Changes in the scope and intent of US state legislation on ivermectin and pharmacy dispensing trends, 2020–2026

State legislation related to ivermectin use has grown in volume and scope since 2020, despite limited evidence for its effectiveness in treating COVID-19. Media reports suggest that public interest in ivermectin continued after the pandemic and has expanded to other indications alongside promotion by social media influencers and podcasters. In this study, we analyzed ivermectin-related bills introduced from January 2020 to September 2026 and assessed their association with ivermectin dispensing trends. We identified 35 states that introduced 129 ivermectin-related bills, with eight enacting legislation. Legislative focus evolved from predominantly off-label use in 2020–2022 to over-the-counter access in 2025–2026. Early legislation specifically mentioned COVID-19 treatment, while later bills omitted specific medical indications. A sub-analysis using Poisson regression to evaluate the association between state-level ivermectin dispensing rates from 2019 to 2023 and legislative trends identified that dispensed ivermectin quantity per 100,000 population was 3.84 (95% confidence interval [CI] 2.96–4.98) times higher during the pandemic and 1.33 (95% CI 1.23–1.43) times higher post-pandemic compared with the pre-pandemic period, regardless of whether states introduced ivermectin-related legislation. Legislative efforts to bypass federal drug regulation and medical oversight for ivermectin access represent a notable trend with potential implications for patient safety.