E-pharmacies must strike a balance between enhancing accessibility and exercising caution to avoid exacerbating the public health threat of antimicrobial resistance (AMR).

One cannot refute the significance of antimicrobials in curing infections, yet a larger issue is at hand that has the potential to break the very backbone of antimicrobial therapy.

Antimicrobial resistance (AMR) is a plague and not fully attributable to the natural course of an infection. Indiscriminate antimicrobial use can be directly attributed to the development of AMR, a global threat. Numerous players appear to facilitate this. What role do e-pharmacies play in this global health concern?

A common story of every household

Sandeep (name changed), a 21-year-old man, developed a runny nose and a sore throat over two days and wants antibiotics for them. Ideally, he would most often not require antibiotics, as runny noses and sore throats are commonly due to viral infections, which are self-resolving.

Sandeep opens an e-pharmacy application on his phone to buy Azithromycin, his go-to antibiotic pill for a sore throat. Since he does not have a prescription, he is asked to talk over the phone to a doctor affiliated with the application, who gives him a prescription for the medicine following a 20-second conversation.

Sandeep is pleased. Azithromycin is prescribed for no clear reason. Sandeep gets better and attributes it to the drug. He now informs his friends and family about the ease of access and further affirms that it’s crucial to always take antibiotics for a common cold.

The emerging market of e-pharmacies

E-pharmacies are essentially similar to how online shopping for clothing replaced the traditional method. Ease of shopping, easy payments, and swift delivery were the cornerstones on which it was advertised, which, having been successful, have now seeped into everyday life. There are currently around 50 e-pharmacies in India, with a market size in 2019 of approximately INR 415 crore. The market is expected to grow at a staggering rate, with a projected valuation of INR 66,400 crores by 2030.

Despite a significant number of such platforms, there is yet no separate set of regulations for the same in India. Presently, the sale of medicines through e-pharmacies is under the purview of the Drugs and Cosmetics Act of 1940 and the Pharmacy Act of 1948. A Draft Drugs, Cosmetics, and Medical Devices Bill, 2022, which was brought out by the Indian Government, has been sent back with revisions and is yet to be implemented.

As it appears, the e-pharmacy platform is still grossly unregulated, as the 1940 Act being pre-independence era legislation, has no provisions to scrutinize the online sale of medicines. This leads to unregulated access to medicines, predominantly antibiotics, in instances where it is not required.

Across the globe, other countries have adopted various laws and regulations to ensure adequate quality control of e-pharmacies. The European Association of E-pharmacies, which lays down guidelines for the procurement and sale, has introduced a separate logo to ensure that all medicines sold online have a legal pharmacy entry that the consumer can check. In the United States, prescription and sale via e-pharmacies are under the purview of state and central laws with periodic verification of the prescriptions.

Does making prescriptions mandatory solve the problem of AMR?

Prescription-based dispensing of antibiotics holds strong value only when the prescriptions aren’t dispensed like candy. Healthcare professionals, especially doctors, must understand the same, as they have the added responsibility of educating patients and, by extension, their families, about situations where one does not need antibiotics.

Doctors affiliated with e-pharmacies must especially be judicious in this regard, as per there is hardly any contact with the patient. They should understand that an antibiotic is not a replacement for an in-person consultation.

As we move forward, we need to stress the need for stringent regulation of antibiotic dispensing in e-pharmacies and also address the overprescription of the same. Patient education is only secondary to the education of the medical practitioner itself.

Educational interventions targeting doctors have been seen to reduce the overprescription of antibiotics. Effective training programs that highlight the growing concern of antimicrobial resistance and the impact of overuse of antibiotics towards the same need to be emphasized to healthcare providers.

As doctors, it remains crucial that we practice what we preach. Often we do come across patients who demand antibiotics. As easy as it is to merely write the drug, a two-minute discussion on why it’s not required holds a much longer-lasting positive impact in curtailing its use.

This piece was originally published on the public health media platform Nivarana during the World AMR Awareness Week as part of SaS x Nivarana AMR series.

About the author: Karun Saathveeg Sam is currently working as an Internal Medicine resident doctor with a passion for public health and holistic patient care.

Edited by Parth Sharma
Image by Deekshith Vodela