The blue one: when the blue pill does not tell the whole story

It is Friday afternoon, half past four, and the pharmacy is quiet. Mr R. comes in. I know him by his first name, which does not mean much here — I know almost all our regulars by their first names. What means more here is that last time I saw him with his wife Erika, and the time before that I did not.

He has a daily paper under his arm that he does not need. He positions himself at the till, looks at the display of the digital scale, then asks, without looking at me: “Do you still have the one from last time? The blue one.”

The blue one is sildenafil. Since 2019 I have been allowed to sell it to him without his having to see his GP. As part of the revision of the Therapeutic Products Act, Switzerland introduced list B+ at that time: certain prescription-only active substances that pharmacists may dispense directly after a standardised check and with documentation. Sildenafil 25 mg is on that list, up to four tablets per dispensation; the higher strengths remain subject to prescription. I ask him about his age, concomitant medication, nitrates, heart problems, dizziness, visual disturbances. I measure his blood pressure. If everything fits, I dispense.

That is a sensible arrangement. The men are grateful because they do not have to go to their GP. The GP is relieved because he does not have to hold the consultation. Nobody talks about it, because it works.

What nobody says about it is that what Mr R. is buying from me here is often not what he has.

Erectile dysfunction in a man over fifty is in most cases not a urological problem in the narrower sense. It is a vascular problem. The penile arteries have an internal diameter of one to two millimetres; the coronary arteries are three to four. Anyone who develops endothelial dysfunction in the smaller vessel often already has it in the larger one, just not yet symptomatically. A 2021 review of several meta-analyses published in BJU International arrives at a relative risk of 1.5 for coronary events and 1.55 for myocardial infarction in men with ED compared with men without. Various cardiology reviews conclude that erectile dysfunction precedes manifest coronary heart disease by an average of three to five years. It is not a quirk of ageing. It is an early warning sign.

Last time, two months ago, Mr R.’s blood pressure at the check was 152 over 96. I had referred him to his GP. Today he comes back, wants the same again, and I do not know whether he went.

I ask. He says he had an appointment, but then he felt better again. He did not call back. It is all under control, he says. I measure his blood pressure again. 148 over 93. The pulse is regular, the breathing calm, but the reading is the reading.

What do I do?

I am allowed to sell him the sildenafil. My OTC check is designed around the question of whether taking sildenafil is safe for him — not around the question of whether his erectile dysfunction is the only problem he has. For that second question nobody is responsible except the GP he does not call.

I sell him the sildenafil. But I write the telephone number of his GP practice on the receipt by hand. I know it by heart. We have shared the same GP for years. I tell him I will call there next week and ask after him. Not out of pressure. Out of interest.

He nods. He takes the sildenafil. He takes the newspaper. He leaves.

Perhaps he will make the appointment after all, because he knows I am going to call. Perhaps not. What is certain is this: what he has just bought is not what is making him ill. It is only what makes the illness bearable for him, just about.

That is the tension in this OTC position. It is a good position. It has eased access, reduced stigma, increased safety. But it has also placed a new junction in the pharmacy — one at which a particular kind of early warning sign passes across the counter with great regularity and, with great probability, will not become what it could be.

Perhaps that is the smallest definition of my work: to preserve the early-warning character of a symptom, even when the medicine against it is directly available.

I will call the GP on Monday.