Guidance

Chief Medical Officer and Chief Pharmaceutical Officer: advice on using antiviral medicines: influenza season 2014 to 2015

Updated 8 January 2016

Influenza season 2014 - 2015: use of antiviral medicines

The most recent surveillance data indicate that there is now a substantial likelihood that people presenting with an influenza-like illness are infected with an influenza virus.

GPs may now prescribe at NHS expense, antiviral medicines for the prophylaxis and treatment of influenza, in accordance with NICE guidance and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc) Regulations 2004), commonly known as the Grey List or Selected List Scheme (SLS).

In November 2010, Schedule 2 to the National Health Service (General Medical Services Contracts)(Prescription Drugs etc) Regulations 2004, was amended to include pregnant women amongst the list of people ‘at clinical risk’ from seasonal flu and eligible to receive antiviral medicines at NHS expense prescribed by General Practitioners. General Practitioners should note the information on use in pregnancy in the Summary of Product Characteristics of both antiviral medicines.

The above Regulations were further amended in April 2011. These regulations give GPs the discretion to prescribe antiviral medicines for a person under 65 years of age, who is not in one of the identified clinical at-risk groups, if in their clinical judgement, they believe that person may be at risk of developing medical complications from influenza if not treated. This discretion is to be guided by the Chief Medical Officer on an annual basis.

1. Chief Medical Officer (CMO) guidance on prescribing of antiviral medicines for people not in the identified at-risk groups, for 2014 to 2015

GPs should only prescribe antiviral medicines for a person under 65 years of age who is not in one of the identified clinical at-risk groups or pregnant, if they consider them at risk of developing medical complications from influenza if not treated. This will also help to ensure that there are enough antiviral medicines in the supply chain to meet, in a timely manner, the needs of patients who are eligible for treatment and who are suffering symptoms of influenza.

Further information on the at-risk groups and patients who are eligible for treatment at NHS expense with either oseltamivir (Tamiflu) or zanamivir (Relenza) can be found in Part XVIIIB of the Drug Tariff (Drugs, Medicines and Other Substances that may be ordered only in certain circumstances).

1.2 NICE guidance

NICE guidance is relevant to all clinicians (primary and secondary care). However, clinicians in secondary care are not subject to the “Grey List” restrictions that GPs are, for prescribing of antiviral medicines, Part XVIIIB of the Drug Tariff (Drugs, Medicines and Other Substances that may be ordered only in certain circumstances). They can therefore use their clinical judgment to prescribe antiviral medicines, including for those not in the ‘at risk’ groups.

For clinicians treating hospitalised patients with suspected influenza, rapid laboratory confirmation with subtype identification is advised to support patient management.

The “Grey List”, which is included within the Drug Tariff, restricts GPs to only prescribe antiviral medicines to specified people who are listed in the Drug Tariff. i.e. the clinical at risk groups, pregnant women, people over the age of 65 years and those people under 65 years of age who are at risk of developing medical complications from influenza.

The full NICE guidance on the use of antiviral medicines can be accessed at:

• for treatment
• for prophylaxis

1.3 Advice for prescribers for endorsing prescriptions

Primary care prescribers are reminded to endorse all prescriptions for oseltamivir (Tamiflu) and zanamivir (Relenza), with the reference “SLS”. Community pharmacies are only able to dispense oseltamivir and zanamivir at NHS expense, if the prescriber endorses the prescription with “SLS”.

1.4 Liaison with manufacturers and wholesalers

The Department of Health is in contact with manufacturers to ensure that there are adequate quantities of antiviral medicines in the supply chain.

We would urge pharmacies not to over order stocks of antiviral medicines. Over ordering could result in shortages in the supply chain. It is, however, important that oseltamivir for adults and children and zanamivir for adults are taken within 48 hours of onset of symptoms. Children 5 years and over and under 13 years of age should start taking zanamivir within 36 hours of onset of symptoms, to obtain maximum benefit.

1.5 Prescribing for children over the age of one year

Wherever possible, for children over the age of one year and for adults who are not able to swallow capsules, the appropriate strength of capsules should be prescribed. The contents of the capsules can be emptied and added to a suitable sugary diluent. As far as possible, the suspension should be restricted for children under 1 year of age. This will support the continuity of supply of the liquid form of oseltamivir for this vulnerable age group.

1.6 Prescribing for children under one year of age

Oseltamivir (Tamiflu) is not licensed for use in children under one year of age for seasonal influenza. Prescribing of oseltamivir for this age group for seasonal influenza, should be based on the judgment of the clinician, after considering the risks and benefits of treatment.

2. Prevention: maximising uptake of flu vaccination, including among healthcare staff

The increase in flu activity also highlights the need to ensure maximum protection through vaccination.

We recognise, and are very grateful for, the excellent work that many health professionals have done to strive to vaccinate as many people as possible in the qualifying groups (those aged 65 and over, those under 65 in ‘at risk’ groups, pregnant women and children aged 2-4). There is still time to vaccinate those in these groups who have not yet been vaccinated, and it is important for GP practices and other health professionals to continue to strive towards achieving high uptake.

It is also important that frontline healthcare workers, including GPs, pharmacists, and their teams, recognise their professional responsibility to minimise the risk of transmitting flu by getting vaccinated themselves and observing strict infection control measures. It is the employer’s responsibility to provide access to vaccination and employers should continue to work with their staff to maximise vaccination rates.