Tom Nolan: Prescribing antivirals – is beyond 48 hours too late?

After Monday’s statement to the House of Commons from Andy Burnham (you can watch all ten hours of the commons session here), the RCGP emailed members to summarise this and other developments.

One question raised by the e-mail is over the recommendation for GPs to prescribe antivirals if the patient has been symptomatic for fewer than seven days. That’s five days longer than was recommended in the old NICE guidelines for seasonal influenza. So why the change? Here’s the response from the Department of Health.

“The decision…was based on accumulating evidence that tamiflu can provide benefit for severe or prolonged cases, whose course of disease is likely to be longer than the 3-4 days in the healthy community cases which were the basis of the licensing process.

“Applications for licensing have to include large ‘pivotal’ studies to demonstrate the efficacy and safety of a medicine. In the community, where most cases last around 4.6-5 days, the medicine had to be given very early, in order to demonstrate any significant shortening of the illness.

“Older patients, those already severely ill and those predisposed to severe illness, however, appear to benefit from treatment started later than this. The Department of Health SAGE (Scientific Advisory Committee for Emergencies) examined current evidence and supported a lengthening of the time-window for treatment.”

Based on the answer given in the last of these paragraphs, couldn’t you argue that the window only be extended beyond 48 hours to those who are “older”, “already severely ill” and “predisposed to illness”? The stockpile of antivirals may be large, but unnecessary prescribing only increases the likelihood of resistance and puts greater strain on services.

Another more subtle but significant change in advice is over the number of symptoms that a child needs before seeking medical advice.

They [parents] should then contact the National Pandemic Flu Service once it has launched, or their GP, if their child has a high temperature and any one of the following symptoms: tiredness, headache, sore throat, shortness of breath, loss of appetite, vomiting and diarrhoea, aching muscles, or limb and joint pain.

Prescribing on Tablets

It’s been a while since this blog has mentioned updates from Michele Drage, Joint CEO of Londonwide LMCs. Here’s the opening line from her email to GPs in London on Monday:

Dear Colleague,
The world has gone nuts.

Indeed it has.

I’m afraid that our job as GPs is getting harder by the minute, as the media and now the midwives and airlines persist in fuelling public anxiety over what we know for the vast majority to be a mild self-limiting viral illness lasting a just few days.  The consequences of this are that you are working longer and harder to target those who really need our help as doctors, be they sick from flu, or sick for other reasons, and the risk of missing something important as a result is increasing.

The rest of the e-mail is just as colourful and includes an opinion on ‘sneeze and click’, to be launched on Friday…

You won’t be surprised to learn that I am not alone in remaining to be convinced about the appropriateness and the capability of this arrangement.

…and the use of vouchers for antiviral prescribing.

They take us back to the Stone Age in terms of prescribing.

Those were the days, when you could go to your doctor and he would write your prescription on a tablet rather than the other way round.

Tom Nolan is the clinical community editor of doc2doc, the BMJ’s professional networking community.