Under the UK's Pharmacy First initiative, people are encouraged to see their pharmacist before consulting their GP - especially for minor ailments. It's a tough four-year course to become a pharmacist in the UK, so you're in good hands if you seek their advice.
Authors
- Colin Davidson
Professor of Neuropharmacology, University of Central Lancashire
- Cathryn Brown
Senior Lecturer in Pharmacy Practice, University of Central Lancashire
However, on stepping in to any community pharmacy, you might be surprised by the welter of products on sale - from decongestant drugs to homeopathic remedies - that have little or no evidence to support their effectiveness.
For example, oral phenylephrine has been shown to be ineffective as a nasal decongestant. Following a review of the evidence, late last year, the US Food and Drug Administration advised that oral versions of the drug (pills, soluble powders and syrups) should no longer be sold as a treatment for a blocked nose.
Phenylephrine is the main decongestant ingredient in many over-the-counter cold remedies.
Meanwhile, the UK's Medicines and Healthcare Products Regulatory Agency's chief safety officer, Alison Cave, said there are "no safety concerns" over phenylephrine products and "people can continue to use as directed". Although safety is not what's in question. Effectiveness is.
The flu drug oseltamivir also has little evidence of effectiveness - at least in otherwise healthy people. The UK government, however, still recommends its use in seasonal flu outbreaks.
A recent meta-analysis of 33 clinical trials , with a combined 19,000 patients, showed that oseltamivir, and similar antivirals, might be useful if given to patients who are at a high risk of severe disease. However, they only worked if given within 48 hours of exposure to the flu virus. These drugs had little or no effect on most people who are at low risk or who look for treatments after the 48-hour window.
In 2017, the World Health Organization (WHO) downgraded the status of oseltamivir from "essential" to "complementary".
The WHO strongly advises against giving oseltamivir to people with "suspected or confirmed non-severe seasonal influenza virus infection". The drug doesn't seem to help people at low risk of severe flu and can have unpleasant side-effects.
What about supplements and other non-medicines?
Of course, pharmacies don't just sell drugs. They also sell supplements, such as vitamins and minerals, herbal medicines and homeopathic remedies.
Although more than half the UK population takes a multivitamin or dietary supplement, scientists still debate their benefits. A recent large study found that taking a daily multivitamin doesn't appear to be associated with a mortality benefit.
On the other hand, taking a vitamin D supplement is recommended for those with a deficiency - especially during the dark winter months. Studies have shown that it may reduce the risk of heart attacks and strokes in older people. And people with periods can benefit from vitamin C as it helps with iron absorption.
Medicines in the UK must demonstrate safety, quality and efficacy - but these criteria don't apply to supplements, herbal medicines and homeopathic products. These products only have to demonstrate safety and quality.
The Royal Pharmaceutical Society states that there is "no evidence from randomised controlled trials for the efficacy of homoeopathy over placebo, and no scientific basis for homoeopathy". However, it was only as recently as 2017 that the NHS agreed to cease providing homeopathic treatments.
If the evidence says that they don't work, why do people take these products?
Placebo effects may be part of the reason. The person may believe that the treatment will work and this may lead to them thinking that they feel better. Most of these products are sold for self-limiting conditions and are aimed at helping people feel better while they recover.
Pharmacies have always sold complementary therapies, although these products have changed with the times. You won't find tonic wine anymore, and there's much less call for malt extract with cod liver oil.
So why do UK pharmacies sell products with little or no evidence of effectiveness?
Data from Community Pharmacy England suggests that 90% of the income of the average pharmacy comes from the NHS. But, over the last ten years, that funding has seen a 30% real-term cut, even in the face of new services, such as Pharmacy First.
Is it any wonder then that community pharmacies are moving into private services, such as weight loss, and expanding the range of lifestyle products they sell?
Also, many pharmacists work for larger companies and these companies might value profit over evidence-based treatments. Their shops can be crammed with dubious products with high profitability.
This conflict between pharmacies making a profit and providing the best treatment options and advice is not new and is something that Australia struggled with quite recently, leading to calls for pharmacies to drop products that lack evidence.
As long as pharmacies face NHS spending cuts and have to rely on the sale of products that have little or no evidence for their efficacy to remain afloat, the situation is unlikely to change. In the meantime, ask questions about anything you are considering buying. You can be reassured that if a product isn't right for your condition, your pharmacist will tell you.
The Conversation offered the Royal Pharmaceutical Society the right of reply and Elen Jones, the society's director for England and Wales wrote:
"Community pharmacies are the ideal place for open conversations with patients to ensure they make informed decisions about their health, including discussing any questions about the evidence of a product's clinical effectiveness …
"In the case of homeopathy, the RPS is clear that it has no scientific evidence to support its clinical efficacy beyond a placebo effect and does not endorse it as a form of treatment. Pharmacists should advise people considering homeopathic products about their lack of efficacy beyond placebo and also advise that individuals do not stop taking their prescribed medicines when considering using a homeopathic product.
"Offering a variety of products can be an opportunity for patients to access the pharmacy as a 'gateway to healthcare,' encouraging them to seek advice for conditions because they trust their pharmacist. Pharmacists play a crucial role in providing evidence-based care daily, guiding patients towards treatments that are safe and clinically effective, with patient care and safety always as the highest priority."
Colin Davidson has previously received funding from the NIH (USA) and the European Community for projects related to drug abuse. He is currently a consultant on novel psychoactive substances for the UK Defence Science Technology Labs and is a member of the Advisory Council on the Misuse of Drugs (UK). He was Head of School of Pharmacy & Biomedical Sciences at the University of Central Lancashire from 2017-2023.
Cathryn Brown is a pharmacist and a member of the Royal Pharmaceutical Society. She is currently a member of the Labour party, and regularly donates to Sense about Science.
