Cautions monitor liver function tests every 3 months, and viral and serological markers for hepatitis B every NICE guidance

5 Cautions monitor liver function tests every 3 months, and viral and serological markers for hepatitis B every NICE guidance

3–6 months; discontinue if deterioration in liver Entecavir and telbivudine for chronic

function, hepatic steatosis, progressive hepatomegaly hepatitis B (August 2008) or unexplained lactic acidosis; recurrent hepatitis may occur on discontinuation; monitor renal function

Entecavir is an option for the treatment of chronic every 3 months, more frequently in renal impairment hepatitis B.

(Appendix 3) or in patients receiving nephrotoxic Telbivudine is not recommended for the treatment

drugs; pregnancy (Appendix 4); elderly; HIV infection of chronic hepatitis B. Patients currently receiving

(particularly if uncontrolled—theoretical risk of HIV telbivudine can continue treatment until they and

resistance)

their clinician consider it appropriate to stop. Contra-indications breast-feeding (Appendix 5) Side-effects nausea, vomiting, dyspepsia, abdominal

pain, flatulence, diarrhoea; asthenia, headache; renal Chronic Hepatitis C Before starting treatment, the

failure; hypophosphataemia; rash and pruritus; also genotype of the infecting hepatitis C virus should be

reported pancreatitis determined and the viral load measured as this may

Dose

affect the choice and duration of treatment. A combina- . ADULT over 18 years, 10 mg once daily tion of ribavirin (see p. 351) and peginterferon alfa Hepsera (section 8.2.4) is used for the treatment of chronic c (Gilead) A

hepatitis C (see NICE guidance, below). The combina- Tablets , adefovir dipivoxil 10 mg, net price 30-tab tion of ribavirin and interferon alfa is less effective than

pack = £315.00

the combination of peginterferon alfa and ribavirin. Peginterferon alfa alone should be used if ribavirin is contra-indicated or not tolerated. Ribavirin monother-

ENTECAVIR

apy is ineffective. Indications chronic hepatitis B infection with com- pensated liver disease, evidence of viral replication, NICE guidance

and histologically documented active liver inflam- Peginterferon alfa and ribavirin for mild

mation or fibrosis chronic hepatitis C (August 2006)

Cautions monitor liver function tests every 3 months, The combination of peginterferon alfa and ribavirin

and viral and serological markers for hepatitis B every can be used for treating mild chronic hepatitis C in

3–6 months; discontinue if deterioration in liver patients over 18 years. Alternatively, treatment can

function, hepatic steatosis, progressive hepatomegaly

be delayed until the disease has reached a moderate or unexplained lactic acidosis; recurrent hepatitis may stage (‘watchful waiting’). Peginterferon alfa alone

occur on discontinuation; HIV infection—risk of HIV can be used if ribavirin is contra-indicated or not

resistance in patients not receiving ‘highly active tolerated.

antiretroviral therapy’; renal impairment (Appendix 3); pregnancy (Appendix 4)

BNF 57

5.3.4 Influenza 349

Contra-indications breast-feeding (Appendix 5) they are licensed for use within 48 hours (within 36 Side-effects nausea, vomiting, dyspepsia, diarrhoea,

hours for zanamivir in children) of the first symptoms. In raised serum amylase and lipase; headache, fatigue,

otherwise healthy individuals they reduce the duration dizziness, sleep disturbances; less commonly throm-

of symptoms by about 1–1.5 days. Oseltamivir or zana- bocytopenia; also reported, rash

mivir can reduce the risk of complications from influ- Dose

enza in the elderly and in patients with chronic disease . ADULT over 18 years, not previously treated with

(see also NICE guidance, p. 350). nucleoside analogues, 500 micrograms once daily

Oseltamivir and zanamivir are licensed for post-expo- . ADULT over 18 years with lamivudine-resistant chronic

sure prophylaxis of influenza when influenza is circulat- hepatitis B, 1 mg once daily

ing in the community (see also NICE guidance, below ). Counselling To be taken at least 2 hours before or 2 hours

Oseltamivir and zanamivir are also licensed for use in after food

exceptional circumstances (e.g. when vaccination does Baraclude c (Bristol-Myers Squibb) not cover the infecting strain) to prevent influenza in an TA epidemic. Tablets , f/c, entecavir (as monohydrate) 500 micr-

ograms (white), net price 30-tab pack = £378.00; 1 mg (pink), 30-tab pack = £378.00. Counselling, adminis- tration

NICE guidance

Oral solution , entecavir (as monohydrate) 50 micr- Oseltamivir, zanamivir, and amantadine for ograms/mL, net price 210-mL pack (orange-fla-

voured) = £441.00. Counselling, administration prophylaxis of influenza (September 2008)

The drugs described here are not a substitute for vaccination, which remains the most effective way of preventing illness from influenza. .

Amantadine is not recommended for prophy-

TELBIVUDINE

laxis of influenza.

Oseltamivir and zanamivir are not recom- Indications chronic hepatitis B infection with com-

mended for seasonal prophylaxis against influ- pensated liver disease, evidence of viral replication,

enza.

and histologically documented active liver inflam-

When influenza is circulating in the community, mation or fibrosis

either oseltamivir or zanamivir are recom- Cautions monitor liver function tests every 3 months

mended (in accordance with UK licensing) for and viral and serological markers of hepatitis B every

post-exposure prophylaxis in at-risk patients

3–6 months; discontinue if deterioration in liver who are not effectively protected by influenza function, hepatic steatosis, progressive hepatomegaly

Infections

vaccine, and who have been in close contact

or unexplained lactic acidosis; hepatitis may recur on with someone suffering from influenza-like ill- discontinuation; renal impairment (Appendix 3);

ness in the same household or residential set- pregnancy (Appendix 4); interactions: Appendix 1

ting. Oseltamivir should be given within 48 (telbivudine)

hours of exposure to influenza while zanamivir Counselling Patients should be advised to promptly report

should be given within 36 hours of exposure to unexplained muscle pain, tenderness, or weakness, or

influenza. National surveillance schemes, numbness, tingling or burning sensations

including those run by the Health Protection Contra-indications breast-feeding (Appendix 5)

Agency, should be used to indicate when influ- Side-effects nausea, diarrhoea, abdominal pain,

enza is circulating in the community. raised serum amylase and lipase; cough; dizziness,

During local outbreaks of influenza-like illness, headache, fatigue; rash; less commonly peripheral

when there is a high level of certainty that influ- neuropathy, arthralgia, myalgia, and myopathy

enza is present, either oseltamivir or zanamivir Dose

may be used for post-exposure prophylaxis in . ADULT and CHILD over 16 years, 600 mg once daily

at-risk patients (regardless of influenza vaccin- ation) living in long-term residential or nursing

homes.

Sebivo c

(Novartis) TA At risk patients include those aged over 65 years or Tablets , f/c, telbivudine 600 mg, net price 28-tab pack

those who have one or more of the following con- = £290.33. Counselling, muscle effects, peripheral

ditions:

neuropathy

chronic respiratory disease (including asthma treated with continuous or repeated use of inhaled or systemic corticosteriods or asthma with previous exacerbations requiring hospital admission);

chronic heart disease;

5.3.4 Influenza

chronic renal disease;

chronic liver disease;

chronic neurological disease; For advice on immunisation against influenza, see sec-

immunosuppression; tion 14.4.

diabetes mellitus. Oseltamivir and zanamivir reduce replication of influ-

enza A and B viruses by inhibiting viral neuraminidase. They are most effective for the treatment of influenza if started within a few hours of the onset of symptoms;

5.3.4 Influenza BNF 57 Lysovir NICE guidance c (Alliance) A

Capsules , red-brown, amantadine hydrochloride Oseltamivir, zanamivir, and amantadine for

100 mg, net price 5-cap pack = £2.40, 14-cap pack = treatment of influenza (February 2003)

£4.80. Counselling, driving The drugs described here are not a substitute for vaccination, which remains the most effective way of

Symmetrel c (Alliance) A preventing illness from influenza. When influenza A or influenza B is circulating in the community:

Section 4.9.1

. amantadine is not recommended for treatment of influenza;

. oseltamivir or zanamivir are not recommended for treatment of otherwise healthy individuals

OSELTAMIVIR

with influenza; .

oseltamivir and zanamivir are recommended (in Indications see notes above accordance with UK licensing) to treat at-risk

Cautions renal impairment (Appendix 3); pregnancy adults who can start treatment within 48 hours

(Appendix 4); breast-feeding (Appendix 5) of the onset of symptoms; oseltamivir is recom-

Side-effects nausea, vomiting, abdominal pain, diarr- mended for at-risk children who can start treat-

hoea; headache; conjunctivitis; less commonly rash; ment within 48 hours of the onset of symptoms.

also reported, hepatitis, arrhythmias, neuropsychiatric At-risk patients include those aged over 65 years or

disorders (in children and adolescents), visual distur- those who have one or more of the following con-

bances, Stevens-Johnson syndrome, and toxic epi- ditions 1 :

dermal necrolysis .

chronic respiratory disease (including chronic

Dose

. Prevention of influenza, .

obstructive pulmonary disease and asthma); significant cardiovascular disease (excluding

ADULT and ADOLESCENT over hypertension) 2 ;

13 years, 75 mg once daily for 10 days for post-

. chronic renal disease; exposure prophylaxis; for up to 6 weeks during an .

ns

immunosuppression; epidemic; CHILD 1–13 years, body-weight under 15 kg, .

diabetes mellitus.

30 mg once daily, body-weight 15–23 kg, 45 mg once daily, body-weight 23–40 kg, 60 mg once daily, body-

Infectio

Community-based virological surveillance schemes weight over 40 kg, adult dose including those run by the Health Protection Agency and the Royal College of General Practitioners

. Treatment of influenza, ADULT and ADOLESCENT 5 over 13

should be used to indicate when influenza is circu- years, 75 mg every 12 hours for 5 days; CHILD 1–13 lating in the community.

years, body-weight under 15 kg, 30 mg every 12 hours, body-weight 15–23 kg, 45 mg every 12 hours, body-weight 23–40 kg, 60 mg every 12 hours, body-

Amantadine is licensed for prophylaxis and treatment weight over 40 kg, adult dose of influenza A but it is no longer recommended (see

NICE guidance).

1 Tamiflu c (Roche) TA Information on pandemic influenza and avian influenza

Capsules , oseltamivir (as phosphate) 30 mg (yellow), may be found at www.dh.gov.uk/pandemicflu and at

net price 10-cap pack = £8.18; 45 mg (grey), 10-cap www.hpa.org.uk

pack = £16.36; 75 mg (grey-yellow), 10-cap pack = £16.36. Label: 9

Suspension , sugar-free, tutti-frutti-flavoured, oselta- mivir (as phosphate) for reconstitution with water,

60 mg/5 mL, net price 75 mL = £16.36. Label: 9

Excipients include sorbitol 1.7 g/5 mL

1. D except for the treatment and prophylaxis of influenza as indicated in the notes above and NICE guidance; endorse

AMANTADINE HYDROCHLORIDE

prescription ‘SLS’

Indications see under Dose; parkinsonism (section 4.9.1) Cautions see section 4.9.1

ZANAMIVIR

Contra-indications see section 4.9.1 Indications see notes above Side-effects see section 4.9.1

Cautions asthma and chronic pulmonary disease (risk Dose

of bronchospasm—short-acting bronchodilator . Influenza A (see also notes above), ADULT and CHILD

should be available; avoid in severe asthma unless over 10 years, treatment, 100 mg daily for 4–5 days;

close monitoring possible and appropriate facilities prophylaxis, 100 mg daily usually for 6 weeks or with

available to treat bronchospasm); uncontrolled influenza vaccination for 2–3 weeks after vaccination

chronic illness; other inhaled drugs should be admi- nistered before zanamivir; pregnancy (Appendix 4)

1. The NICE guidelines on Prophylaxis of Influenza (Septem- Contra-indications breast-feeding (Appendix 5) ber 2008) also include patients with chronic liver disease or chronic neurological disease in the at-risk group.

Side-effects very rarely , bronchospasm, respiratory 2. The NICE guidelines on Prophylaxis of Influenza (Septem-

impairment, angioedema, urticaria, and rash; also ber 2008) include patients with chronic heart disease in the

reported, neuropsychiatric disorders (especially in at-risk group.

children and adolescents)

Dose . By inhalation of powder , post-exposure prophylaxis

of influenza, ADULT and CHILD over 5 years, 10 mg once daily for 10 days Prevention of influenza during an epidemic, ADULT and CHILD over 12 years, 10 mg once daily for up to 28 days

Treatment of influenza, ADULT and CHILD over 5 years,

10 mg twice daily for 5 days

1 Relenza c (GSK) A Dry powder for inhalation disks containing 4 blisters

of zanamivir 5 mg/blister, net price 5 disks with Dis- khaler c device = £16.36

1. D except for the treatment and prophylaxis of influenza as indicated in the notes above and NICE guidance; endorse prescription ‘SLS’