Last week, a patient entered Rachel Lee’s pharmacy in an affluent San Diego neighborhood to ask about his ivermectin prescription. She had braced herself for this moment since her pharmacy started getting calls about the drug’s availability.
“I was like, ‘Oh great, here it is. Here’s my first one,’ ” said Lee, who asked that her real name not be used to protect her job at a national chain pharmacy.
The prescription lacked a diagnosis code, which many pharmacists use to ensure a drug is prescribed for valid medical reasons. The prescribing doctor was licensed outside of the state, in Florida. When she called the doctor’s office for more information, an employee said the ivermectin was for prophylactic COVID treatment. Lee turned the patient away.
Many pharmacists across the country are finding themselves in similarly uncomfortable situations. Demand for ivermectin, which in tablet form is used to treat parasitic worms in humans, has surged 24-fold because of the scientifically unsupported belief that it can treat, or prevent, COVID-19. Prior to the pandemic, the Centers for Disease Control and Prevention reported an average of 3,600 ivermectin prescriptions per week. The number of prescriptions began to rise rapidly in early July, spurred in part by fringe doctors advocating for its use. By mid-August, the CDC reported more than 88,000 prescriptions per week.
The FDA has not approved ivermectin for this indication, and the National Institutes of Health, World Health Organization, and even the drug’s manufacturer, Merck, have all said that the scientific evidence for its use in treating or preventing COVID is insufficient. Nevertheless, some physicians are writing prescriptions—shady websites offering them for a fee abound—and celebrities like Joe Rogan and Alex Jones have promoted it. While some pharmacies fill these prescriptions, many others are having to turn away frustrated patients.
“We’re put in a tough spot,” said Lee. “I have been very strict with it, just because at the end of the day, it is my license.”
On Sept. 1, a trio of leading national health care groups—the American Pharmacist Association, the American Society of Health-System Pharmacists, and the American Medical Association—issued a joint statement calling for an end to the ordering, prescribing, or dispensing ivermectin for COVID-19 prevention or treatment. The way people intend to use it is dangerous, say pharmacy experts.
Pharmacists are seeing prescriptions for varying dosages and longer periods of time than ivermectin is currently approved for use, said Anne Burns, a pharmacist and VP of practice affairs at the APhA. In oral tablet form, ivermectin is approved as a one-time treatment, and occasionally a follow-up dose is prescribed several months afterward. “We’re hearing of prescriptions for ivermectin for several days up to a month, and sometimes longer,” said Burns. (A topical version of ivermectin also exists for certain human skin infections.) Burns also noted that the APhA recently received a report about a physician asking to fill a 30-day prescription of ivermectin for himself.
Overdoses of ivermectin can cause symptoms ranging from nausea and vomiting to seizures, coma, and death. It may also react negatively with other medications a person is taking. There are also reports (and memes) of people using veterinary-grade ivermectin, a paste used to deworm horses, cows, and swine. Though the active ingredient is the same, it bears repeating that drugs for livestock are dangerous because their extremely high dosage is meant for large animals, and they may also contain inactive ingredients not meant for human consumption.
Despite these risks, prescriptions for human ivermectin are being called into pharmacies.
Some come from physicians operating via dubious online groups offering telemedicine services, like the Front Line Doctors. Burns cautions people that these online options are a buyer beware market. “There are telemedicine sites that may not be reputable,” she said, and though guidelines for prescribing via telemedicine differ from state to state, during COVID “there’s a lot of relaxation for operating across state lines.”
“If you are asked to fill out an online form that results in a prescription, that’s a red flag,” she said.
The increased demand has led to shortages of ivermectin tablets in some pharmacies, which is a problem for people who actually need it for its approved treatment. These shortages come with a grim silver lining for pharmacists. “I’m reluctant to call a drug shortage helpful,” said Michael Ganio, a senior director at ASHP, but if a “pharmacy does not have ivermectin in stock, it’s a black and white decision” for the pharmacist not to fill it.
Pharmacists are under no obligation to fill a prescription that they think is unsafe.
“It’s our responsibility as a profession to keep our patients safe, and whether the patient or prescriber agrees with that is really not a part of the equation,” said Ganio. This means checking for correct dosage, looking out for potential interactions with other drugs, and refusing to give a drug when it’s not prescribed for a valid medical reason. Ganio said he has heard reports of physicians and patients giving pharmacists a hard time, but patients seem to be moving on to the next pharmacy to find a source rather than get into an argument.
Some pharmacies have filled those prescriptions. Helen Lim, a pharmacist at a CVS near Los Angeles, said that at CVS, it’s company policy to turn away people with ivermectin prescriptions. But she noted that at large chain pharmacies, staff fill such a massive volume of prescriptions that, when it comes to ivermectin requests, “sometimes it just doesn’t get caught.”
Pharmacists who find themselves being asked to fill ivermectin prescriptions should decline and respond by educating patients, said Ganio. “Pharmacists, who are aware of the evidence and the guidelines, should be able to talk to the patient to help them understand the evidence, why it’s not recommended, why it can be harmful.”
At her San Diego pharmacy, Lee explained to her patient she wasn’t comfortable filling his ivermectin prescription because the FDA hadn’t approved it for that use. She told the employee at his doctor’s office the same thing. Rather than put up a fight, the employee said they’d just send the prescription to another pharmacy.
“At the end of the day,” said Lee, “it’s up to the dispensing pharmacist.”