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5.3 Antiviral drugs

Link to BHIVA Guidelines

Link to Inoculation Incident Policy

5.3.1 HIV Infection

Note: Updated advice on body-fat changes and lactic acidosis with anti-retrovirals: See DSU December 2015

1. Nucleoside reverse transcriptase inhibitors
Lamivudine tablets, oral solution (specialist use only)
Zidovudine tablets
Emtricitabine capsules, oral solution
Abacavir tablet, oral solution

 

2. Non-nucleoside reverse transcriptase inhibitors
Efavirenz tablets, capsules (first line)
Etravirine tablets (for resistant cases only)
Nevirapine tablets, MR tablets
Rilpivirine tablets

 

3. Protease Inhibitors
Atazanavir capsules
Darunavir tablets - 2nd line protease inhibitor
Fosamprenavir, tablets, suspension - 1st line protease inhibitor
Ritonavir tablets, oral solution - see note 3
Tipranavir capsules - 2nd line protease inhibitor
Tenofovir tablets 

 

4. Other antiretrovirals
Dolutegravir tablets – for patients unable to tolerate first-line HIV therapy or who fail prior treatment or where resistance is an issue (see NHSE Commissioning policy)
Enfuvirtide for HIV patients resistant to conventional anti-retrovirals (in combination therapy) specialist use only in conjunction with BHIVA guidelines.
Maraviroc tablets - for CCR5-tropic infection
Raltegravir tablets- for patients with triple class resistance to HIV therapy

 

Combination Tablets
Abacavir and Lamivudine
Abacavir, Lamivudine and Zidovudine (Trizivir) tablets
Atazanavir/cobicistat (Evotaz) tablets - see note 3
Darunavir/cobicistat (Rezolsta) tablets - see note 3
Elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (Genvoya) tablets - see note 3
Lamivudine, abacavir, and dolutegravir (Triumeq) tablets
Lopinavir and Ritonavir (Kaletra)
Tenofovir and Emtricitabine (Truvada)
Tenofovir alafenamide and Emtricitabine (Descovy)
Zidovudine and Lamivudine (Combivir)
Efavirenz, Emtricitabine and Tenofovir (Atripla) (front line HAART)
Elvitegravir, cobicistat, emtricitabine, and tenofovir (Stribild) (front line HAART) - see note 3
Rilpivirine, Emtricitabine and Tenofovir (Eviplera)
Rilpiverine, Emtricitabine and Tenofovir alafenamide (Odefsey)

1. For post exposure prophylaxis, antiretroviral prophylaxis is available from pharmacy or the on-call pharmacist, day or night, after discussion with a consultant microbiologist, consultant G.U.M. physician or consultant haematologist.  See post-exposure prophylaxis in the blood-borne virus section of the Infection Control Manual.

2. Kaletra and raltegravir are the preferred treatment for post-exposure HIV prophylaxis (see Inoculation Incident Policy). 

3. Co-administration of a corticosteroid with an HIV-treatment-boosting agent (e.g. ritonavir, cobicistat) may increase the risk of adrenal suppression (including Cushing’s syndrome) due to a pharmacokinetic interaction. This may occur even with no-systemically administered steroids e.g. inhaled, intranasal, and intra-articular routes. See here.
 

5.3.2 Herpes virus Infections

Aciclovir tablets, dispersible tablets, suspension under specific guidelines or only on the advice of a consultant microbiologist.  
Aciclovir IV Infusion under specific guidelines or only on the advice of a consultant microbiologist.  
Famciclovir tablets under specific guidelines or only on the advice of a consultant microbiologist.  
Valaciclovir tablets (G.U.M. use only): under specific guidelines or only on the advice of a consultant microbiologist. 

Note:

Shingles: Oral antivirals are expensive and offer only marginal clinical benefits in most patients with shingles. They should be used in cases affecting the eye, and in the immunocompromised. They should be started as soon as possible after the onset of the rash (within 72 hours).  

 

5.3.2.2 Cytomegalovirus Infections

Ganciclovir IV infusion (G.U.M. use only): under specific guidelines or only on the advice of a consultant microbiologist.  
Ganciclovir intravitreal injection: under specific guidelines or only on the advice of a consultant microbiologist.
Ganciclovir capsules (G.U.M. use only): under specific guidelines or only on the advice of a consultant microbiologist.
Valganciclovir tablets, oral solution

 

5.3.3 Viral Hepatitis

Lamivudine tablets (chronic hepatitis B) - please see NICE TA 173
Tenofovir tablets (chronic hepatitis B) - please see NICE TA 173
Adefovir tablets (chronic hepatitis B) - please see NICE TA 96
Ribavirin capsules (in combination with peg interferon alfa -2b for chronic moderate to chronic hepatitis C, specialist use gastroenterologist only) - please see NICE Technical Appraisals 75, 106 ,200300
Interferon Alfa (-2a, -2b)
Peginterferon Alfa (-2a) (for chronic hepatitis B) - please see NICE TA 96
Entecavir
Sofosbuvir tablets (chronic hepatitis C) – see note below; see NICE TA330
Simeprevir capsules (chronic hepatitis C) - see note below; see NICE TA331
Sofosbuvir / Ledipasvir (Harvoni) tablets (chronic hepatitis C)
Sofosbuvir / Velpatasvir (Epclusa) tablets (chronic hepatitis C) – see NICE TA 430
Daclatasvir tablets (chronic hepatitis C)
Ombitasvir / paritaprevir / ritonavir (Viekirax) tablets (chronic hepatitis C) - see NICE TA365
Dasabuvir tablets (chronic hepatitis C)
Elbasvir / grazoprevir (Zepatier) tablets (Chronic hepatitis C) – see NICE TA413

Notes

1. Direct-acting antivirals (interferon-free regimens): All patients should be screened for hepatitis B before starting treatment for chronic hepatitis C with direct-acting antiviral interferon-free regimens. Patients co-infected with hepatitis B and C viruses are at risk of hepatitis B reactivation, and should be monitored and managed according to current clinical guidelines. See MHRA DSU.

2. Entecavir is reserved for patients with lamivudine-resistant chronic hepatitis B, those with very high viral loads, or with severe liver disease e.g. hepatic decompensation / fibrosis. Please see NICE Technical Appraisal 153

3. To avoid confusion with peginterferon preparations it is recommended they be prescribed by brand name.

4. Sofosbuvir is available through the NHSE early access scheme. It has activity across all genotypes of hepatitis C.

5. Sofosbuvir + daclatasvir, and sofosbuvir + ledipasvir and sofosbuvir + simeprevir have been associated with severe bradycardia and heart block when used in patients on amiodarone. See DSU May 2015 and DSU Aug 2015.

6.  Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists (e.g. warfarin). INR should be monitored closely during concurrent treatment. See MHRA DSU.


5.3.4 Influenza

Oseltamivir capsules and suspension (prescribe dose in millilitres ml - see the SPC dosing table)
Zanamivir dry powder inhaler

An unlicensed preparation of aqueous zanamivir for nebulisation or intravenous infusion is available on a named patient basis. Use is restricted. See the influenza treatment pages on the antibiotic intranet site for further information.

NICE considers that having flu immunisation is the most effective way of preventing illness from flu, and that the drugs for the treatment of flu shouldn’t be used instead of immunisation.

Influenza treatment

Please see the relevant section Medicines Update (p 2-4, Vol.3, Issue 1 August 2009):

Safety information on oseltamivir (Tamiflu) and zanamivir (Relenza) forpandemic swine influenza A/H1N1 (includes side effect drug interactions and use in renal impairment)

Please see Nice Guidance TA168

NICE has recommended that amantadine should not be used for the treatment of flu.

It has also recommended that zanamivir or oseltamivir should not be used to treat a flu-like illness in people who are otherwise healthy (that is, they are unlikely to be at risk of developing complications from flu).

NICE recommends that when the number of people with flu reaches a high-enough level (that is, when influenza virus A or B is said to be ‘circulating in the community’), zanamivir or oseltamivir should be used to treat a flu-like illness in people who are considered to be at risk of developing complications, provided that they can start treatment within 48 hours of the symptoms starting. People who are considered to be ‘at-risk’ are those who are in at least one of the following groups.

People who:

- are aged 65 years or older
- have long-term (‘chronic’) lung disease (including asthma and chronic obstructive pulmonary disease)
- have heart disease (but not including people who have high blood pressure but do not have other problems with their heart or blood vessels)
- have long-term kidney disease
- have diabetes
- have an immune system that does not work well.
- Zanamivir or oseltamivir should be used to treat flu-like illness in at-risk adults (for the purposes of this guidance, this means people aged over 12 years). Oseltamivir should be used to treat flu-like illness in at-risk children (aged over 1 year).

NICE has also recommended that monitoring schemes, such as those organised by the Public Health Laboratory Service and the Royal College of General Practitioners, should be used so that the start of an outbreak of influenza can be spotted as quickly as possible.

Although safety data are limited, BNF 58 recommends that either oseltamivir or zanamivir can be used in women who are pregnant or breast-feeding when the potential benefit outweighs the risk (e.g. during a pandemic). Zanamivir is the preferred drug during pregnancy; however, oseltamivir is recommended during severe infection or when zanamivir cannot be used. Oseltamivir is the preferred drug in women who are breast-feeding.

Influenza prophylaxis

Please see NICE TA 158

NICE has said that its recommendations about oseltamivir and zanamivir should not reduce efforts to give vaccination (also called the flu jab) to people for whom it is recommended in national guidelines.

The guidance does not cover widespread epidemics.

Oseltamivir and zanamivir are recommended to prevent flu if all of the following apply:

  • The amount of flu virus going around is enough that if someone has a flu-like illness it is likely that it has been caused by the flu virus

  • The person is in an at-risk group (see below). The person has been in contact with someone with a flu-like illness and can start treatment within 36 hours (for zanamivir) or within 48 hours (for oseltamivir)

  • The person has not been effectively protected by vaccination

At-risk groups include:

  • chronic respiratory disease (including asthma that requires continuous or repeated use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission)

  • chronic heart diseases

  • chronic renal diseaschronic liver disease

  • chronic neurological disease

  • immunosuppression

  • diabetes mellitus.

People who are aged 65 years or older are also defined as at-risk for the purpose of this guidance.

 

5.3.5 Respiratory syncytial virus

Palivizumab Injection for high risk patients - see guidelines

 

TOPICAL - See Section 13.10.3

 

 

 

 For the link to the BNF section: 5.3 Antiviral drugs