The General Pharmaceutical Council's (GPhC) chief pharmacy officer, Roz Gittins, wants pharmacies to take extra care while dispensing high-risk medicines.
In an email to pharmacists, pharmacy technicians and pharmacy owners, Gittins has highlighted the concerns and provided advice.
He said the GPhC recently received a concern involving methotrexate which was dispensed with a label instructing to take once daily rather than once-weekly.
"Pharmacy teams must take particular care when dispensing and supplying high risk medicines."
Gittins said the pharmacy teams should counsel and remind patients/carers on once-weekly administration, the specific day of the week for dosing, and risks of potential overdose.
He also cited instances of some lapses in checks before medicines were supplied.
One example involved the supply of antibiotics through the NHS Pharmacy First Service in England to a severely immunocompromised patient taking methotrexate, which can increase the risk of toxicity/ myelosuppression.
"Another incident involved a patient who was routinely prescribed a long-term medicine and was provided with an antibiotic where an interaction was present. In some cases, such interactions can result in serious patient harm and, rarely, life-threatening outcomes."
"While pharmacy teams may not always have access to a patient’s complete medication history, they should take all reasonable steps to ensure a safe and appropriate supply. This includes consultations, checking records where possible, providing counselling, and communicating with other healthcare professionals."
Gittins also highlighted instances where fluoroquinolones have been prescribed despite not being the recommended first-line option.
The MHRA had, in January 2024, restricted the use of systemic fluoroquinolone antibiotics only when other commonly recommended options are inappropriate.
"Pharmacy teams should remain vigilant when encountering fluoroquinolone prescriptions, ensure that their use is clinically justified, and provide clear counselling so that patients."
Gittins wanted pharmacy professionals to report suspected adverse reactions through the MHRA Yellow Card Scheme, and to inform patients that they too can submit a report.
He urged pharmacy teams to explore how IT systems and prompt functionalities can be utilised to optimise patient care.
"This is especially important in online settings, where automated prompts can alert prescribers to repeated or early ordering of medication. This can safeguard patients from stockpiling and inadvertently taking more medication than prescribed."
