COVID-19 Information for Prescribers
Due to supply concerns related to COVID-19, drug wholesalers have implemented allocation percent strategies for the distribution of drugs. Although manufacturers and distributors have not identified any specific, widespread COVID-19-related shortages, these measures are needed to preserve stock and avoid unnecessary stockpiling. Every level of the drug supply chain is working to ensure sustainable drug distribution in B.C., given the current situation.
To check for up-to-date information on any drug shortages, consult the Canadian Drug Shortages or the PharmaCare Drug Information websites. If you have concerns about a patient's ability to obtain a drug you prescribe for them, please call a local pharmacy to discuss options with a pharmacist.
The Limited Coverage Criteria for all limited coverage, direct-acting anticoagulants (DOACs) has changed for the duration of the COVID-19 pandemic.
Patients newly starting anticoagulation treatments are no longer required to trial warfarin before getting approved for a DOAC. Warfarin is the long-established anticoagulant for preventing ischemic strokes in patients with atrial fibrillation (AF) and for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). Its use requires frequent lab testing when therapy is started, which may not be desirable for social distancing during the COVID-19 pandemic. DOACs are as effective as warfarin in treating the aforementioned indications and do not require lab testing as frequently.
Patients on Warfarin
INR testing options for patients on warfarin may be limited for the duration of the COVID-19 crisis as some labs will be either closed or operating with limited hours. A decision tree for switching patients from warfarin to a DOAC has been developed for prescriber use.
Larger centres such as the lower mainland or southern Vancouver Island have functioning collection sites for INR. For remote patients or those with mobility issues that preclude more than usual travel, the following options may be available:
- Home collection (available in some locations - please contact LifeLabs for details)
- Mobile testing clinics (contact your local health authority for more information)
- CoaguChek® device (exceptional coverage may be considered in some cases)
- Private point-of-care testing (not funded)
Please note that collection sites and protocols may differ for patients assessed as vulnerable during the COVID-19 crisis. LifeLabs, Valley Medical Laboratories, Hospital Laboratories, and Health Authority Laboratories will keep their websites updated with pertinent information and instructions for immunologically vulnerable populations
If no INR testing is feasible for patients, consider switching them to a DOAC.
Clopidogrel is now a regular benefit and no longer requires Special Authority approval for coverage. Note: brand Plavix® is a partial benefit and requires SA for full coverage.
Effective March 26, 2020, PharmaCare has implemented the following changes to ensure efficient access to medications and promote patient safety during the COVID-19 pandemic.
To assist pharmacists, if prescribers are not available:
- More staff are available on the Special Authority (SA) phone lines to help resolve issues with faxing requests because the prescriber is not in the office.
- Temporary manual extensions are available over the phone for select drugs where infusion dates are already planned and the prescriber is not available for completion of a renewal request.
For prescribers, to avoid having to see patients to renew Special Authority coverage during this time, PharmaNet has been updated to automatically extend SAs for the following limited coverage drugs that are expiring between now and July 1, 2020:
- Special Authority Criteria that require patients to attend a lab or undergo any non-essential diagnostic test may be waived, to reduce patient contact with others and enable better adherence to social distancing requirements.
Patients will still need to meet other criteria points on a given application form for approval. These allowances are exceptional and will be reassessed again in six months. Instances will be considered on a case-by-case basis and include the following examples:
2 A1C values are still required for adjudication. Time period has been expanded to 1 value within the past 6 months, and 1 value within the past 12 months.
Dalteparin, Tinzaparin for treatment of venous thromboembolism in cancer patients
Requirement of a trial of warfarin, or rationale to avoid warfarin is waived. Dalteparin and tinzaparin will be first line treatment options.
- Idiopathic pulmonary fibrosis: Approvals for nintedanib or pirfenidone expiring before July 1, 2020 will be given an automatic 6-month extension to October 1, 2020, as non-critical pulmonary function tests have been suspended due to the COVID-19 outbreak. Current Special Authority applications are not necessary to enact this extension.
Prior to the COVID-19 pandemic, British Columbia was experiencing a public health emergency in the form of the opioid overdose crisis. This crisis is ongoing and has been further complicated by the COVID-19 situation. While the COVID-19 pandemic affects the ability of everyone to interact safely with others, people who use drugs (PWUD) are especially vulnerable due to the combination of co-morbidities (often respiratory), their high risk of contracting or spreading the COVID-19 virus while obtaining their drugs, and the risks associated with withdrawal from those drugs.
To support the Provincial Health Officer’s orders for social distancing and self-isolation related to COVID-19, including people with previously-untreated substance use disorders, the British Columbia Centre on Substance Use (BCCSU) has prepared Clinical Guidance for Risk Mitigation in the Context of Dual Health Emergencies. This document is intended to guide prescribers assisting PWUD to access safe alternatives to illicit substances they were using prior to the pandemic. All measures are intended to reduce barriers to access, interpersonal contact, and the risk of either health emergency worsening the other. Prescribers and pharmacists are urged to keep this intent in mind when interacting with PWUD. These measures are a public health approach to help reduce the spread of COVID-19 and reduce its impacts on PWUD, our communities, our health system, our healthcare workers, and all British Columbians.
Telemedicine is covered by MSP in British Columbia, and patients may connect with physicians using such a service to obtain a prescription appropriate to prevent withdrawal during self-isolation and/or to enable social distancing. Prescribers may now fax or phone these prescriptions to a pharmacy identified by the patient, and subsequently deliver the original paper duplicate prescription to the pharmacy for the pharmacy’s required record-keeping.
In addition to existing therapies for alcohol use disorder and opioid use disorder, the BCCSU guidance now recommends use of
- 8 mg hydromorphone tablets for opioid use disorder;
- methylphenidate or dextroamphetamine for stimulant use disorder; and
- lorazepam or diazepam for benzodiazepine use disorder.
Except where noted in the guidance document, the specific medications recommended by the BCCSU are regular benefits under Fair PharmaCare and Plans C, G, and W.
Please note the Plan G registration process permits physicians to sign on patients’ behalf if they are unable to do so; consultation in a telemedicine or otherwise remote fashion with a patient fits this definition.
Delivery of Controlled Substances (including OAT)
To prevent unnecessary personal interactions, a temporary exemption to the federal Controlled Drugs and Substances Act has been issued to allow pharmacy staff to deliver controlled substances.
The College of Pharmacists of British Columbia updated PPP-71 on March 17, 2020, allowing pharmacists to initiate delivery of OAT medications when appropriate, rather than requiring prescriber pre-approval. For OAT medications, pharmacists must notify prescribers as soon as is practical that delivery has commenced, and delivery must cease if the prescriber indicates it is not permitted.
Long-acting muscarinic antagonists (LAMA) and inhaled corticosteroid (ICS)-long-acting β-antagonist (LABA) combination therapy inhalers for asthma and COPD are now available on the Practitioner Info Line as option #6 on the Special Authority Accelerated Request (SAAR) options for prescribers.
This option includes a temporary waiver of the pulmonary function test requirement, as these tests are not being conducted at this time because they constitute a risk for patients during the pandemic. As a reminder, respirologists already have Special Authority exemptions for these products.
Products available through this service:
- formoterol combination with budesonide
- formoterol combination with mometasone
- salmeterol combination with fluticasone
- vilanterol combination with fluticasone
- aclidinium combination with formoterol
- glycopyrronium combination with indacaterol
- tiotropium combination with olodaterol
- umeclidinium combination with vilanterol
These products can be requested by prescribers and selected using a new inhaler menu option present among options for other drugs in the SAAR line.
As a reminder, inhaler products are currently in high demand across Canada. For information regarding availability, prescribers and pharmacists can check the Canada-wide drug shortages website or contact a local pharmacy to inquire about stock.