed antidepressants. Half of these patients become long-term users, with average treatment durations reaching 4 years – well beyond the recommended 6–12 month course to treat a single depressive episode. While these medicines play a critical role in managing mental health, extended use can result in adverse effects, particularly in older adults. Yet safely discontinuing antidepressants remains a challenge.
Key among the hurdles is dose inflexibility.
‘With the lack of commercially available liquid antidepressant formulations available in Australia, there are limited dosing options for people to withdraw from antidepressant medications,’ Ms Cooper said.
The recently released Maudsley Deprescribing Guidelines recommend a hyperbolic tapering method – small, incremental decreases in dose over time – to minimise withdrawal symptoms and support the body’s physiological adjustment. However, this method often requires doses lower than commercially available tablet strengths.
In Australia, the lowest available strength of citalopram – the most commonly prescribed antidepressant – is a 10 mg tablet, which can make safe and effective tapering difficult.
Seeking safer deprescribing methods
When tapering antidepressants, current guidelines often suggest that low doses of certain formulations can be crushed up and dispersed in water, Ms Cooper said.
‘Getting patients to do this imprecise method at home didn’t sound safe to me,’ she said. ‘So I reached out to the Wilson Foundation and asked “why don't we utilise liquid formulations to [deprescribe] in a safe and effective way?’”
In response, the Wilson Foundation funded an 18-month project aimed at producing professional, evidence-based formulation alternatives that all registered pharmacists can readily compound.
‘By creating easy-to-prepare, cost-effective liquid antidepressant formulations that any pharmacy can compound, we’re tackling a major barrier to antidepressant discontinuation,’ Ms Cooper said.
Choosing the right antidepressants for compounding
The research team selected 11 antidepressants for development, targeting those most commonly prescribed in Australia, including mirtazapine, paroxetine and fluoxetine.
‘There are some that aren't as commonly prescribed, but if there’s a patient who needs to come off them, they have an option available,’ Ms Cooper said.
Out of 15 antidepressants listed in the Maudsley Deprescribing Guidelines, four were identified as controlled-release formulations – such as venlafaxine – that can’t be easily transformed into liquid forms.
‘We have gone with the antidepressants we know are immediate release and can be formulated into liquid formulations,’ she said.
The formulations that have sustained-release properties will still require a compounding pharmacist’s expertise to formulate alternate dosage forms.
Developing evidence-based liquid formulations
Designed for ease and accessibility, the proposed liquid formulations can be compounded using standard equipment and readily available ingredients.
‘We're conducting stability testing on these liquid formulations using the commercially available tablets and accessible bases such as ORA-Sweet and ORA-Plus,’ Ms Cooper said. ‘So pharmacists can compound them when they get a prescription from a GP for individual patient supply.’
Once stability and microbial safety are confirmed, the formulations will be submitted to the Australian Pharmaceutical Formulary and Handbook (APF) to be considered for inclusion.
If they are in the APF, they will be available to every single pharmacist and pharmacy in Australia to compound.
The rollout will be incremental, with three formulations submitted each quarter until all 11 are included by the project’s completion.
Bridging gaps in access and affordability
Compounded formulations of antidepressants have traditionally only been available through specialised pharmacies. For patients and prescribers alike, this has presented a barrier to optimal care.
‘Some people may be getting specialised compounded fluoxetine capsules in a low dose through a compounding pharmacy, for example. But they can be quite expensive,’ Ms Cooper said. ‘Accessing a compounding pharmacy also can be quite difficult.’
Dr Anna Seth, a Tasmanian GP, echoed these concerns from the prescriber’s perspective.
‘Existing options for gradual discontinuation of antidepressants are very limited, creating a barrier for patients and the doctors who support them,’ she said. ‘The cost of compounding these medications is prohibitive for many of my patients who are then stuck with either trying to crush and disperse tablets at home or stopping medications more abruptly and risking unpleasant withdrawal effects.’
The new liquid formulations will allow prescribers to instruct patients in volume-based dosing, simplifying the regimen.
Pharmacists’ role in interdisciplinary care
Beyond compounding, pharmacists will play a crucial role in patient and prescriber education.
‘It’s important to get it out through networks to let prescribers know that these formulas are available for pharmacists to compound,’ Ms Cooper said. ‘Communication between the doctor and the pharmacist will help patients be able to achieve effective withdrawal from antidepressants.’
Joanne Gross, President of PSA’s Tasmania Branch, reinforced the importance of pharmacist leadership in deprescribing initiatives.
‘Antidepressant deprescribing remains a challenge, particularly for long-term users experiencing withdrawal symptoms,’ she said.
‘PSA looks forward to continuing to work with the University to potentially make their findings accessible to all Australian pharmacists through the APF, supporting flexible, individualised tapering regimens and improving patient outcomes.’
To find out more about when and how pharmacists can compound and the compliance obligations required, attend the ‘Compounding essentials for 2025’ session at PSA25 held in Sydney from 1–3 August. Register here to attend.
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[post_content] => As vaccine-preventable diseases resurface, pharmacies must lead proactive, informed conversations that close gaps and restore community protection.
Despite a world-class immunisation framework and high levels of public trust, Australia has seen vaccination coverage fall short of its 95% target across most cohorts since 2020, said Professor Michael Kidd at the 9th Annual Immunisation Forum 2025, in his first speech Australia's new Chief Medical Officer.
[caption id="attachment_29704" align="alignright" width="281"]
Professor Michael Kidd[/caption]
‘If we don't halt the decline in vaccination rates and improve our vaccination coverage … we're risking more disease outbreaks, more serious illness and death among members of our most vulnerable populations, including our children and older people,’ he said.
It’s a troubling trend, especially with the re-emergence of measles both locally and globally, the increase in reported cases of influenza and pertussis, and the outbreak of polio just to our north in Papua New Guinea.
The good news? Pharmacists, as the most accessible health professionals, have already proven themselves to be a trusted, convenient and indispensable vaccination workforce. But there are ways to harness this accessibility, credibility and community reach to increase vaccination uptake – particularly as expanded scopes of practice and new immunisation programs roll out nationwide.
Taking every opportunity
The key to improving vaccination rates is proactive engagement, particularly during patient interactions, said pharmacist Bec Rogers.
‘One of the most effective strategies is the identification of eligible patients during dispensing,’ she said. Whether it’s offering an influenza shot to a patient collecting an asthma inhaler, or recommending a shingles vaccine to an older adult – the opportunities are endless.
‘Opportunistic conversations at the counter or in a consultation room prompt patients to take action that they may not have considered before, because the recommendation is coming from their trusted and respected health professional,’ she said.
For example, in areas with a high proportion of young families, offering family-friendly vaccination clinics – which could mean extended hours or group appointments – can help remove barriers and boost participation.
Other appointment types, such as medication reviews, health checks or minor ailment consultations, can be leveraged as an opportunity to identify recommended vaccines.
‘For instance, if you're in the consult room talking to someone about their cardiovascular risk, it's a great time to bring up what vaccinations they might need, such as influenza or pneumococcal vaccination,’ Ms Rogers said. ‘Our software enables us to check their immunisation history through integration with AIR to really streamline that process.’
Employing marketing and communication strategies
A strong digital marketing strategy can make all the difference in driving vaccination uptake. ‘Automated SMS reminders are one of the most effective tools,’ Ms Rogers said. ‘They can be used to remind patients about upcoming appointments, boosters that might be due, or seasonal campaigns.’
Email campaigns offer another channel to reach patients who may not visit regularly. ‘They can provide more detailed information about available vaccines, eligibility criteria and also how to book,’ she said. ‘They're particularly useful for engaging with patients who may not be visiting your pharmacy as frequently as others.’
Social media platforms such as Facebook and Instagram extend community reach – allowing pharmacists to share timely updates, highlight new services and showcase the accessibility and professionalism of pharmacy teams.
In-store signage also plays a vital role. ‘Posters, window decals and digital screens really help reinforce the message for walk-in customers,’ Ms Rogers said.
As pharmacists expand their service offerings, it's crucial to promote new programs – including new NIP vaccines and travel health services.
‘This not only broadens the scope of pharmacy-based vaccination, but also creates new touchpoints for engaging with patients and improving public health outcomes,’ she said.
Staying on top of legislation changes
As pharmacists administer more and more vaccinations, it’s crucial to keep pace with evolving legislation and vaccine eligibility, said immunisation nurse Georgina Lewis, manager of Victoria’s Vaccine Safety Service.
‘The NIP is forever changing,’ she said. ‘Even if you're not delivering them, you need to be able to engage with families who are interested in vaccines and be opportunistic in your recommendations.’
RSV vaccine eligibility is a particularly dynamic space. ‘We’ve got two vaccines recommended for older adults, Arexy and Abrysvo,’ Ms Lewis said. ‘Both can be given at any time of year, but there's seasonality in some states and for others, it's all year round – particularly in tropical regions.’
Expanding service offering through travel vaccinations
There's an expanded role for some pharmacists to provide travel vaccines, Ms Lewis said.
‘You need to be cognisant of what your legislative requirements are, and in some circumstances [these vaccinations] will be in collaboration with other healthcare providers,’ Ms Rogers said. ‘There may be a scenario where a family or individual comes in with a prescription from a GP for Hepatitis A for example, so you dispense the vaccine and then realise that perhaps you have an opportunity to administer it … which is more convenient for the patient and prevents potential cold chain issues.’
However, a conversation needs to occur with the patient's GP. ‘You also need to make sure it’s recorded in AIR so we don’t get double-ups,’ she said.
Travel advice might be sought through pharmacists, which presents further vaccination opportunities when within scope. ‘It’s important to check vaccination status as part of those discussions, as you may identify gaps and opportunities to catch individuals up,’ she said. ‘And then always refer back to a GP or travel specialist as appropriate. Key questions include: Are you going somewhere? Have you had your travel vaccines? Have you spoken to your GP or a travel specialist?
Co-administration and avoiding common errors
As pharmacists take on a greater role in immunisation, it’s essential to approach co-administration of vaccines with care and clinical confidence, Ms Lewis said.
‘If you're not comfortable doing more than one injection, don't do it,’ she said. ‘You're better off doing them separately or sending them somewhere where they are more confident to do that, because we don't want people coming away with the incorrect technique leading to something like a shoulder injury related to vaccine administration.”
The Vaccine Safety Service has received reports of shoulder injuries occurring in both pharmacy and general practice settings due to improper injection technique.
‘So it's really important you know your anatomical sites if you're going for co-administration, focusing on the deltoid which is recommended [for patients] over 12 months of age,’ Ms Lewis said. ‘Injecting too high into the shoulder area can cause restricted movement and ongoing pain and suffering for individuals.’
Common vaccine errors reported to the Vaccine Safety Service also underscore the importance of vigilance. Confusion between RSV vaccine products has been observed, particularly during the initial rollout phases. ‘[There was] a bit of inadvertent administration of Arexy in pregnancy when Abrysvo wasn't on the NIP, which has settled down now,’ Ms Lewis noted. ‘But it's been replaced by Abrysvo being given to infants instead of the monoclonal antibody.’
Another avoidable issue is the administration of expired vaccines. ‘We get a lot of expired vaccine [reports],’ she said. ‘So it's another opportunity to check and get your products and storage right.’
Looking ahead
The National Immunisation Strategy for Australia 2025–2030, released on Thursday 12 June, outlines national consistency and public trust as key pillars in increasing vaccination rates – recommending an expanded vaccination scope for pharmacists that encompasses more NIP vaccines.
This is something PSA has long advocated for.
‘Harmonising the regulation of pharmacist-administered vaccines is overdue. It just makes sense. Now it has been recommended by a number of policy leaders from the Interim Australian Centre for Disease Control to the Grattan Institute,’ said PSA National President Associate Professor Fei Sim FPS.
‘PSA has said previously that the Australian Immunisation Handbook should be the national standard for defining vaccine formularies, instead of relying on complex regulatory instruments unique to each state and territory. The National Immunisation Strategy has supported this approach. Now it’s time for action.
In the meantime, the message for pharmacists is clear: continue doing what you do best – connect with your community, provide trusted care, and stay informed.
‘You're all in a fantastic position to do something about this,’ Prof Kidd said. ‘Please continue to do all you can.’
[post_title] => How pharmacists can stop the slide in immunisation coverage
[post_excerpt] => As vaccine-preventable diseases resurface, pharmacies must lead informed conversations that close gaps and restore community protection.
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[post_content] => From 1 July 2025, pharmacists will see a range of adjustments to how they deliver and bill for vaccination.
Here, Australian Pharmacist outlines the changes in vaccination services and fees pharmacists can expect from early next month.
1. NIPVIP vaccine administration fees will (slightly) increase
In 2025, the Consumer Price Index (CPI) rose by 2.4%. So from next month, there will be a CPI increase applied to all National Immunisation Program Vaccinations in Pharmacy (NIPVIP) vaccines administered. Pharmacists will receive $20.05 per vaccine administered, up from $19.60.
2. The COVID-19 vaccination payment will (significantly) drop
In less than a week, community pharmacists will see a significant reduction in the COVID-19 vaccine administration fee. The new rate will be $20.05 per vaccine administration in all Australian locations.
This is a significant decrease from the previous rates per dose, which were:
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[post_content] => As investigations reveal many popular high-SPF sunscreens don’t live up to their labels, both pharmacists and pharmacy assistants have a greater role to play in promoting a holistic sun protection routine.
On 12 June 2025, consumer advocacy group CHOICE released findings of a review on 20 popular SPF50 and SPF50+ brands – revealing that many don’t stack up as claimed.
According to the findings, only 20% (4) sunscreens met their SPF claims – with one Australian brand, Ultra Violette Lean Screen SPF 50+ Matifying Zinc Skinscreen, measuring only SPF 4.
Last week, the Therapeutic Goods Administration (TGA) vowed to investigate the matter.
With confidence in sunscreen already undermined via social media claims that its ingredients are toxic, how should pharmacists promote sun safety?
How do SPF numbers translate into real-world UV protection?
Australia has the highest incidence of melanoma in the world. So when the UV Index is 3 or above, it’s advisable to use a broad-spectrum, water-resistant sunscreen with an SPF30 or higher to protect against both UVA and UVB rays.
Despite the CHOICE findings, the difference in SPF ratings is not as stark as it seems. For example, Sunscreens with SPF 50 block around 98% of ultraviolet radiation (UVR), whereas SPF 30 formulations block roughly 96.7%.
So if unprotected skin begins to redden after 5 minutes in the sun, using an SPF50 formulation should, in theory, delay that reaction by fifty times – equating to roughly 250 minutes of protection. Likewise, an SPF30 product would ideally extend safe exposure to about 150 minutes. But by that rationale, an SPF4 sunscreen would only provide 20 minutes of protection – proving very limited benefit.
Application thickness also matters, Professor Rachel Neale, Senior Group Leader at the QIMR Berghofer Medical Research Institute told Australian Pharmacist.
‘The amount of sunscreen people apply will make a substantial difference to the SPF.’
What advice should pharmacists provide?
Even if the sunscreens don't meet their marketed claims, pharmacists should remind patients that they likely still offer a reasonable level of protection if used according to reapplication instructions.
Since pharmacy assistants often field questions about over-the-counter products such as sunscreen, pharmacists must ensure they’re fully across this messaging, including:
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[post_content] => Case scenario
Mrs Alvarez, an 82-year-old woman, presents to your pharmacy with a new prescription for apixaban 5 mg twice daily and some discharge paperwork, following a recent hospital admission after a fall at home. You notice that she was diagnosed with AF during her stay. Her medical history includes a myocardial infarction (MI) 2 years ago, for which she has been taking metoprolol, atorvastatin and aspirin.
Sponsorship statement
Funded by the Australian Government through the Quality Use of Diagnostics, Therapeutics and Pathology Program
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Atrial fibrillation (AF) is the most common recurrent arrhythmia worldwide,1 characterised by uncoordinated atrial activity and irregular ventricular contractions. While its causes and contributors are many, all share a common sequela – an increased risk of ischaemic stroke that can be mitigated by anticoagulation.1 While the use of anticoagulants since the emergence of direct-acting oral anticoagulants has increased, the prevalence of AF has grown.1 This has been accompanied by a rise in hospitalisations both directly due to AF, and indirectly due to stroke and its complications.1 Pharmacists can significantly enhance AF care through direct patient engagement and collaboration with other healthcare professionals across all practice settings. Understanding key aspects of AF, its clinical features and evidence-based treatment strategies allows pharmacists to contribute positively to the overall management of individuals living with the condition.
The prevalence of AF is rising, with over 500,000 Australians estimated to have the condition in 2020,1 and over 600,000 projected by 2034.2 Although this is likely to be an underestimate of the true prevalence of AF in Australia.2
Complications arising from AF pose a substantial health burden, with a fivefold increase in the risk of stroke.3 In 2017–18 there were over 72,000 hospitalisations for AF in Australia, with the condition contributing to 9% of deaths in 2018.1 In 2015–16, AF-related healthcare expenditure in Australia was $881 million, with 69% attributed to hospital costs.1
AF results from electrophysiological abnormalities that underlie impulse generation in the heart, and/or structural irregularities that impair rapid and uniform impulse conduction.4 AF often arises from abnormal electrical activity triggered by ectopic action potentials originating in the pulmonary veins of the left atrium.4 Ongoing clinically meaningful AF requires underlying structural or electrical changes in the heart that continue to disrupt normal conduction and contraction.5 An interactive animation demonstrating cardiac activity in AF from the American Heart Association is available at https://watchlearnlive.heart.org/CVML_Mobile.php?moduleSelect=atrfib.
AF arises from a combination of genetic, metabolic, and environmental factors.4 Contributors include oxidative stress (such as alcohol intake or sleep-disordered breathing), pro-inflammatory states (diabetes and obesity), structural atrial changes (heart failure), genetics and aging.4 These conditions are interlinked, reinforcing the concept that “AF begets AF”.4 In other words, the conditions that cause AF can worsen AF, and AF can also worsen these conditions. The main sequela to this is increased stroke risk. This is caused due to the irregular contractions of the left atria leading to stasis of blood, predisposing to thrombus formation. If the thrombus embolises, it can shift into the ventricle and enter systemic circulation and subsequently the carotid arteries, leading to the embolus becoming lodged in the cerebral arteries.
Beyond the arrhythmia, AF often signals broader pathological processes that impair cardiac function and reduce quality of life and life expectancy.5 Many of these conditions are closely linked to social determinants of health, disproportionately affecting populations with socioeconomic disadvantage. Effective AF management requires addressing both the arrhythmia and its underlying contributors.4
Symptoms
Like many cardiac conditions, AF symptoms can vary between individuals and overlap with other conditions, including coronary syndromes, heart failure, COPD and asthma. Common symptoms include5:
In addition, some individuals with AF may be completely asymptomatic.4
AF is also linked to higher rates of dementia and depression compared to the general population.5 Several tools are available to assess symptom burden and stratify the impact of symptoms, such as the modified European Heart Rhythm Association Score.5 Understanding the burden of AF and its associated comorbidities is essential for providing a holistic approach to patient care.
Stroke risk
The first sign of AF can be a stroke. The Australian Institute of Health and Welfare reported that in 2017–18, AF was present in 15.5% of patients hospitalised for stroke.1
Stroke risk varies, and the CHA2DS2-VA calculator is widely used in clinical practice to estimate the risk of stroke in AF.6 Points are assigned based on the following parameters7:
Scores range from 0 (ischaemic stroke incidence rate of 0.5 per 100 patient years) through to 8 (19.5 per 100 patient years).7 Scores may be used to inform decisions around initiating anticoagulation. There are other tools available, such as the GARFIELD-AF calculator, which offer more precise risk prediction, including bleeding and mortality, but require more detailed data.4
AF is diagnosed with the use of a 12-lead electrocardiogram (ECG). The ECG typically demonstrates an absence of discernible P waves and an irregularly irregular rhythm.5
Most recent international guidelines recommend further investigation for episodes lasting 30 seconds or more, with many anticoagulant trials requiring at least two separate ECGs demonstrating AF.5 Ambulatory monitors (e.g. Holter monitor) can be used for periods of 24 hours to a week and should not be confused with personal wearable devices.5
It is considered good practice to opportunistically screen for AF in patients ≥65 years of age or Aboriginal and Torres Strait Islander patients ≥50 years of age.8,9 Pharmacists may have the opportunity to do so when performing a blood pressure check, however it should be noted that automatic blood pressure machines may not always reliably detect the presence of AF.9
Wearable devices
TGA-approved wearable smart watches and devices are appropriate tools to assist in screening for AF,10 although diagnosis needs to be confirmed by an ECG that has been interpreted by a physician.5
Atrial flutter versus atrial fibrillation
Atrial flutter, a separate diagnosis to AF, is characterised as an atrial tachyarrhythmia but with regular atrial and ventricular activity. Nearly half of those diagnosed with atrial flutter will progress to atrial fibrillation.5 While stroke risk is elevated, it is not always elevated to the extent of AF.5
To address underlying causes or factors contributing to AF, tests recommended at diagnosis include5:
Further tests (e.g. for obstructive sleep apnoea and coronary artery disease) may be required for some patients to optimise management and improve outcomes.5
Treatments
The latest European Society of Cardiology (ESC) guidelines introduced the AF-CARE pathway, which emphasises treating contributing comorbidities and adopting a holistic person-centred approach to AF management.5 This replaces the previous ABC approach (Anticoagulation, Better symptom control, and Comorbidity management).5
C – Comorbidity and risk factor management
As outlined, many comorbidities increase the risk of developing AF, and contribute to increased risk of stroke (e.g. diabetes, hypertension, heart failure). Monitoring and managing these conditions is a priority in AF. Class 1 recommendations include5:
A – Avoid stroke and thromboembolism
Stroke risk assessment is important for determining anticoagulation needs. Across all guidelines there is consensus supporting anticoagulation for CHA2DS2-VA ≥2.4,5,11,12 There is less evidence for anticoagulant use in lower risk scores. In all cases, ongoing risk assessment and shared decision-making in balancing modifiable and non-modifiable risks for stroke and bleeding are key for successful management.5
R – Reduce symptoms by rate and rhythm control
Many patients with AF require interventions or treatments that control heart rate, revert to sinus rhythm or maintain sinus rhythm, leading to improved symptoms and outcomes.5 Treatment options include5:
E – Evaluation and dynamic reassessment
The ‘newest’ addition to previous treatment pathways ensures management adapts to changes in stroke risk, symptoms, comorbidities and other individual needs.5 Generally, a 6–12 monthly follow-up is recommended.5 Further guidance is available from the Quality Use of Medicines Alliance clinical guidance at https://go.medcast.com.au/anticoagulant-management-atrial-fibrillation-clinical-guide.
The role of anticoagulant therapy
AF significantly increases the risk of stroke, making timely assessment and anticoagulation critical. Oral anticoagulants reduce the risk of stroke by 64% and all-cause mortality by 26% in patients with AF.13,14
Direct-acting oral anticoagulants (DOACs)
DOACs have transformed ischaemic stroke prevention in AF (excluding patients with moderate/severe mitral stenosis or mechanical heart valves).5
Landmark trials (RE-LY, Rocket AF, and Aristotle) demonstrated their non-inferiority to warfarin in reducing the risk of stroke and systemic embolism, while halving the risk of intracranial haemorrhage.5
While DOACs offer advantages, no direct comparisons exist between apixaban, rivaroxaban and dabigatran. Choice of agent relies heavily on patient-specific factors such as age, renal function, comorbidities and bleeding risk, as well as practical considerations like accessibility and practicality of dosing regimens.
While stroke prevention benefits are well-established, prescribers must also address potential harms, including bleeding risk. Guidelines recommend addressing bleeding risk factors such as: discontinuing NSAIDs, reducing alcohol intake, lowering falls risk, and ceasing concomitant antiplatelets >12 months post-MI.4,5
However, limitations in the current DOAC evidence base warrant careful consideration. For instance, challenges remain for patients with extremes of bodyweight (BMI) above 40 kg/m² or >120 kg, where data on safety and efficacy remain sparse.4 Additionally, DOACs’ short half-lives mean anticoagulation will be compromised with any missed doses or therapy interruptions.15 Table 1 provides information on currently available oral anticoagulants.16
Warfarin
While DOACs are recommended over vitamin K antagonists (VKA) to prevent ischaemic stroke and thromboembolism in AF, patients with mechanical heart valves or moderate-to-severe mitral stenosis and AF should be anticoagulated with a VKA such as warfarin.5 Pharmacists may support patients prescribed warfarin by taking time to discuss their INR target range, the importance of consistent INR recording, and by providing strategies to improve INR control.
Role of the electrophysiologists
Electrophysiologists are cardiologists specialising in arrhythmias and rhythm control procedures such as catheter ablations. They practise in both public and private settings, and are often consulted for difficult-to-treat AF. While cardiologist referral is important for follow-up and treatment escalation, it should not delay assessing risk and commencing anticoagulation or arrhythmia treatments.
Role of the GP
GPs are integral to diagnosis and commencing the initial management of AF, as well as commencing appropriate therapies and specialist referral. Importantly, comorbidity diagnosis and ongoing management are also central to the GP role.
Role of the pharmacist
Stroke and bleeding risk change over time and may be influenced by new medical conditions or medicines that increase or decrease anticoagulant activity. Pharmacists play a pivotal role in addressing these issues by providing advice on day-to-day medicine use, reducing risks such as bleeding, medicine interactions and ongoing monitoring. Like all chronic conditions, adherence to risk-reducing therapies is an ongoing challenge, and there are a range of mitigating strategies pharmacists can use.17 Pharmacists may consider offering tailored solutions to suit individual needs – this might be in the form of dose administration aids or dose reminders. Encouraging Home Medicines Reviews and supporting patients to keep an up-to-date medicines list can all encourage patients’ self-advocacy and clinicians’ decision-making. Tools like the PSA’s Quick Reference Guide can further aid pharmacists in optimising medicine use. See www.psa.org.au/career-and-support/qum/qum-alliance/oral-anticoagulants/
All patients with recent presentations for AF may be eligible for publicly funded cardiac rehabilitation, which combines education, exercise assessments and ongoing planning by a multidisciplinary team. These programs improve exercise tolerance, support weight loss and promote physical activity – all key AF management strategies.5 Many centres also offer ongoing exercise therapy or referral to tailored programs. All health professionals can refer patients, and the Heart Foundation provides an Australia-wide cardiac rehabilitation directory. Further information on these centres is available at: www.heartfoundation.org.au/your-heart/cardiac-services-directory.
Pharmacists have an essential role in providing medicines education to individuals who are prescribed anticoagulant medicines. Education should be patient-centred, culturally appropriate and include details on the importance of adherence, expected side effects and potential drug interactions. Pharmacists can offer personalised education on minimising bleeding risk by recommending reduced alcohol consumption, avoiding NSAIDs and addressing fall prevention strategies. Incorporating broader cardiovascular risk advice, like smoking cessation, weight management, and promoting blood pressure and diabetes control, may improve AF outcomes. Patients with AF can be offered further support in the form of an anticoagulation plan. A sample anticoagulation plan is available at https://go.medcast.com.au/anticoagulant-care-plan. It is essential that anticoagulants are dosed in accordance with patient characteristics. Pharmacists should flag patients who may benefit from dose adjustment based on weight, renal function or age. When appropriate, patients can be referred to their local cardiac rehabilitation centres.
Given the increasing prevalence of AF, the importance of individualised anticoagulant treatment plans cannot be overstated. Pharmacists can support early detection of AF in at-risk patients and optimise use of oral anticoagulants through medication management services, patient education and ongoing monitoring. By working collaboratively as part of the multidisciplinary team, pharmacists can significantly impact the care of patients with AF.
| Case scenario continued Prior to dispensing Mrs Alvarez her apixaban, you assess the prescribed dose. You ask her if she would mind being weighed and record her weight as 57 kg. Given her age (≥80 years) and low weight (<60 kg), you identify that she meets the criteria for a dose reduction of apixaban to 2.5 mg twice daily, regardless of her renal function. You contact the prescriber, who agrees to the dose reduction. During the conversation, you also raise your concern about the elevated bleeding risk with the concurrent use of aspirin. The prescriber confirms the intention was to discontinue aspirin before starting apixaban. You then counsel Mrs Alvarez on her updated medication regimen. You discuss the importance of adherence, signs of bleeding and stroke, and strategies for fall prevention to ensure safe and effective anticoagulation therapy. |
Adam Livori BAppSci(NucMed), BPharm(Hons), MClinPharm, FSCANZ, FAdPha, FANZCAP(Cardiol, Research) is a cardiology pharmacist and the Lead Pharmacist for Medicine and Continuing Care at Grampians Health.
Jarrah Anderson BPharm is a Clinical Lead at Medcast.
Rawa Osman MPharm, MClinTria(Res), FSHPA, FANZCAP (MedsMgmt, PublicHlth) is a Director at QUM Connect, and Research and Design Lead for the Quality Use of Medicines Alliance.
Julie Briggs MPS (she/her) B Pharm, CredPharm (MMR), FANZCAP (Generalist, PublicHlth)
Rawa Osman is currently Design Lead for the Quality Use of Medicines Alliance, which is leading a national program focused on oral anticoagulants used in AF.
[post_title] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [post_excerpt] => Atrial fibrillation is the most common recurrent arrhythmia worldwide, and can put patients at increased risk of stroke. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => balancing-the-scale-the-role-of-oral-anticoagulants-in-atrial-fibrillation [to_ping] => [pinged] => [post_modified] => 2025-06-25 16:14:57 [post_modified_gmt] => 2025-06-25 06:14:57 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=29266 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [title] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [href] => https://www.australianpharmacist.com.au/balancing-the-scale-the-role-of-oral-anticoagulants-in-atrial-fibrillation/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 29742 [authorType] => )td_module_mega_menu Object
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[post_content] => In a significant advancement for patient-centred care, a team of pharmacists from the University of Tasmania is reshaping the landscape of antidepressant deprescribing.
Their latest research aims to close a long-standing clinical gap by making easy-to-prepare, cost-effective oral liquid formulations of commonly prescribed antidepressants accessible to every Australian pharmacist.
[caption id="attachment_29732" align="alignright" width="263"] Natalie Cooper[/caption]
These new formulas will help to ensure that patients have options to access safe and effective medications when deprescribing antidepressants, said Natalie Cooper, Research Project Lead at the University of Tasmania’s School of Pharmacy and Pharmacology.
‘Prescribers can also have confidence that when they are prescribing these formulas and suggesting a deprescribing regime, the patient is going to receive an accurate and effective dose,’ she said.
Long-term use with limited tapering options
Each year, over 3.5 million Australians are prescribed antidepressants. Half of these patients become long-term users, with average treatment durations reaching 4 years – well beyond the recommended 6–12 month course to treat a single depressive episode. While these medicines play a critical role in managing mental health, extended use can result in adverse effects, particularly in older adults. Yet safely discontinuing antidepressants remains a challenge.
Key among the hurdles is dose inflexibility.
‘With the lack of commercially available liquid antidepressant formulations available in Australia, there are limited dosing options for people to withdraw from antidepressant medications,’ Ms Cooper said.
The recently released Maudsley Deprescribing Guidelines recommend a hyperbolic tapering method – small, incremental decreases in dose over time – to minimise withdrawal symptoms and support the body’s physiological adjustment. However, this method often requires doses lower than commercially available tablet strengths.
In Australia, the lowest available strength of citalopram – the most commonly prescribed antidepressant – is a 10 mg tablet, which can make safe and effective tapering difficult.
Seeking safer deprescribing methods
When tapering antidepressants, current guidelines often suggest that low doses of certain formulations can be crushed up and dispersed in water, Ms Cooper said.
‘Getting patients to do this imprecise method at home didn’t sound safe to me,’ she said. ‘So I reached out to the Wilson Foundation and asked “why don't we utilise liquid formulations to [deprescribe] in a safe and effective way?’”
In response, the Wilson Foundation funded an 18-month project aimed at producing professional, evidence-based formulation alternatives that all registered pharmacists can readily compound.
‘By creating easy-to-prepare, cost-effective liquid antidepressant formulations that any pharmacy can compound, we’re tackling a major barrier to antidepressant discontinuation,’ Ms Cooper said.
Choosing the right antidepressants for compounding
The research team selected 11 antidepressants for development, targeting those most commonly prescribed in Australia, including mirtazapine, paroxetine and fluoxetine.
‘There are some that aren't as commonly prescribed, but if there’s a patient who needs to come off them, they have an option available,’ Ms Cooper said.
Out of 15 antidepressants listed in the Maudsley Deprescribing Guidelines, four were identified as controlled-release formulations – such as venlafaxine – that can’t be easily transformed into liquid forms.
‘We have gone with the antidepressants we know are immediate release and can be formulated into liquid formulations,’ she said.
The formulations that have sustained-release properties will still require a compounding pharmacist’s expertise to formulate alternate dosage forms.
Developing evidence-based liquid formulations
Designed for ease and accessibility, the proposed liquid formulations can be compounded using standard equipment and readily available ingredients.
‘We're conducting stability testing on these liquid formulations using the commercially available tablets and accessible bases such as ORA-Sweet and ORA-Plus,’ Ms Cooper said. ‘So pharmacists can compound them when they get a prescription from a GP for individual patient supply.’
Once stability and microbial safety are confirmed, the formulations will be submitted to the Australian Pharmaceutical Formulary and Handbook (APF) to be considered for inclusion.
If they are in the APF, they will be available to every single pharmacist and pharmacy in Australia to compound.
The rollout will be incremental, with three formulations submitted each quarter until all 11 are included by the project’s completion.
Bridging gaps in access and affordability
Compounded formulations of antidepressants have traditionally only been available through specialised pharmacies. For patients and prescribers alike, this has presented a barrier to optimal care.
‘Some people may be getting specialised compounded fluoxetine capsules in a low dose through a compounding pharmacy, for example. But they can be quite expensive,’ Ms Cooper said. ‘Accessing a compounding pharmacy also can be quite difficult.’
Dr Anna Seth, a Tasmanian GP, echoed these concerns from the prescriber’s perspective.
‘Existing options for gradual discontinuation of antidepressants are very limited, creating a barrier for patients and the doctors who support them,’ she said. ‘The cost of compounding these medications is prohibitive for many of my patients who are then stuck with either trying to crush and disperse tablets at home or stopping medications more abruptly and risking unpleasant withdrawal effects.’
The new liquid formulations will allow prescribers to instruct patients in volume-based dosing, simplifying the regimen.
Pharmacists’ role in interdisciplinary care
Beyond compounding, pharmacists will play a crucial role in patient and prescriber education.
‘It’s important to get it out through networks to let prescribers know that these formulas are available for pharmacists to compound,’ Ms Cooper said. ‘Communication between the doctor and the pharmacist will help patients be able to achieve effective withdrawal from antidepressants.’
Joanne Gross, President of PSA’s Tasmania Branch, reinforced the importance of pharmacist leadership in deprescribing initiatives.
‘Antidepressant deprescribing remains a challenge, particularly for long-term users experiencing withdrawal symptoms,’ she said.
‘PSA looks forward to continuing to work with the University to potentially make their findings accessible to all Australian pharmacists through the APF, supporting flexible, individualised tapering regimens and improving patient outcomes.’
To find out more about when and how pharmacists can compound and the compliance obligations required, attend the ‘Compounding essentials for 2025’ session at PSA25 held in Sydney from 1–3 August. Register here to attend.
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[post_content] => As vaccine-preventable diseases resurface, pharmacies must lead proactive, informed conversations that close gaps and restore community protection.
Despite a world-class immunisation framework and high levels of public trust, Australia has seen vaccination coverage fall short of its 95% target across most cohorts since 2020, said Professor Michael Kidd at the 9th Annual Immunisation Forum 2025, in his first speech Australia's new Chief Medical Officer.
[caption id="attachment_29704" align="alignright" width="281"] Professor Michael Kidd[/caption]
‘If we don't halt the decline in vaccination rates and improve our vaccination coverage … we're risking more disease outbreaks, more serious illness and death among members of our most vulnerable populations, including our children and older people,’ he said.
It’s a troubling trend, especially with the re-emergence of measles both locally and globally, the increase in reported cases of influenza and pertussis, and the outbreak of polio just to our north in Papua New Guinea.
The good news? Pharmacists, as the most accessible health professionals, have already proven themselves to be a trusted, convenient and indispensable vaccination workforce. But there are ways to harness this accessibility, credibility and community reach to increase vaccination uptake – particularly as expanded scopes of practice and new immunisation programs roll out nationwide.
Taking every opportunity
The key to improving vaccination rates is proactive engagement, particularly during patient interactions, said pharmacist Bec Rogers.
‘One of the most effective strategies is the identification of eligible patients during dispensing,’ she said. Whether it’s offering an influenza shot to a patient collecting an asthma inhaler, or recommending a shingles vaccine to an older adult – the opportunities are endless.
‘Opportunistic conversations at the counter or in a consultation room prompt patients to take action that they may not have considered before, because the recommendation is coming from their trusted and respected health professional,’ she said.
For example, in areas with a high proportion of young families, offering family-friendly vaccination clinics – which could mean extended hours or group appointments – can help remove barriers and boost participation.
Other appointment types, such as medication reviews, health checks or minor ailment consultations, can be leveraged as an opportunity to identify recommended vaccines.
‘For instance, if you're in the consult room talking to someone about their cardiovascular risk, it's a great time to bring up what vaccinations they might need, such as influenza or pneumococcal vaccination,’ Ms Rogers said. ‘Our software enables us to check their immunisation history through integration with AIR to really streamline that process.’
Employing marketing and communication strategies
A strong digital marketing strategy can make all the difference in driving vaccination uptake. ‘Automated SMS reminders are one of the most effective tools,’ Ms Rogers said. ‘They can be used to remind patients about upcoming appointments, boosters that might be due, or seasonal campaigns.’
Email campaigns offer another channel to reach patients who may not visit regularly. ‘They can provide more detailed information about available vaccines, eligibility criteria and also how to book,’ she said. ‘They're particularly useful for engaging with patients who may not be visiting your pharmacy as frequently as others.’
Social media platforms such as Facebook and Instagram extend community reach – allowing pharmacists to share timely updates, highlight new services and showcase the accessibility and professionalism of pharmacy teams.
In-store signage also plays a vital role. ‘Posters, window decals and digital screens really help reinforce the message for walk-in customers,’ Ms Rogers said.
As pharmacists expand their service offerings, it's crucial to promote new programs – including new NIP vaccines and travel health services.
‘This not only broadens the scope of pharmacy-based vaccination, but also creates new touchpoints for engaging with patients and improving public health outcomes,’ she said.
Staying on top of legislation changes
As pharmacists administer more and more vaccinations, it’s crucial to keep pace with evolving legislation and vaccine eligibility, said immunisation nurse Georgina Lewis, manager of Victoria’s Vaccine Safety Service.
‘The NIP is forever changing,’ she said. ‘Even if you're not delivering them, you need to be able to engage with families who are interested in vaccines and be opportunistic in your recommendations.’
RSV vaccine eligibility is a particularly dynamic space. ‘We’ve got two vaccines recommended for older adults, Arexy and Abrysvo,’ Ms Lewis said. ‘Both can be given at any time of year, but there's seasonality in some states and for others, it's all year round – particularly in tropical regions.’
Expanding service offering through travel vaccinations
There's an expanded role for some pharmacists to provide travel vaccines, Ms Lewis said.
‘You need to be cognisant of what your legislative requirements are, and in some circumstances [these vaccinations] will be in collaboration with other healthcare providers,’ Ms Rogers said. ‘There may be a scenario where a family or individual comes in with a prescription from a GP for Hepatitis A for example, so you dispense the vaccine and then realise that perhaps you have an opportunity to administer it … which is more convenient for the patient and prevents potential cold chain issues.’
However, a conversation needs to occur with the patient's GP. ‘You also need to make sure it’s recorded in AIR so we don’t get double-ups,’ she said.
Travel advice might be sought through pharmacists, which presents further vaccination opportunities when within scope. ‘It’s important to check vaccination status as part of those discussions, as you may identify gaps and opportunities to catch individuals up,’ she said. ‘And then always refer back to a GP or travel specialist as appropriate. Key questions include: Are you going somewhere? Have you had your travel vaccines? Have you spoken to your GP or a travel specialist?
Co-administration and avoiding common errors
As pharmacists take on a greater role in immunisation, it’s essential to approach co-administration of vaccines with care and clinical confidence, Ms Lewis said.
‘If you're not comfortable doing more than one injection, don't do it,’ she said. ‘You're better off doing them separately or sending them somewhere where they are more confident to do that, because we don't want people coming away with the incorrect technique leading to something like a shoulder injury related to vaccine administration.”
The Vaccine Safety Service has received reports of shoulder injuries occurring in both pharmacy and general practice settings due to improper injection technique.
‘So it's really important you know your anatomical sites if you're going for co-administration, focusing on the deltoid which is recommended [for patients] over 12 months of age,’ Ms Lewis said. ‘Injecting too high into the shoulder area can cause restricted movement and ongoing pain and suffering for individuals.’
Common vaccine errors reported to the Vaccine Safety Service also underscore the importance of vigilance. Confusion between RSV vaccine products has been observed, particularly during the initial rollout phases. ‘[There was] a bit of inadvertent administration of Arexy in pregnancy when Abrysvo wasn't on the NIP, which has settled down now,’ Ms Lewis noted. ‘But it's been replaced by Abrysvo being given to infants instead of the monoclonal antibody.’
Another avoidable issue is the administration of expired vaccines. ‘We get a lot of expired vaccine [reports],’ she said. ‘So it's another opportunity to check and get your products and storage right.’
Looking ahead
The National Immunisation Strategy for Australia 2025–2030, released on Thursday 12 June, outlines national consistency and public trust as key pillars in increasing vaccination rates – recommending an expanded vaccination scope for pharmacists that encompasses more NIP vaccines.
This is something PSA has long advocated for.
‘Harmonising the regulation of pharmacist-administered vaccines is overdue. It just makes sense. Now it has been recommended by a number of policy leaders from the Interim Australian Centre for Disease Control to the Grattan Institute,’ said PSA National President Associate Professor Fei Sim FPS.
‘PSA has said previously that the Australian Immunisation Handbook should be the national standard for defining vaccine formularies, instead of relying on complex regulatory instruments unique to each state and territory. The National Immunisation Strategy has supported this approach. Now it’s time for action.
In the meantime, the message for pharmacists is clear: continue doing what you do best – connect with your community, provide trusted care, and stay informed.
‘You're all in a fantastic position to do something about this,’ Prof Kidd said. ‘Please continue to do all you can.’
[post_title] => How pharmacists can stop the slide in immunisation coverage
[post_excerpt] => As vaccine-preventable diseases resurface, pharmacies must lead informed conversations that close gaps and restore community protection.
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[post_content] => From 1 July 2025, pharmacists will see a range of adjustments to how they deliver and bill for vaccination.
Here, Australian Pharmacist outlines the changes in vaccination services and fees pharmacists can expect from early next month.
1. NIPVIP vaccine administration fees will (slightly) increase
In 2025, the Consumer Price Index (CPI) rose by 2.4%. So from next month, there will be a CPI increase applied to all National Immunisation Program Vaccinations in Pharmacy (NIPVIP) vaccines administered. Pharmacists will receive $20.05 per vaccine administered, up from $19.60.
2. The COVID-19 vaccination payment will (significantly) drop
In less than a week, community pharmacists will see a significant reduction in the COVID-19 vaccine administration fee. The new rate will be $20.05 per vaccine administration in all Australian locations.
This is a significant decrease from the previous rates per dose, which were:
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[post_content] => As investigations reveal many popular high-SPF sunscreens don’t live up to their labels, both pharmacists and pharmacy assistants have a greater role to play in promoting a holistic sun protection routine.
On 12 June 2025, consumer advocacy group CHOICE released findings of a review on 20 popular SPF50 and SPF50+ brands – revealing that many don’t stack up as claimed.
According to the findings, only 20% (4) sunscreens met their SPF claims – with one Australian brand, Ultra Violette Lean Screen SPF 50+ Matifying Zinc Skinscreen, measuring only SPF 4.
Last week, the Therapeutic Goods Administration (TGA) vowed to investigate the matter.
With confidence in sunscreen already undermined via social media claims that its ingredients are toxic, how should pharmacists promote sun safety?
How do SPF numbers translate into real-world UV protection?
Australia has the highest incidence of melanoma in the world. So when the UV Index is 3 or above, it’s advisable to use a broad-spectrum, water-resistant sunscreen with an SPF30 or higher to protect against both UVA and UVB rays.
Despite the CHOICE findings, the difference in SPF ratings is not as stark as it seems. For example, Sunscreens with SPF 50 block around 98% of ultraviolet radiation (UVR), whereas SPF 30 formulations block roughly 96.7%.
So if unprotected skin begins to redden after 5 minutes in the sun, using an SPF50 formulation should, in theory, delay that reaction by fifty times – equating to roughly 250 minutes of protection. Likewise, an SPF30 product would ideally extend safe exposure to about 150 minutes. But by that rationale, an SPF4 sunscreen would only provide 20 minutes of protection – proving very limited benefit.
Application thickness also matters, Professor Rachel Neale, Senior Group Leader at the QIMR Berghofer Medical Research Institute told Australian Pharmacist.
‘The amount of sunscreen people apply will make a substantial difference to the SPF.’
What advice should pharmacists provide?
Even if the sunscreens don't meet their marketed claims, pharmacists should remind patients that they likely still offer a reasonable level of protection if used according to reapplication instructions.
Since pharmacy assistants often field questions about over-the-counter products such as sunscreen, pharmacists must ensure they’re fully across this messaging, including:
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[post_content] => Case scenario
Mrs Alvarez, an 82-year-old woman, presents to your pharmacy with a new prescription for apixaban 5 mg twice daily and some discharge paperwork, following a recent hospital admission after a fall at home. You notice that she was diagnosed with AF during her stay. Her medical history includes a myocardial infarction (MI) 2 years ago, for which she has been taking metoprolol, atorvastatin and aspirin.
Sponsorship statement
Funded by the Australian Government through the Quality Use of Diagnostics, Therapeutics and Pathology Program
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Atrial fibrillation (AF) is the most common recurrent arrhythmia worldwide,1 characterised by uncoordinated atrial activity and irregular ventricular contractions. While its causes and contributors are many, all share a common sequela – an increased risk of ischaemic stroke that can be mitigated by anticoagulation.1 While the use of anticoagulants since the emergence of direct-acting oral anticoagulants has increased, the prevalence of AF has grown.1 This has been accompanied by a rise in hospitalisations both directly due to AF, and indirectly due to stroke and its complications.1 Pharmacists can significantly enhance AF care through direct patient engagement and collaboration with other healthcare professionals across all practice settings. Understanding key aspects of AF, its clinical features and evidence-based treatment strategies allows pharmacists to contribute positively to the overall management of individuals living with the condition.
The prevalence of AF is rising, with over 500,000 Australians estimated to have the condition in 2020,1 and over 600,000 projected by 2034.2 Although this is likely to be an underestimate of the true prevalence of AF in Australia.2
Complications arising from AF pose a substantial health burden, with a fivefold increase in the risk of stroke.3 In 2017–18 there were over 72,000 hospitalisations for AF in Australia, with the condition contributing to 9% of deaths in 2018.1 In 2015–16, AF-related healthcare expenditure in Australia was $881 million, with 69% attributed to hospital costs.1
AF results from electrophysiological abnormalities that underlie impulse generation in the heart, and/or structural irregularities that impair rapid and uniform impulse conduction.4 AF often arises from abnormal electrical activity triggered by ectopic action potentials originating in the pulmonary veins of the left atrium.4 Ongoing clinically meaningful AF requires underlying structural or electrical changes in the heart that continue to disrupt normal conduction and contraction.5 An interactive animation demonstrating cardiac activity in AF from the American Heart Association is available at https://watchlearnlive.heart.org/CVML_Mobile.php?moduleSelect=atrfib.
AF arises from a combination of genetic, metabolic, and environmental factors.4 Contributors include oxidative stress (such as alcohol intake or sleep-disordered breathing), pro-inflammatory states (diabetes and obesity), structural atrial changes (heart failure), genetics and aging.4 These conditions are interlinked, reinforcing the concept that “AF begets AF”.4 In other words, the conditions that cause AF can worsen AF, and AF can also worsen these conditions. The main sequela to this is increased stroke risk. This is caused due to the irregular contractions of the left atria leading to stasis of blood, predisposing to thrombus formation. If the thrombus embolises, it can shift into the ventricle and enter systemic circulation and subsequently the carotid arteries, leading to the embolus becoming lodged in the cerebral arteries.
Beyond the arrhythmia, AF often signals broader pathological processes that impair cardiac function and reduce quality of life and life expectancy.5 Many of these conditions are closely linked to social determinants of health, disproportionately affecting populations with socioeconomic disadvantage. Effective AF management requires addressing both the arrhythmia and its underlying contributors.4
Symptoms
Like many cardiac conditions, AF symptoms can vary between individuals and overlap with other conditions, including coronary syndromes, heart failure, COPD and asthma. Common symptoms include5:
In addition, some individuals with AF may be completely asymptomatic.4
AF is also linked to higher rates of dementia and depression compared to the general population.5 Several tools are available to assess symptom burden and stratify the impact of symptoms, such as the modified European Heart Rhythm Association Score.5 Understanding the burden of AF and its associated comorbidities is essential for providing a holistic approach to patient care.
Stroke risk
The first sign of AF can be a stroke. The Australian Institute of Health and Welfare reported that in 2017–18, AF was present in 15.5% of patients hospitalised for stroke.1
Stroke risk varies, and the CHA2DS2-VA calculator is widely used in clinical practice to estimate the risk of stroke in AF.6 Points are assigned based on the following parameters7:
Scores range from 0 (ischaemic stroke incidence rate of 0.5 per 100 patient years) through to 8 (19.5 per 100 patient years).7 Scores may be used to inform decisions around initiating anticoagulation. There are other tools available, such as the GARFIELD-AF calculator, which offer more precise risk prediction, including bleeding and mortality, but require more detailed data.4
AF is diagnosed with the use of a 12-lead electrocardiogram (ECG). The ECG typically demonstrates an absence of discernible P waves and an irregularly irregular rhythm.5
Most recent international guidelines recommend further investigation for episodes lasting 30 seconds or more, with many anticoagulant trials requiring at least two separate ECGs demonstrating AF.5 Ambulatory monitors (e.g. Holter monitor) can be used for periods of 24 hours to a week and should not be confused with personal wearable devices.5
It is considered good practice to opportunistically screen for AF in patients ≥65 years of age or Aboriginal and Torres Strait Islander patients ≥50 years of age.8,9 Pharmacists may have the opportunity to do so when performing a blood pressure check, however it should be noted that automatic blood pressure machines may not always reliably detect the presence of AF.9
Wearable devices
TGA-approved wearable smart watches and devices are appropriate tools to assist in screening for AF,10 although diagnosis needs to be confirmed by an ECG that has been interpreted by a physician.5
Atrial flutter versus atrial fibrillation
Atrial flutter, a separate diagnosis to AF, is characterised as an atrial tachyarrhythmia but with regular atrial and ventricular activity. Nearly half of those diagnosed with atrial flutter will progress to atrial fibrillation.5 While stroke risk is elevated, it is not always elevated to the extent of AF.5
To address underlying causes or factors contributing to AF, tests recommended at diagnosis include5:
Further tests (e.g. for obstructive sleep apnoea and coronary artery disease) may be required for some patients to optimise management and improve outcomes.5
Treatments
The latest European Society of Cardiology (ESC) guidelines introduced the AF-CARE pathway, which emphasises treating contributing comorbidities and adopting a holistic person-centred approach to AF management.5 This replaces the previous ABC approach (Anticoagulation, Better symptom control, and Comorbidity management).5
C – Comorbidity and risk factor management
As outlined, many comorbidities increase the risk of developing AF, and contribute to increased risk of stroke (e.g. diabetes, hypertension, heart failure). Monitoring and managing these conditions is a priority in AF. Class 1 recommendations include5:
A – Avoid stroke and thromboembolism
Stroke risk assessment is important for determining anticoagulation needs. Across all guidelines there is consensus supporting anticoagulation for CHA2DS2-VA ≥2.4,5,11,12 There is less evidence for anticoagulant use in lower risk scores. In all cases, ongoing risk assessment and shared decision-making in balancing modifiable and non-modifiable risks for stroke and bleeding are key for successful management.5
R – Reduce symptoms by rate and rhythm control
Many patients with AF require interventions or treatments that control heart rate, revert to sinus rhythm or maintain sinus rhythm, leading to improved symptoms and outcomes.5 Treatment options include5:
E – Evaluation and dynamic reassessment
The ‘newest’ addition to previous treatment pathways ensures management adapts to changes in stroke risk, symptoms, comorbidities and other individual needs.5 Generally, a 6–12 monthly follow-up is recommended.5 Further guidance is available from the Quality Use of Medicines Alliance clinical guidance at https://go.medcast.com.au/anticoagulant-management-atrial-fibrillation-clinical-guide.
The role of anticoagulant therapy
AF significantly increases the risk of stroke, making timely assessment and anticoagulation critical. Oral anticoagulants reduce the risk of stroke by 64% and all-cause mortality by 26% in patients with AF.13,14
Direct-acting oral anticoagulants (DOACs)
DOACs have transformed ischaemic stroke prevention in AF (excluding patients with moderate/severe mitral stenosis or mechanical heart valves).5
Landmark trials (RE-LY, Rocket AF, and Aristotle) demonstrated their non-inferiority to warfarin in reducing the risk of stroke and systemic embolism, while halving the risk of intracranial haemorrhage.5
While DOACs offer advantages, no direct comparisons exist between apixaban, rivaroxaban and dabigatran. Choice of agent relies heavily on patient-specific factors such as age, renal function, comorbidities and bleeding risk, as well as practical considerations like accessibility and practicality of dosing regimens.
While stroke prevention benefits are well-established, prescribers must also address potential harms, including bleeding risk. Guidelines recommend addressing bleeding risk factors such as: discontinuing NSAIDs, reducing alcohol intake, lowering falls risk, and ceasing concomitant antiplatelets >12 months post-MI.4,5
However, limitations in the current DOAC evidence base warrant careful consideration. For instance, challenges remain for patients with extremes of bodyweight (BMI) above 40 kg/m² or >120 kg, where data on safety and efficacy remain sparse.4 Additionally, DOACs’ short half-lives mean anticoagulation will be compromised with any missed doses or therapy interruptions.15 Table 1 provides information on currently available oral anticoagulants.16
Warfarin
While DOACs are recommended over vitamin K antagonists (VKA) to prevent ischaemic stroke and thromboembolism in AF, patients with mechanical heart valves or moderate-to-severe mitral stenosis and AF should be anticoagulated with a VKA such as warfarin.5 Pharmacists may support patients prescribed warfarin by taking time to discuss their INR target range, the importance of consistent INR recording, and by providing strategies to improve INR control.
Role of the electrophysiologists
Electrophysiologists are cardiologists specialising in arrhythmias and rhythm control procedures such as catheter ablations. They practise in both public and private settings, and are often consulted for difficult-to-treat AF. While cardiologist referral is important for follow-up and treatment escalation, it should not delay assessing risk and commencing anticoagulation or arrhythmia treatments.
Role of the GP
GPs are integral to diagnosis and commencing the initial management of AF, as well as commencing appropriate therapies and specialist referral. Importantly, comorbidity diagnosis and ongoing management are also central to the GP role.
Role of the pharmacist
Stroke and bleeding risk change over time and may be influenced by new medical conditions or medicines that increase or decrease anticoagulant activity. Pharmacists play a pivotal role in addressing these issues by providing advice on day-to-day medicine use, reducing risks such as bleeding, medicine interactions and ongoing monitoring. Like all chronic conditions, adherence to risk-reducing therapies is an ongoing challenge, and there are a range of mitigating strategies pharmacists can use.17 Pharmacists may consider offering tailored solutions to suit individual needs – this might be in the form of dose administration aids or dose reminders. Encouraging Home Medicines Reviews and supporting patients to keep an up-to-date medicines list can all encourage patients’ self-advocacy and clinicians’ decision-making. Tools like the PSA’s Quick Reference Guide can further aid pharmacists in optimising medicine use. See www.psa.org.au/career-and-support/qum/qum-alliance/oral-anticoagulants/
All patients with recent presentations for AF may be eligible for publicly funded cardiac rehabilitation, which combines education, exercise assessments and ongoing planning by a multidisciplinary team. These programs improve exercise tolerance, support weight loss and promote physical activity – all key AF management strategies.5 Many centres also offer ongoing exercise therapy or referral to tailored programs. All health professionals can refer patients, and the Heart Foundation provides an Australia-wide cardiac rehabilitation directory. Further information on these centres is available at: www.heartfoundation.org.au/your-heart/cardiac-services-directory.
Pharmacists have an essential role in providing medicines education to individuals who are prescribed anticoagulant medicines. Education should be patient-centred, culturally appropriate and include details on the importance of adherence, expected side effects and potential drug interactions. Pharmacists can offer personalised education on minimising bleeding risk by recommending reduced alcohol consumption, avoiding NSAIDs and addressing fall prevention strategies. Incorporating broader cardiovascular risk advice, like smoking cessation, weight management, and promoting blood pressure and diabetes control, may improve AF outcomes. Patients with AF can be offered further support in the form of an anticoagulation plan. A sample anticoagulation plan is available at https://go.medcast.com.au/anticoagulant-care-plan. It is essential that anticoagulants are dosed in accordance with patient characteristics. Pharmacists should flag patients who may benefit from dose adjustment based on weight, renal function or age. When appropriate, patients can be referred to their local cardiac rehabilitation centres.
Given the increasing prevalence of AF, the importance of individualised anticoagulant treatment plans cannot be overstated. Pharmacists can support early detection of AF in at-risk patients and optimise use of oral anticoagulants through medication management services, patient education and ongoing monitoring. By working collaboratively as part of the multidisciplinary team, pharmacists can significantly impact the care of patients with AF.
| Case scenario continued Prior to dispensing Mrs Alvarez her apixaban, you assess the prescribed dose. You ask her if she would mind being weighed and record her weight as 57 kg. Given her age (≥80 years) and low weight (<60 kg), you identify that she meets the criteria for a dose reduction of apixaban to 2.5 mg twice daily, regardless of her renal function. You contact the prescriber, who agrees to the dose reduction. During the conversation, you also raise your concern about the elevated bleeding risk with the concurrent use of aspirin. The prescriber confirms the intention was to discontinue aspirin before starting apixaban. You then counsel Mrs Alvarez on her updated medication regimen. You discuss the importance of adherence, signs of bleeding and stroke, and strategies for fall prevention to ensure safe and effective anticoagulation therapy. |
Adam Livori BAppSci(NucMed), BPharm(Hons), MClinPharm, FSCANZ, FAdPha, FANZCAP(Cardiol, Research) is a cardiology pharmacist and the Lead Pharmacist for Medicine and Continuing Care at Grampians Health.
Jarrah Anderson BPharm is a Clinical Lead at Medcast.
Rawa Osman MPharm, MClinTria(Res), FSHPA, FANZCAP (MedsMgmt, PublicHlth) is a Director at QUM Connect, and Research and Design Lead for the Quality Use of Medicines Alliance.
Julie Briggs MPS (she/her) B Pharm, CredPharm (MMR), FANZCAP (Generalist, PublicHlth)
Rawa Osman is currently Design Lead for the Quality Use of Medicines Alliance, which is leading a national program focused on oral anticoagulants used in AF.
[post_title] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [post_excerpt] => Atrial fibrillation is the most common recurrent arrhythmia worldwide, and can put patients at increased risk of stroke. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => balancing-the-scale-the-role-of-oral-anticoagulants-in-atrial-fibrillation [to_ping] => [pinged] => [post_modified] => 2025-06-25 16:14:57 [post_modified_gmt] => 2025-06-25 06:14:57 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=29266 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [title] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [href] => https://www.australianpharmacist.com.au/balancing-the-scale-the-role-of-oral-anticoagulants-in-atrial-fibrillation/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 29742 [authorType] => )td_module_mega_menu Object
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[post_content] => In a significant advancement for patient-centred care, a team of pharmacists from the University of Tasmania is reshaping the landscape of antidepressant deprescribing.
Their latest research aims to close a long-standing clinical gap by making easy-to-prepare, cost-effective oral liquid formulations of commonly prescribed antidepressants accessible to every Australian pharmacist.
[caption id="attachment_29732" align="alignright" width="263"] Natalie Cooper[/caption]
These new formulas will help to ensure that patients have options to access safe and effective medications when deprescribing antidepressants, said Natalie Cooper, Research Project Lead at the University of Tasmania’s School of Pharmacy and Pharmacology.
‘Prescribers can also have confidence that when they are prescribing these formulas and suggesting a deprescribing regime, the patient is going to receive an accurate and effective dose,’ she said.
Long-term use with limited tapering options
Each year, over 3.5 million Australians are prescribed antidepressants. Half of these patients become long-term users, with average treatment durations reaching 4 years – well beyond the recommended 6–12 month course to treat a single depressive episode. While these medicines play a critical role in managing mental health, extended use can result in adverse effects, particularly in older adults. Yet safely discontinuing antidepressants remains a challenge.
Key among the hurdles is dose inflexibility.
‘With the lack of commercially available liquid antidepressant formulations available in Australia, there are limited dosing options for people to withdraw from antidepressant medications,’ Ms Cooper said.
The recently released Maudsley Deprescribing Guidelines recommend a hyperbolic tapering method – small, incremental decreases in dose over time – to minimise withdrawal symptoms and support the body’s physiological adjustment. However, this method often requires doses lower than commercially available tablet strengths.
In Australia, the lowest available strength of citalopram – the most commonly prescribed antidepressant – is a 10 mg tablet, which can make safe and effective tapering difficult.
Seeking safer deprescribing methods
When tapering antidepressants, current guidelines often suggest that low doses of certain formulations can be crushed up and dispersed in water, Ms Cooper said.
‘Getting patients to do this imprecise method at home didn’t sound safe to me,’ she said. ‘So I reached out to the Wilson Foundation and asked “why don't we utilise liquid formulations to [deprescribe] in a safe and effective way?’”
In response, the Wilson Foundation funded an 18-month project aimed at producing professional, evidence-based formulation alternatives that all registered pharmacists can readily compound.
‘By creating easy-to-prepare, cost-effective liquid antidepressant formulations that any pharmacy can compound, we’re tackling a major barrier to antidepressant discontinuation,’ Ms Cooper said.
Choosing the right antidepressants for compounding
The research team selected 11 antidepressants for development, targeting those most commonly prescribed in Australia, including mirtazapine, paroxetine and fluoxetine.
‘There are some that aren't as commonly prescribed, but if there’s a patient who needs to come off them, they have an option available,’ Ms Cooper said.
Out of 15 antidepressants listed in the Maudsley Deprescribing Guidelines, four were identified as controlled-release formulations – such as venlafaxine – that can’t be easily transformed into liquid forms.
‘We have gone with the antidepressants we know are immediate release and can be formulated into liquid formulations,’ she said.
The formulations that have sustained-release properties will still require a compounding pharmacist’s expertise to formulate alternate dosage forms.
Developing evidence-based liquid formulations
Designed for ease and accessibility, the proposed liquid formulations can be compounded using standard equipment and readily available ingredients.
‘We're conducting stability testing on these liquid formulations using the commercially available tablets and accessible bases such as ORA-Sweet and ORA-Plus,’ Ms Cooper said. ‘So pharmacists can compound them when they get a prescription from a GP for individual patient supply.’
Once stability and microbial safety are confirmed, the formulations will be submitted to the Australian Pharmaceutical Formulary and Handbook (APF) to be considered for inclusion.
If they are in the APF, they will be available to every single pharmacist and pharmacy in Australia to compound.
The rollout will be incremental, with three formulations submitted each quarter until all 11 are included by the project’s completion.
Bridging gaps in access and affordability
Compounded formulations of antidepressants have traditionally only been available through specialised pharmacies. For patients and prescribers alike, this has presented a barrier to optimal care.
‘Some people may be getting specialised compounded fluoxetine capsules in a low dose through a compounding pharmacy, for example. But they can be quite expensive,’ Ms Cooper said. ‘Accessing a compounding pharmacy also can be quite difficult.’
Dr Anna Seth, a Tasmanian GP, echoed these concerns from the prescriber’s perspective.
‘Existing options for gradual discontinuation of antidepressants are very limited, creating a barrier for patients and the doctors who support them,’ she said. ‘The cost of compounding these medications is prohibitive for many of my patients who are then stuck with either trying to crush and disperse tablets at home or stopping medications more abruptly and risking unpleasant withdrawal effects.’
The new liquid formulations will allow prescribers to instruct patients in volume-based dosing, simplifying the regimen.
Pharmacists’ role in interdisciplinary care
Beyond compounding, pharmacists will play a crucial role in patient and prescriber education.
‘It’s important to get it out through networks to let prescribers know that these formulas are available for pharmacists to compound,’ Ms Cooper said. ‘Communication between the doctor and the pharmacist will help patients be able to achieve effective withdrawal from antidepressants.’
Joanne Gross, President of PSA’s Tasmania Branch, reinforced the importance of pharmacist leadership in deprescribing initiatives.
‘Antidepressant deprescribing remains a challenge, particularly for long-term users experiencing withdrawal symptoms,’ she said.
‘PSA looks forward to continuing to work with the University to potentially make their findings accessible to all Australian pharmacists through the APF, supporting flexible, individualised tapering regimens and improving patient outcomes.’
To find out more about when and how pharmacists can compound and the compliance obligations required, attend the ‘Compounding essentials for 2025’ session at PSA25 held in Sydney from 1–3 August. Register here to attend.
[post_title] => Making antidepressant tapering safer and easier
[post_excerpt] => In a significant advancement for patient-centred care, a team of pharmacists is reshaping the landscape of antidepressant deprescribing.
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[post_content] => As vaccine-preventable diseases resurface, pharmacies must lead proactive, informed conversations that close gaps and restore community protection.
Despite a world-class immunisation framework and high levels of public trust, Australia has seen vaccination coverage fall short of its 95% target across most cohorts since 2020, said Professor Michael Kidd at the 9th Annual Immunisation Forum 2025, in his first speech Australia's new Chief Medical Officer.
[caption id="attachment_29704" align="alignright" width="281"] Professor Michael Kidd[/caption]
‘If we don't halt the decline in vaccination rates and improve our vaccination coverage … we're risking more disease outbreaks, more serious illness and death among members of our most vulnerable populations, including our children and older people,’ he said.
It’s a troubling trend, especially with the re-emergence of measles both locally and globally, the increase in reported cases of influenza and pertussis, and the outbreak of polio just to our north in Papua New Guinea.
The good news? Pharmacists, as the most accessible health professionals, have already proven themselves to be a trusted, convenient and indispensable vaccination workforce. But there are ways to harness this accessibility, credibility and community reach to increase vaccination uptake – particularly as expanded scopes of practice and new immunisation programs roll out nationwide.
Taking every opportunity
The key to improving vaccination rates is proactive engagement, particularly during patient interactions, said pharmacist Bec Rogers.
‘One of the most effective strategies is the identification of eligible patients during dispensing,’ she said. Whether it’s offering an influenza shot to a patient collecting an asthma inhaler, or recommending a shingles vaccine to an older adult – the opportunities are endless.
‘Opportunistic conversations at the counter or in a consultation room prompt patients to take action that they may not have considered before, because the recommendation is coming from their trusted and respected health professional,’ she said.
For example, in areas with a high proportion of young families, offering family-friendly vaccination clinics – which could mean extended hours or group appointments – can help remove barriers and boost participation.
Other appointment types, such as medication reviews, health checks or minor ailment consultations, can be leveraged as an opportunity to identify recommended vaccines.
‘For instance, if you're in the consult room talking to someone about their cardiovascular risk, it's a great time to bring up what vaccinations they might need, such as influenza or pneumococcal vaccination,’ Ms Rogers said. ‘Our software enables us to check their immunisation history through integration with AIR to really streamline that process.’
Employing marketing and communication strategies
A strong digital marketing strategy can make all the difference in driving vaccination uptake. ‘Automated SMS reminders are one of the most effective tools,’ Ms Rogers said. ‘They can be used to remind patients about upcoming appointments, boosters that might be due, or seasonal campaigns.’
Email campaigns offer another channel to reach patients who may not visit regularly. ‘They can provide more detailed information about available vaccines, eligibility criteria and also how to book,’ she said. ‘They're particularly useful for engaging with patients who may not be visiting your pharmacy as frequently as others.’
Social media platforms such as Facebook and Instagram extend community reach – allowing pharmacists to share timely updates, highlight new services and showcase the accessibility and professionalism of pharmacy teams.
In-store signage also plays a vital role. ‘Posters, window decals and digital screens really help reinforce the message for walk-in customers,’ Ms Rogers said.
As pharmacists expand their service offerings, it's crucial to promote new programs – including new NIP vaccines and travel health services.
‘This not only broadens the scope of pharmacy-based vaccination, but also creates new touchpoints for engaging with patients and improving public health outcomes,’ she said.
Staying on top of legislation changes
As pharmacists administer more and more vaccinations, it’s crucial to keep pace with evolving legislation and vaccine eligibility, said immunisation nurse Georgina Lewis, manager of Victoria’s Vaccine Safety Service.
‘The NIP is forever changing,’ she said. ‘Even if you're not delivering them, you need to be able to engage with families who are interested in vaccines and be opportunistic in your recommendations.’
RSV vaccine eligibility is a particularly dynamic space. ‘We’ve got two vaccines recommended for older adults, Arexy and Abrysvo,’ Ms Lewis said. ‘Both can be given at any time of year, but there's seasonality in some states and for others, it's all year round – particularly in tropical regions.’
Expanding service offering through travel vaccinations
There's an expanded role for some pharmacists to provide travel vaccines, Ms Lewis said.
‘You need to be cognisant of what your legislative requirements are, and in some circumstances [these vaccinations] will be in collaboration with other healthcare providers,’ Ms Rogers said. ‘There may be a scenario where a family or individual comes in with a prescription from a GP for Hepatitis A for example, so you dispense the vaccine and then realise that perhaps you have an opportunity to administer it … which is more convenient for the patient and prevents potential cold chain issues.’
However, a conversation needs to occur with the patient's GP. ‘You also need to make sure it’s recorded in AIR so we don’t get double-ups,’ she said.
Travel advice might be sought through pharmacists, which presents further vaccination opportunities when within scope. ‘It’s important to check vaccination status as part of those discussions, as you may identify gaps and opportunities to catch individuals up,’ she said. ‘And then always refer back to a GP or travel specialist as appropriate. Key questions include: Are you going somewhere? Have you had your travel vaccines? Have you spoken to your GP or a travel specialist?
Co-administration and avoiding common errors
As pharmacists take on a greater role in immunisation, it’s essential to approach co-administration of vaccines with care and clinical confidence, Ms Lewis said.
‘If you're not comfortable doing more than one injection, don't do it,’ she said. ‘You're better off doing them separately or sending them somewhere where they are more confident to do that, because we don't want people coming away with the incorrect technique leading to something like a shoulder injury related to vaccine administration.”
The Vaccine Safety Service has received reports of shoulder injuries occurring in both pharmacy and general practice settings due to improper injection technique.
‘So it's really important you know your anatomical sites if you're going for co-administration, focusing on the deltoid which is recommended [for patients] over 12 months of age,’ Ms Lewis said. ‘Injecting too high into the shoulder area can cause restricted movement and ongoing pain and suffering for individuals.’
Common vaccine errors reported to the Vaccine Safety Service also underscore the importance of vigilance. Confusion between RSV vaccine products has been observed, particularly during the initial rollout phases. ‘[There was] a bit of inadvertent administration of Arexy in pregnancy when Abrysvo wasn't on the NIP, which has settled down now,’ Ms Lewis noted. ‘But it's been replaced by Abrysvo being given to infants instead of the monoclonal antibody.’
Another avoidable issue is the administration of expired vaccines. ‘We get a lot of expired vaccine [reports],’ she said. ‘So it's another opportunity to check and get your products and storage right.’
Looking ahead
The National Immunisation Strategy for Australia 2025–2030, released on Thursday 12 June, outlines national consistency and public trust as key pillars in increasing vaccination rates – recommending an expanded vaccination scope for pharmacists that encompasses more NIP vaccines.
This is something PSA has long advocated for.
‘Harmonising the regulation of pharmacist-administered vaccines is overdue. It just makes sense. Now it has been recommended by a number of policy leaders from the Interim Australian Centre for Disease Control to the Grattan Institute,’ said PSA National President Associate Professor Fei Sim FPS.
‘PSA has said previously that the Australian Immunisation Handbook should be the national standard for defining vaccine formularies, instead of relying on complex regulatory instruments unique to each state and territory. The National Immunisation Strategy has supported this approach. Now it’s time for action.
In the meantime, the message for pharmacists is clear: continue doing what you do best – connect with your community, provide trusted care, and stay informed.
‘You're all in a fantastic position to do something about this,’ Prof Kidd said. ‘Please continue to do all you can.’
[post_title] => How pharmacists can stop the slide in immunisation coverage
[post_excerpt] => As vaccine-preventable diseases resurface, pharmacies must lead informed conversations that close gaps and restore community protection.
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[post_content] => From 1 July 2025, pharmacists will see a range of adjustments to how they deliver and bill for vaccination.
Here, Australian Pharmacist outlines the changes in vaccination services and fees pharmacists can expect from early next month.
1. NIPVIP vaccine administration fees will (slightly) increase
In 2025, the Consumer Price Index (CPI) rose by 2.4%. So from next month, there will be a CPI increase applied to all National Immunisation Program Vaccinations in Pharmacy (NIPVIP) vaccines administered. Pharmacists will receive $20.05 per vaccine administered, up from $19.60.
2. The COVID-19 vaccination payment will (significantly) drop
In less than a week, community pharmacists will see a significant reduction in the COVID-19 vaccine administration fee. The new rate will be $20.05 per vaccine administration in all Australian locations.
This is a significant decrease from the previous rates per dose, which were:
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[post_content] => As investigations reveal many popular high-SPF sunscreens don’t live up to their labels, both pharmacists and pharmacy assistants have a greater role to play in promoting a holistic sun protection routine.
On 12 June 2025, consumer advocacy group CHOICE released findings of a review on 20 popular SPF50 and SPF50+ brands – revealing that many don’t stack up as claimed.
According to the findings, only 20% (4) sunscreens met their SPF claims – with one Australian brand, Ultra Violette Lean Screen SPF 50+ Matifying Zinc Skinscreen, measuring only SPF 4.
Last week, the Therapeutic Goods Administration (TGA) vowed to investigate the matter.
With confidence in sunscreen already undermined via social media claims that its ingredients are toxic, how should pharmacists promote sun safety?
How do SPF numbers translate into real-world UV protection?
Australia has the highest incidence of melanoma in the world. So when the UV Index is 3 or above, it’s advisable to use a broad-spectrum, water-resistant sunscreen with an SPF30 or higher to protect against both UVA and UVB rays.
Despite the CHOICE findings, the difference in SPF ratings is not as stark as it seems. For example, Sunscreens with SPF 50 block around 98% of ultraviolet radiation (UVR), whereas SPF 30 formulations block roughly 96.7%.
So if unprotected skin begins to redden after 5 minutes in the sun, using an SPF50 formulation should, in theory, delay that reaction by fifty times – equating to roughly 250 minutes of protection. Likewise, an SPF30 product would ideally extend safe exposure to about 150 minutes. But by that rationale, an SPF4 sunscreen would only provide 20 minutes of protection – proving very limited benefit.
Application thickness also matters, Professor Rachel Neale, Senior Group Leader at the QIMR Berghofer Medical Research Institute told Australian Pharmacist.
‘The amount of sunscreen people apply will make a substantial difference to the SPF.’
What advice should pharmacists provide?
Even if the sunscreens don't meet their marketed claims, pharmacists should remind patients that they likely still offer a reasonable level of protection if used according to reapplication instructions.
Since pharmacy assistants often field questions about over-the-counter products such as sunscreen, pharmacists must ensure they’re fully across this messaging, including:
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[post_content] => Case scenario
Mrs Alvarez, an 82-year-old woman, presents to your pharmacy with a new prescription for apixaban 5 mg twice daily and some discharge paperwork, following a recent hospital admission after a fall at home. You notice that she was diagnosed with AF during her stay. Her medical history includes a myocardial infarction (MI) 2 years ago, for which she has been taking metoprolol, atorvastatin and aspirin.
Sponsorship statement
Funded by the Australian Government through the Quality Use of Diagnostics, Therapeutics and Pathology Program
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Atrial fibrillation (AF) is the most common recurrent arrhythmia worldwide,1 characterised by uncoordinated atrial activity and irregular ventricular contractions. While its causes and contributors are many, all share a common sequela – an increased risk of ischaemic stroke that can be mitigated by anticoagulation.1 While the use of anticoagulants since the emergence of direct-acting oral anticoagulants has increased, the prevalence of AF has grown.1 This has been accompanied by a rise in hospitalisations both directly due to AF, and indirectly due to stroke and its complications.1 Pharmacists can significantly enhance AF care through direct patient engagement and collaboration with other healthcare professionals across all practice settings. Understanding key aspects of AF, its clinical features and evidence-based treatment strategies allows pharmacists to contribute positively to the overall management of individuals living with the condition.
The prevalence of AF is rising, with over 500,000 Australians estimated to have the condition in 2020,1 and over 600,000 projected by 2034.2 Although this is likely to be an underestimate of the true prevalence of AF in Australia.2
Complications arising from AF pose a substantial health burden, with a fivefold increase in the risk of stroke.3 In 2017–18 there were over 72,000 hospitalisations for AF in Australia, with the condition contributing to 9% of deaths in 2018.1 In 2015–16, AF-related healthcare expenditure in Australia was $881 million, with 69% attributed to hospital costs.1
AF results from electrophysiological abnormalities that underlie impulse generation in the heart, and/or structural irregularities that impair rapid and uniform impulse conduction.4 AF often arises from abnormal electrical activity triggered by ectopic action potentials originating in the pulmonary veins of the left atrium.4 Ongoing clinically meaningful AF requires underlying structural or electrical changes in the heart that continue to disrupt normal conduction and contraction.5 An interactive animation demonstrating cardiac activity in AF from the American Heart Association is available at https://watchlearnlive.heart.org/CVML_Mobile.php?moduleSelect=atrfib.
AF arises from a combination of genetic, metabolic, and environmental factors.4 Contributors include oxidative stress (such as alcohol intake or sleep-disordered breathing), pro-inflammatory states (diabetes and obesity), structural atrial changes (heart failure), genetics and aging.4 These conditions are interlinked, reinforcing the concept that “AF begets AF”.4 In other words, the conditions that cause AF can worsen AF, and AF can also worsen these conditions. The main sequela to this is increased stroke risk. This is caused due to the irregular contractions of the left atria leading to stasis of blood, predisposing to thrombus formation. If the thrombus embolises, it can shift into the ventricle and enter systemic circulation and subsequently the carotid arteries, leading to the embolus becoming lodged in the cerebral arteries.
Beyond the arrhythmia, AF often signals broader pathological processes that impair cardiac function and reduce quality of life and life expectancy.5 Many of these conditions are closely linked to social determinants of health, disproportionately affecting populations with socioeconomic disadvantage. Effective AF management requires addressing both the arrhythmia and its underlying contributors.4
Symptoms
Like many cardiac conditions, AF symptoms can vary between individuals and overlap with other conditions, including coronary syndromes, heart failure, COPD and asthma. Common symptoms include5:
In addition, some individuals with AF may be completely asymptomatic.4
AF is also linked to higher rates of dementia and depression compared to the general population.5 Several tools are available to assess symptom burden and stratify the impact of symptoms, such as the modified European Heart Rhythm Association Score.5 Understanding the burden of AF and its associated comorbidities is essential for providing a holistic approach to patient care.
Stroke risk
The first sign of AF can be a stroke. The Australian Institute of Health and Welfare reported that in 2017–18, AF was present in 15.5% of patients hospitalised for stroke.1
Stroke risk varies, and the CHA2DS2-VA calculator is widely used in clinical practice to estimate the risk of stroke in AF.6 Points are assigned based on the following parameters7:
Scores range from 0 (ischaemic stroke incidence rate of 0.5 per 100 patient years) through to 8 (19.5 per 100 patient years).7 Scores may be used to inform decisions around initiating anticoagulation. There are other tools available, such as the GARFIELD-AF calculator, which offer more precise risk prediction, including bleeding and mortality, but require more detailed data.4
AF is diagnosed with the use of a 12-lead electrocardiogram (ECG). The ECG typically demonstrates an absence of discernible P waves and an irregularly irregular rhythm.5
Most recent international guidelines recommend further investigation for episodes lasting 30 seconds or more, with many anticoagulant trials requiring at least two separate ECGs demonstrating AF.5 Ambulatory monitors (e.g. Holter monitor) can be used for periods of 24 hours to a week and should not be confused with personal wearable devices.5
It is considered good practice to opportunistically screen for AF in patients ≥65 years of age or Aboriginal and Torres Strait Islander patients ≥50 years of age.8,9 Pharmacists may have the opportunity to do so when performing a blood pressure check, however it should be noted that automatic blood pressure machines may not always reliably detect the presence of AF.9
Wearable devices
TGA-approved wearable smart watches and devices are appropriate tools to assist in screening for AF,10 although diagnosis needs to be confirmed by an ECG that has been interpreted by a physician.5
Atrial flutter versus atrial fibrillation
Atrial flutter, a separate diagnosis to AF, is characterised as an atrial tachyarrhythmia but with regular atrial and ventricular activity. Nearly half of those diagnosed with atrial flutter will progress to atrial fibrillation.5 While stroke risk is elevated, it is not always elevated to the extent of AF.5
To address underlying causes or factors contributing to AF, tests recommended at diagnosis include5:
Further tests (e.g. for obstructive sleep apnoea and coronary artery disease) may be required for some patients to optimise management and improve outcomes.5
Treatments
The latest European Society of Cardiology (ESC) guidelines introduced the AF-CARE pathway, which emphasises treating contributing comorbidities and adopting a holistic person-centred approach to AF management.5 This replaces the previous ABC approach (Anticoagulation, Better symptom control, and Comorbidity management).5
C – Comorbidity and risk factor management
As outlined, many comorbidities increase the risk of developing AF, and contribute to increased risk of stroke (e.g. diabetes, hypertension, heart failure). Monitoring and managing these conditions is a priority in AF. Class 1 recommendations include5:
A – Avoid stroke and thromboembolism
Stroke risk assessment is important for determining anticoagulation needs. Across all guidelines there is consensus supporting anticoagulation for CHA2DS2-VA ≥2.4,5,11,12 There is less evidence for anticoagulant use in lower risk scores. In all cases, ongoing risk assessment and shared decision-making in balancing modifiable and non-modifiable risks for stroke and bleeding are key for successful management.5
R – Reduce symptoms by rate and rhythm control
Many patients with AF require interventions or treatments that control heart rate, revert to sinus rhythm or maintain sinus rhythm, leading to improved symptoms and outcomes.5 Treatment options include5:
E – Evaluation and dynamic reassessment
The ‘newest’ addition to previous treatment pathways ensures management adapts to changes in stroke risk, symptoms, comorbidities and other individual needs.5 Generally, a 6–12 monthly follow-up is recommended.5 Further guidance is available from the Quality Use of Medicines Alliance clinical guidance at https://go.medcast.com.au/anticoagulant-management-atrial-fibrillation-clinical-guide.
The role of anticoagulant therapy
AF significantly increases the risk of stroke, making timely assessment and anticoagulation critical. Oral anticoagulants reduce the risk of stroke by 64% and all-cause mortality by 26% in patients with AF.13,14
Direct-acting oral anticoagulants (DOACs)
DOACs have transformed ischaemic stroke prevention in AF (excluding patients with moderate/severe mitral stenosis or mechanical heart valves).5
Landmark trials (RE-LY, Rocket AF, and Aristotle) demonstrated their non-inferiority to warfarin in reducing the risk of stroke and systemic embolism, while halving the risk of intracranial haemorrhage.5
While DOACs offer advantages, no direct comparisons exist between apixaban, rivaroxaban and dabigatran. Choice of agent relies heavily on patient-specific factors such as age, renal function, comorbidities and bleeding risk, as well as practical considerations like accessibility and practicality of dosing regimens.
While stroke prevention benefits are well-established, prescribers must also address potential harms, including bleeding risk. Guidelines recommend addressing bleeding risk factors such as: discontinuing NSAIDs, reducing alcohol intake, lowering falls risk, and ceasing concomitant antiplatelets >12 months post-MI.4,5
However, limitations in the current DOAC evidence base warrant careful consideration. For instance, challenges remain for patients with extremes of bodyweight (BMI) above 40 kg/m² or >120 kg, where data on safety and efficacy remain sparse.4 Additionally, DOACs’ short half-lives mean anticoagulation will be compromised with any missed doses or therapy interruptions.15 Table 1 provides information on currently available oral anticoagulants.16
Warfarin
While DOACs are recommended over vitamin K antagonists (VKA) to prevent ischaemic stroke and thromboembolism in AF, patients with mechanical heart valves or moderate-to-severe mitral stenosis and AF should be anticoagulated with a VKA such as warfarin.5 Pharmacists may support patients prescribed warfarin by taking time to discuss their INR target range, the importance of consistent INR recording, and by providing strategies to improve INR control.
Role of the electrophysiologists
Electrophysiologists are cardiologists specialising in arrhythmias and rhythm control procedures such as catheter ablations. They practise in both public and private settings, and are often consulted for difficult-to-treat AF. While cardiologist referral is important for follow-up and treatment escalation, it should not delay assessing risk and commencing anticoagulation or arrhythmia treatments.
Role of the GP
GPs are integral to diagnosis and commencing the initial management of AF, as well as commencing appropriate therapies and specialist referral. Importantly, comorbidity diagnosis and ongoing management are also central to the GP role.
Role of the pharmacist
Stroke and bleeding risk change over time and may be influenced by new medical conditions or medicines that increase or decrease anticoagulant activity. Pharmacists play a pivotal role in addressing these issues by providing advice on day-to-day medicine use, reducing risks such as bleeding, medicine interactions and ongoing monitoring. Like all chronic conditions, adherence to risk-reducing therapies is an ongoing challenge, and there are a range of mitigating strategies pharmacists can use.17 Pharmacists may consider offering tailored solutions to suit individual needs – this might be in the form of dose administration aids or dose reminders. Encouraging Home Medicines Reviews and supporting patients to keep an up-to-date medicines list can all encourage patients’ self-advocacy and clinicians’ decision-making. Tools like the PSA’s Quick Reference Guide can further aid pharmacists in optimising medicine use. See www.psa.org.au/career-and-support/qum/qum-alliance/oral-anticoagulants/
All patients with recent presentations for AF may be eligible for publicly funded cardiac rehabilitation, which combines education, exercise assessments and ongoing planning by a multidisciplinary team. These programs improve exercise tolerance, support weight loss and promote physical activity – all key AF management strategies.5 Many centres also offer ongoing exercise therapy or referral to tailored programs. All health professionals can refer patients, and the Heart Foundation provides an Australia-wide cardiac rehabilitation directory. Further information on these centres is available at: www.heartfoundation.org.au/your-heart/cardiac-services-directory.
Pharmacists have an essential role in providing medicines education to individuals who are prescribed anticoagulant medicines. Education should be patient-centred, culturally appropriate and include details on the importance of adherence, expected side effects and potential drug interactions. Pharmacists can offer personalised education on minimising bleeding risk by recommending reduced alcohol consumption, avoiding NSAIDs and addressing fall prevention strategies. Incorporating broader cardiovascular risk advice, like smoking cessation, weight management, and promoting blood pressure and diabetes control, may improve AF outcomes. Patients with AF can be offered further support in the form of an anticoagulation plan. A sample anticoagulation plan is available at https://go.medcast.com.au/anticoagulant-care-plan. It is essential that anticoagulants are dosed in accordance with patient characteristics. Pharmacists should flag patients who may benefit from dose adjustment based on weight, renal function or age. When appropriate, patients can be referred to their local cardiac rehabilitation centres.
Given the increasing prevalence of AF, the importance of individualised anticoagulant treatment plans cannot be overstated. Pharmacists can support early detection of AF in at-risk patients and optimise use of oral anticoagulants through medication management services, patient education and ongoing monitoring. By working collaboratively as part of the multidisciplinary team, pharmacists can significantly impact the care of patients with AF.
| Case scenario continued Prior to dispensing Mrs Alvarez her apixaban, you assess the prescribed dose. You ask her if she would mind being weighed and record her weight as 57 kg. Given her age (≥80 years) and low weight (<60 kg), you identify that she meets the criteria for a dose reduction of apixaban to 2.5 mg twice daily, regardless of her renal function. You contact the prescriber, who agrees to the dose reduction. During the conversation, you also raise your concern about the elevated bleeding risk with the concurrent use of aspirin. The prescriber confirms the intention was to discontinue aspirin before starting apixaban. You then counsel Mrs Alvarez on her updated medication regimen. You discuss the importance of adherence, signs of bleeding and stroke, and strategies for fall prevention to ensure safe and effective anticoagulation therapy. |
Adam Livori BAppSci(NucMed), BPharm(Hons), MClinPharm, FSCANZ, FAdPha, FANZCAP(Cardiol, Research) is a cardiology pharmacist and the Lead Pharmacist for Medicine and Continuing Care at Grampians Health.
Jarrah Anderson BPharm is a Clinical Lead at Medcast.
Rawa Osman MPharm, MClinTria(Res), FSHPA, FANZCAP (MedsMgmt, PublicHlth) is a Director at QUM Connect, and Research and Design Lead for the Quality Use of Medicines Alliance.
Julie Briggs MPS (she/her) B Pharm, CredPharm (MMR), FANZCAP (Generalist, PublicHlth)
Rawa Osman is currently Design Lead for the Quality Use of Medicines Alliance, which is leading a national program focused on oral anticoagulants used in AF.
[post_title] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [post_excerpt] => Atrial fibrillation is the most common recurrent arrhythmia worldwide, and can put patients at increased risk of stroke. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => balancing-the-scale-the-role-of-oral-anticoagulants-in-atrial-fibrillation [to_ping] => [pinged] => [post_modified] => 2025-06-25 16:14:57 [post_modified_gmt] => 2025-06-25 06:14:57 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=29266 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [title] => Balancing the scale: the role of oral anticoagulants in atrial fibrillation [href] => https://www.australianpharmacist.com.au/balancing-the-scale-the-role-of-oral-anticoagulants-in-atrial-fibrillation/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 29742 [authorType] => )td_module_mega_menu Object
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[post_content] => In a significant advancement for patient-centred care, a team of pharmacists from the University of Tasmania is reshaping the landscape of antidepressant deprescribing.
Their latest research aims to close a long-standing clinical gap by making easy-to-prepare, cost-effective oral liquid formulations of commonly prescribed antidepressants accessible to every Australian pharmacist.
[caption id="attachment_29732" align="alignright" width="263"] Natalie Cooper[/caption]
These new formulas will help to ensure that patients have options to access safe and effective medications when deprescribing antidepressants, said Natalie Cooper, Research Project Lead at the University of Tasmania’s School of Pharmacy and Pharmacology.
‘Prescribers can also have confidence that when they are prescribing these formulas and suggesting a deprescribing regime, the patient is going to receive an accurate and effective dose,’ she said.
Long-term use with limited tapering options
Each year, over 3.5 million Australians are prescribed antidepressants. Half of these patients become long-term users, with average treatment durations reaching 4 years – well beyond the recommended 6–12 month course to treat a single depressive episode. While these medicines play a critical role in managing mental health, extended use can result in adverse effects, particularly in older adults. Yet safely discontinuing antidepressants remains a challenge.
Key among the hurdles is dose inflexibility.
‘With the lack of commercially available liquid antidepressant formulations available in Australia, there are limited dosing options for people to withdraw from antidepressant medications,’ Ms Cooper said.
The recently released Maudsley Deprescribing Guidelines recommend a hyperbolic tapering method – small, incremental decreases in dose over time – to minimise withdrawal symptoms and support the body’s physiological adjustment. However, this method often requires doses lower than commercially available tablet strengths.
In Australia, the lowest available strength of citalopram – the most commonly prescribed antidepressant – is a 10 mg tablet, which can make safe and effective tapering difficult.
Seeking safer deprescribing methods
When tapering antidepressants, current guidelines often suggest that low doses of certain formulations can be crushed up and dispersed in water, Ms Cooper said.
‘Getting patients to do this imprecise method at home didn’t sound safe to me,’ she said. ‘So I reached out to the Wilson Foundation and asked “why don't we utilise liquid formulations to [deprescribe] in a safe and effective way?’”
In response, the Wilson Foundation funded an 18-month project aimed at producing professional, evidence-based formulation alternatives that all registered pharmacists can readily compound.
‘By creating easy-to-prepare, cost-effective liquid antidepressant formulations that any pharmacy can compound, we’re tackling a major barrier to antidepressant discontinuation,’ Ms Cooper said.
Choosing the right antidepressants for compounding
The research team selected 11 antidepressants for development, targeting those most commonly prescribed in Australia, including mirtazapine, paroxetine and fluoxetine.
‘There are some that aren't as commonly prescribed, but if there’s a patient who needs to come off them, they have an option available,’ Ms Cooper said.
Out of 15 antidepressants listed in the Maudsley Deprescribing Guidelines, four were identified as controlled-release formulations – such as venlafaxine – that can’t be easily transformed into liquid forms.
‘We have gone with the antidepressants we know are immediate release and can be formulated into liquid formulations,’ she said.
The formulations that have sustained-release properties will still require a compounding pharmacist’s expertise to formulate alternate dosage forms.
Developing evidence-based liquid formulations
Designed for ease and accessibility, the proposed liquid formulations can be compounded using standard equipment and readily available ingredients.
‘We're conducting stability testing on these liquid formulations using the commercially available tablets and accessible bases such as ORA-Sweet and ORA-Plus,’ Ms Cooper said. ‘So pharmacists can compound them when they get a prescription from a GP for individual patient supply.’
Once stability and microbial safety are confirmed, the formulations will be submitted to the Australian Pharmaceutical Formulary and Handbook (APF) to be considered for inclusion.
If they are in the APF, they will be available to every single pharmacist and pharmacy in Australia to compound.
The rollout will be incremental, with three formulations submitted each quarter until all 11 are included by the project’s completion.
Bridging gaps in access and affordability
Compounded formulations of antidepressants have traditionally only been available through specialised pharmacies. For patients and prescribers alike, this has presented a barrier to optimal care.
‘Some people may be getting specialised compounded fluoxetine capsules in a low dose through a compounding pharmacy, for example. But they can be quite expensive,’ Ms Cooper said. ‘Accessing a compounding pharmacy also can be quite difficult.’
Dr Anna Seth, a Tasmanian GP, echoed these concerns from the prescriber’s perspective.
‘Existing options for gradual discontinuation of antidepressants are very limited, creating a barrier for patients and the doctors who support them,’ she said. ‘The cost of compounding these medications is prohibitive for many of my patients who are then stuck with either trying to crush and disperse tablets at home or stopping medications more abruptly and risking unpleasant withdrawal effects.’
The new liquid formulations will allow prescribers to instruct patients in volume-based dosing, simplifying the regimen.
Pharmacists’ role in interdisciplinary care
Beyond compounding, pharmacists will play a crucial role in patient and prescriber education.
‘It’s important to get it out through networks to let prescribers know that these formulas are available for pharmacists to compound,’ Ms Cooper said. ‘Communication between the doctor and the pharmacist will help patients be able to achieve effective withdrawal from antidepressants.’
Joanne Gross, President of PSA’s Tasmania Branch, reinforced the importance of pharmacist leadership in deprescribing initiatives.
‘Antidepressant deprescribing remains a challenge, particularly for long-term users experiencing withdrawal symptoms,’ she said.
‘PSA looks forward to continuing to work with the University to potentially make their findings accessible to all Australian pharmacists through the APF, supporting flexible, individualised tapering regimens and improving patient outcomes.’
To find out more about when and how pharmacists can compound and the compliance obligations required, attend the ‘Compounding essentials for 2025’ session at PSA25 held in Sydney from 1–3 August. Register here to attend.
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[post_excerpt] => In a significant advancement for patient-centred care, a team of pharmacists is reshaping the landscape of antidepressant deprescribing.
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[post_content] => As vaccine-preventable diseases resurface, pharmacies must lead proactive, informed conversations that close gaps and restore community protection.
Despite a world-class immunisation framework and high levels of public trust, Australia has seen vaccination coverage fall short of its 95% target across most cohorts since 2020, said Professor Michael Kidd at the 9th Annual Immunisation Forum 2025, in his first speech Australia's new Chief Medical Officer.
[caption id="attachment_29704" align="alignright" width="281"] Professor Michael Kidd[/caption]
‘If we don't halt the decline in vaccination rates and improve our vaccination coverage … we're risking more disease outbreaks, more serious illness and death among members of our most vulnerable populations, including our children and older people,’ he said.
It’s a troubling trend, especially with the re-emergence of measles both locally and globally, the increase in reported cases of influenza and pertussis, and the outbreak of polio just to our north in Papua New Guinea.
The good news? Pharmacists, as the most accessible health professionals, have already proven themselves to be a trusted, convenient and indispensable vaccination workforce. But there are ways to harness this accessibility, credibility and community reach to increase vaccination uptake – particularly as expanded scopes of practice and new immunisation programs roll out nationwide.
Taking every opportunity
The key to improving vaccination rates is proactive engagement, particularly during patient interactions, said pharmacist Bec Rogers.
‘One of the most effective strategies is the identification of eligible patients during dispensing,’ she said. Whether it’s offering an influenza shot to a patient collecting an asthma inhaler, or recommending a shingles vaccine to an older adult – the opportunities are endless.
‘Opportunistic conversations at the counter or in a consultation room prompt patients to take action that they may not have considered before, because the recommendation is coming from their trusted and respected health professional,’ she said.
For example, in areas with a high proportion of young families, offering family-friendly vaccination clinics – which could mean extended hours or group appointments – can help remove barriers and boost participation.
Other appointment types, such as medication reviews, health checks or minor ailment consultations, can be leveraged as an opportunity to identify recommended vaccines.
‘For instance, if you're in the consult room talking to someone about their cardiovascular risk, it's a great time to bring up what vaccinations they might need, such as influenza or pneumococcal vaccination,’ Ms Rogers said. ‘Our software enables us to check their immunisation history through integration with AIR to really streamline that process.’
Employing marketing and communication strategies
A strong digital marketing strategy can make all the difference in driving vaccination uptake. ‘Automated SMS reminders are one of the most effective tools,’ Ms Rogers said. ‘They can be used to remind patients about upcoming appointments, boosters that might be due, or seasonal campaigns.’
Email campaigns offer another channel to reach patients who may not visit regularly. ‘They can provide more detailed information about available vaccines, eligibility criteria and also how to book,’ she said. ‘They're particularly useful for engaging with patients who may not be visiting your pharmacy as frequently as others.’
Social media platforms such as Facebook and Instagram extend community reach – allowing pharmacists to share timely updates, highlight new services and showcase the accessibility and professionalism of pharmacy teams.
In-store signage also plays a vital role. ‘Posters, window decals and digital screens really help reinforce the message for walk-in customers,’ Ms Rogers said.
As pharmacists expand their service offerings, it's crucial to promote new programs – including new NIP vaccines and travel health services.
‘This not only broadens the scope of pharmacy-based vaccination, but also creates new touchpoints for engaging with patients and improving public health outcomes,’ she said.
Staying on top of legislation changes
As pharmacists administer more and more vaccinations, it’s crucial to keep pace with evolving legislation and vaccine eligibility, said immunisation nurse Georgina Lewis, manager of Victoria’s Vaccine Safety Service.
‘The NIP is forever changing,’ she said. ‘Even if you're not delivering them, you need to be able to engage with families who are interested in vaccines and be opportunistic in your recommendations.’
RSV vaccine eligibility is a particularly dynamic space. ‘We’ve got two vaccines recommended for older adults, Arexy and Abrysvo,’ Ms Lewis said. ‘Both can be given at any time of year, but there's seasonality in some states and for others, it's all year round – particularly in tropical regions.’
Expanding service offering through travel vaccinations
There's an expanded role for some pharmacists to provide travel vaccines, Ms Lewis said.
‘You need to be cognisant of what your legislative requirements are, and in some circumstances [these vaccinations] will be in collaboration with other healthcare providers,’ Ms Rogers said. ‘There may be a scenario where a family or individual comes in with a prescription from a GP for Hepatitis A for example, so you dispense the vaccine and then realise that perhaps you have an opportunity to administer it … which is more convenient for the patient and prevents potential cold chain issues.’
However, a conversation needs to occur with the patient's GP. ‘You also need to make sure it’s recorded in AIR so we don’t get double-ups,’ she said.
Travel advice might be sought through pharmacists, which presents further vaccination opportunities when within scope. ‘It’s important to check vaccination status as part of those discussions, as you may identify gaps and opportunities to catch individuals up,’ she said. ‘And then always refer back to a GP or travel specialist as appropriate. Key questions include: Are you going somewhere? Have you had your travel vaccines? Have you spoken to your GP or a travel specialist?
Co-administration and avoiding common errors
As pharmacists take on a greater role in immunisation, it’s essential to approach co-administration of vaccines with care and clinical confidence, Ms Lewis said.
‘If you're not comfortable doing more than one injection, don't do it,’ she said. ‘You're better off doing them separately or sending them somewhere where they are more confident to do that, because we don't want people coming away with the incorrect technique leading to something like a shoulder injury related to vaccine administration.”
The Vaccine Safety Service has received reports of shoulder injuries occurring in both pharmacy and general practice settings due to improper injection technique.
‘So it's really important you know your anatomical sites if you're going for co-administration, focusing on the deltoid which is recommended [for patients] over 12 months of age,’ Ms Lewis said. ‘Injecting too high into the shoulder area can cause restricted movement and ongoing pain and suffering for individuals.’
Common vaccine errors reported to the Vaccine Safety Service also underscore the importance of vigilance. Confusion between RSV vaccine products has been observed, particularly during the initial rollout phases. ‘[There was] a bit of inadvertent administration of Arexy in pregnancy when Abrysvo wasn't on the NIP, which has settled down now,’ Ms Lewis noted. ‘But it's been replaced by Abrysvo being given to infants instead of the monoclonal antibody.’
Another avoidable issue is the administration of expired vaccines. ‘We get a lot of expired vaccine [reports],’ she said. ‘So it's another opportunity to check and get your products and storage right.’
Looking ahead
The National Immunisation Strategy for Australia 2025–2030, released on Thursday 12 June, outlines national consistency and public trust as key pillars in increasing vaccination rates – recommending an expanded vaccination scope for pharmacists that encompasses more NIP vaccines.
This is something PSA has long advocated for.
‘Harmonising the regulation of pharmacist-administered vaccines is overdue. It just makes sense. Now it has been recommended by a number of policy leaders from the Interim Australian Centre for Disease Control to the Grattan Institute,’ said PSA National President Associate Professor Fei Sim FPS.
‘PSA has said previously that the Australian Immunisation Handbook should be the national standard for defining vaccine formularies, instead of relying on complex regulatory instruments unique to each state and territory. The National Immunisation Strategy has supported this approach. Now it’s time for action.
In the meantime, the message for pharmacists is clear: continue doing what you do best – connect with your community, provide trusted care, and stay informed.
‘You're all in a fantastic position to do something about this,’ Prof Kidd said. ‘Please continue to do all you can.’
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