Abstract Introduction In the last 20 years, Italian pharmaceutical policies have moved to contain public expenditure. This study analyses the trajectory of retail pharmaceutical expenditures to investigate whether there has been a switch from public to private expenditure, how the composition of private and public expenditure has changed, and whether there are correlations with supply/demand variables. These research questions have received little attention in the literature. Methods This study used secondary data from Italy covering the period 2010 to 2019. A time-trend analysis was performed using the average annual percent change (AAPC) as the summary measure for the rate of change over the period 2010/19. The AAPC was estimated by fitting a linear regression model for the logarithm of each aggregate indicator. Kendall's τ coefficient investigates the correlation between the 2010-19 pharmaceutical expenditure items and other relevant health statistics (ages, categories of practising physicians, Gini coefficient, etc.). Results Italy's public pharmaceutical expenditure did not change significantly between 2010 and 2019 (AAPC = +0.03%, 95% CI = -1.4% to + 1.4%), nor did private spending (AAPC = +0.6%, 95% CI = -0.2% to + 1.3%). Public expenditure without the direct distribution of drugs in class A experienced a slowdown (-3.9%), and public expenditure with the direct distribution of drugs in class A exhibited a significant increase (+8.4%). The regression analysis evaluates the relationship between supply/demand variables and pharmaceutical expenditures. A significant result relates to the positive correlation between income inequality and out-of-pocket expenses for over-the-counter drugs (τ = 0.62, p-value = 0.046). Conclusions Pharmaceutical spending has increased over time, especially for drugs reimbursable by the NHS but paid for by citizens. This could be an alarm for a public healthcare system that should be able to guarantee healthcare services to all citizens. Key messages Public expenditure with the direct distribution of drugs in class A exhibited a significant increase (+8.4%). There has been increasing expenditure on drugs reimbursable by the NHS but paid for by citizens.