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A faulty production line

Antivirals should not be routinely used in care homes to prevent flu, experts conclude

GPs should not be asked to routinely prescribe antivirals like Tamiflu to large groups of care home residents to prevent them getting flu, according to experts who said they found too little evidence to support the practice.

Researchers from the Academy of Medical Sciences and the Wellcome Trust said that GPs should instead be allowed to use their clinical judgement over use of antivirals on a case-by-case basis.

NICE currently still recommends the drugs should be used both for treatment and prevention of flu, despite calls from critics to reconsider their advice in the light of the Cochrane analysis.

However, GP leaders have criticised public health officials for enforcing the widespread use of Tamiflu in care homes, after GPs in some areas reported being bullied into issuing bulk prescriptions at very short notice.

The team carried out a wide-ranging review of the evidence for using neuraminidase inhibitors (NAIs) for treating and preventing flu, after a Cochrane review challenged the basis for government policy on their use – in particular the decision to stockpile the drugs in case of a flu pandemic.

The report concluded that there is ‘a paucity of evidence from the recent studies to inform a single approach for prophylaxis in care homes’ and that ‘these decisions must therefore be made on a case-by-case basis using clinical judgement and be based on the severity of the outbreak’.

The researchers called for more research ‘to inform decisions on whether or not to use NAIs in prophylaxis in care homes’, and to evaluate the benefits and side-effects for individuals – particularly as ‘unwanted effects may be higher in more frail, older people’.

It also concluded that antivirals should not be routinely used for seasonal flu as unless the flu strain is particularly severe or the individual is very ill, the benefits are unlikely to outweigh the risks of side-effects.

The researchers said treatment of large numbers of people with antivirals could still be useful in the event of a particularly severe outbreak of flu – and called for plans to carry out randomised trials in the event of a future outbreak, to properly test their effectiveness and safety.

Dr Dean Marshall, GPC negotiator, told Pulse that the GPC was still advising that practices should not agree to provide bulk Tamiflu prescriptions to care homes unless NHS England and Public Health England arrange funding for the work.

Dr Marshall said: ‘The advice is the same as last year - this work has not been commissioned and is not part of the GP contract.’

He added: ‘GPs should advise whoever requests them to carry out the work that PHE/NHS England have chosen not to commission this service from practices and unless their CCG has commissioned the service they should decline to carry out the work.’

Readers' comments (4)

  • Vinci Ho

    Hard to see this will draw a line in the sand yet. The bigotry of NICE and some of its academics is unbelievable.....

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  • As a public health consultant, who has been involved in supporting many flu outbreaks in care homes (indeed saw a number of deaths due to flu in these outbreaks last year), I would just make the point that the paucity of RCT evidence regarding how to support care home outbreaks does not mean there is evidence of lack of effect. There is RCT evidence to support prophylaxis in households (taking into account other factors), as the review states, what makes care homes any different? Care homes often have clinically vulnerable residents.

    How will clinical decisions be made on a case by case basis, depending on the "severity" of the outbreak. How will we judge severity - how many deaths (so far), how many people affected (so far)?

    There is a danger here and we need to listen to WHO, CDC and PHE. Evidence isn't perfect but it can guide us to the right course of action.

    Regarding GP contracts, certainly locally we consider outbreaks as emergencies, and therefore respond to them as such, and so this would not be part of core business, but we all have a responsibility in emergencies.

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  • Please also see page 1025 of these guidelines:

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  • I take on board the comments from public health.
    However, those of us who prescribed tamiflu to numerous patients during the overblown 'swine flu epidemic' had real life experience of how useless a drug it was. Very poor efficacy in return for significant adverse effects.

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