Q & A - Pharmacist Prescribing for Minor Ailments
Q: How and when was this change in scope developed?
A: There was a lengthy consultation process, starting with an advisory group in June 2019, and continuing with further stakeholder input and public consultation. The Ontario government approved the regulation changes in April 2022, and they took effect in January 2023. (see references for link)
Q: Is this being done anywhere else?
A: Yes, Ontario is actually one of the last provinces/territories to implement some form of pharmacist prescribing. It has been well-established for years in some provinces, such as Nova Scotia and Alberta. (see references for link)
Q: What’s the definition of a Minor Ailment?
A: The Ontario College of Pharmacists (OCP) defines minor ailments as health conditions that can be managed with minimal treatment and/or self-care strategies. Additional criteria include: usually a short-term condition; lab tests are not usually required; low risk of treatment masking underlying conditions; medications and medical histories can reliably differentiate more serious conditions; and, only minimal or short-term follow-up is required.
Q: How are pharmacists trained to do this?
A: There is a mandatory training module from OCP that covers the details of the legislation, regulations and ethical issues. Ontario schools of pharmacy have now included the assessment and treatment of minor ailments into their curriculum. There are optional clinical training modules to introduce these skills to currently practicing pharmacists. From OCP: “It is the expectation of the College that pharmacists understand their ethical, legal and professional obligations and that they possess the required knowledge, clinical skills, and judgment to safely prescribe medications for minor ailments.” Pharmacies may also choose to use a software program to guide them through the process, with clinical decision support to help identify conditions that don’t meet the criteria for pharmacist prescribing.
Q: What about access to lab data?
A: Pharmacies have access to Ontario Health clinical viewers
Q: How does the reimbursement work?
A: There should not be a cost to the patient. It is billed to the Ministry of Health through the current online ODB system and paid to the pharmacy. There is a payment of $19 for an in-person assessment and $15 for a virtual one (only to be done if appropriate for the assessment). There is a different code used depending on whether an Rx was written or not, and there is a maximum number of fees allowed per year per condition.
Q: Isn’t this a conflict of interest as the pharmacist writes a prescription and then fills it?
A: The patient must be informed that they are free to take the prescription to the pharmacy of their choice. The fee is still billed for the assessment whether there was an Rx initiated or not, reducing the incentive to necessarily prescribe something.
Q: Who is responsible for the decisions made in the assessment and the prescribing?
A: Pharmacists carry their own liability insurance and are responsible for their actions.
Q: How are family doctors/NP’s informed if one of their patients is seen?
A: If the patient has a Primary Care Physician, they are notified of the interaction and the result. If the pharmacist has prescribed something and is following up, there is no action expected from the PCP. If the pharmacist determines that this condition would be better assessed by someone else, they will refer the patient to their PCP.
Q: What is the follow-up?
A: Depending on the condition and the recommendation, the pharmacist will schedule a follow-up, usually just a phone call in 2 days or longer. If, at that time, the condition is not improving or shows any worrisome features, the patient will be advised to seek further medical care.
Q: What conditions can a pharmacist treat under this program?
A:
- Allergic rhinitis
- Candidal stomatitis (oral thrush)
- Conjunctivitis (bacterial, allergic and viral)
- Dermatitis (atopic, eczema, allergic and contact)
- Dysmenorrhea
- Gastroesophageal reflux disease (GERD)
- Hemorrhoids
- Herpes labialis (cold sores)
- Impetigo
- Insect bites and urticaria (hives)
- Tick bites, post-exposure prophylaxis to prevent Lyme disease
- Musculoskeletal sprains and strains
- Urinary tract infections (uncomplicated)
Q: What drugs can a pharmacist prescribe?
A: The regulations refer to the American Hospital Formulary System (AHFS) category for each minor ailment. This is a bit more cumbersome than just a straight list but it was done so that the legislation doesn’t have to be updated every time there is a new drug released on the market.
Example #1 - Allergic Rhinitis
Allowable drugs:
AHFS 4:08 Second Generation Antihistamines (examples: cetirizine, loratadine)
52:02 Eye, Ear, Nose and Throat (EENT) Preparations — Anti Allergic Agents (example: Cromolyn Na eyedrops)
52:08.08 Eye, Ear, Nose and Throat (EENT) Preparations — Anti-inflammatory Agents — Corticosteroids (example: fluticasone nasal spray)
Example #2 - UTI
Allowable drugs:
AHFS 8:12.20 Anti-infective Agents — Antibacterials — Sulfonamides
8:36 Anti-infective Agents — Urinary Anti-infectives
It really comes down to just nitrofurantoin, fosfomycin, and TMP/SMX. There is no requirement for a urine sample, based on the premise that most uncomplicated UTI’s are caused by E.coli. From the antibiogram published by Public Health in 2021, E. coli was responsible for 8900 out of 11,000 isolates in outpatient urinary infections in the SE region. Of those, 98% were sensitive to nitrofurantoin and 83% to SMX/TMP. (see references for link)
It is a fairly narrow authorization, anything complicated has to be referred to MD/NP.
For example, refer if fever, chills, gross hematuria, flank pain, vaginal discharge, recent history of UTI, antibiotic use within past three months, increase in severity of symptoms, poorly controlled diabetes, male, patients appearing systemically unwell or septic, renal insufficiency, nephrolithiasis, pregnancy, anatomical or functional abnormality of urinary tract, immunocompromised.
These last two are from the FAQ document on the OCP website:
Q: Do I need an appointment, or can I just visit my pharmacy?
A: Individual pharmacies may have their own processes in place to provide minor ailments services. Patients are encouraged to speak to their pharmacist to find out what healthcare services they offer, the format of the services offered, and whether they are right for their needs.
Q: Can pharmacists prescribe medications for minor ailments to patients of any age?
A: While the regulations authorizing pharmacists to prescribe for minor ailments do not include age restrictions, it is possible that age may be relevant to the treatment of specific minor ailments. Pharmacists will assess each patient seeking treatment for minor ailments, and if age or any other factor impacts their decision to prescribe medications, it should be explained to the patient along with a follow-up plan for monitoring and/or next steps. This could include a referral to another healthcare provider.
For more information:
- Minor Ailments Advisory Group report:
- Ontario College of Pharmacists website at OCPinfo.com
https://www.ocpinfo.com/practice-education/expanded-scope-of-practice/minor-ailment/
- Ontario Agency of Health Protection and Promotion (Public Health Ontario). Ontario Antibiogram [Internet]. 2021. Available from:
(click on the Ontario Antibiogram spreadsheet, and then when the Excel document opens, go to the Urinary Antibiogram tab)
- National Association of Pharmacy Regulatory Authorities summary of pharmacist scope of practice: