COVID-19 Community Access to Neutralising Monoclonal Antibodies (nMAB) and Oral Antivirals for Covid-19 Treatment - Western locality

Key Messages

The way patients access COVID-19 treatments has changed. Those patients known to be eligible have already been sent a letter from NHS England informing them of this change.

Patients will no longer be automatically contacted by the NHS after reporting a positive COVID-19 test result.

Instead, patients have been advised to contact their GP practice, NHS 111, or hospital specialist as soon as possible after a test positive.

Oral antivirals are available through CMDUs or community pharmacies as well as through CMDUs.

So, GPs may either assess and:

  • refer to the local CMDU:
    • complete the referral template and refer to a CMDU by searching for the CMDU services on e-RS (see Referral section)

OR

  • prescribe directly (if appropriate¥), as per General Medical Council good practice and NHS England prescribing advice⃰.

¥please note that currently Paxlovid is a ‘Hospital Only – Red Drug’ on the Formulary and Referral website. Discussions with the Formulary Intervention Group and the LMC are ongoing, but a GP with appropriate knowledge may choose to prescribe ‘off formulary’.

The LMC’s current guidance for GP’s states:

‘The General Medical Council’s Good Medical Practice guidance is clear that ‘in providing clinical care, you must prescribe medicines only when you have adequate knowledge of the patient’s health and a re satisfied that the medicine serves the patients needs’, and ‘that the treatment you provide is compatible with any other treatments the patient is receiving’. ‘This therefore does not allow for most GPs to prescribe under this guidance'.

We therefore recommend that GPs do not agree to prescribe antiviral medication, such as Paxlovid, unless as part of an appropriate commissioned service. This may include where these medications have been through local medicines governance processes and local guidance to support prescribing with appropriate specialist input as required.

⃰ please also note that community pharmacies are unlikely to have Paxlovid in stock and will have to order it (which may be up to 24 hours). As long as the patient meets all the eligibility and exclusion criteria, this time delay is acceptable. If this time delay may push the patient outside the ‘treatment window’ of 5 days (i.e., prescribing on day 5), then a referral to the local CMDU would be appropriate.

There is also prescribing training available the NHS Learning Hub here.

A list of those eligible for these treatments can be found on the referral form and on the national website here – under ‘Recommendations update: Box 1 and Box 2’. This list does change, so it is important to check when assessing a patient with a positive COVID-19 test.

Assessment

  • If safe to be managed in the community:

Pre-hospitalised patients are eligible for treatment if:

  • SARS-CoV-2 infection is confirmed by polymerase chain reaction (PCR) or lateral flow testing within the last 5 days

AND

  • Onset of symptoms of COVID-19 within the last 5 days (day 0 is the 1st day of symptoms)

AND

  • The patient is symptomatic and not showing signs of improvement

AND

AND

  • NOT requiring hospitalisation or oxygen for COVID-19

AND

  • NOT under 12 years old

AND

  • NOT a child weighing less than 40kg

Please Note: patients should be made aware that not all patients within “high risk” groups will need treatment e.g., neurological conditions, if mild and not on immunosuppressive treatment.

Other Essential Information:

  • COVID-19 vaccination status - how many received and date of last one (for example, 2 vaccines 2 years ago may not protect against Omicron)
  • a complete and accurate list of the patient’s current medication (essential for drug interactions)
  • recent chemotherapy

This information is essential for safe prescribing of COVID-19 antiviral medication.

Red Flags

Patients who require hospitalisation for COVID-19 should be referred to an acute trust.

COVID-19 rapid guideline: managing COVID-19

Investigations

SARS-CoV-2 polymerase chain reaction (PCR) or lateral flow testing within the last 5 days

  • Eligible patients can order tests free of charge from gov.uk order COVID-19 rapid lateral flow tests or by calling 119.
  • From 1 October 2023, the way patients access tests may change. Patients will be able to check nhs.uk treatments for COVID-19 for more information closer to the time.
  • Eligible patients have been advised to keep tests at home. However, tests can also be purchased from a pharmacy or shop if required.

Advice on when to test

The advice from NHS England states:

‘If you have Covid symptoms you should take a test immediately, even if your symptoms are mild.

If your test is negative but you continue to have symptoms, you should take another test on each of the next two days (three tests in total over three days).

You should report your test result where possible at gov.uk report a free NHS COVID-19 rapid lateral flow test result or by calling 119, using your NHS number and postcode (at the top of this letter). This will ensure your test result is visible to the NHS, to support referral and assessment.

You will not be able to report the result of a test purchased from a pharmacy or shop, but this will not affect your access to an assessment for treatment.’

Management

Patients should be assessed to ensure they can be managed safely in the community (including giving appropriate safety netting advice). See:

COVID-19 rapid guideline: managing COVID-19

If safe to be managed in the community:

  • Assess Patient Eligibility (see Assessment section)

If eligible:

  • Arrange for appropriate COVID-19 antiviral treatment:

Oral antivirals are available through CMDUs or community pharmacies as well as through CMDUs.

So, GPs may either assess and:

  • refer to the local CMDU:
    • complete the referral template and refer to a CMDU by searching for the CMDU services on e-RS (see Referral section)
    • As treatment is time sensitive, referrers are requested to complete referrals at their earliest opportunity (ideally on the day of assessment).

Referring via the A&G/R route allows the CMDUs an efficient way to communicate with the referrer (without having to cancel the original referral):

  • When referrer is specifically asking for advice (e.g., if unsure regarding patient eligibility)
  • When additional information is required by the CMDU (e.g., incomplete referral form)

Referrals to CMDU via A&G on e-RS will only be returned to the referrer if:

a) the referrer has specifically asked for advice.

or

b) additional information is required.

All other referrals will be converted to a referral and managed by the CMDUs.

Referrals made on day 5 will still be triaged and actioned by CMDUs, even if these are seen after day 5 (e.g., referral on Friday evening). Clinical judgement will be used.

OR

  • prescribe directly (if appropriate¥), as per General Medical Council good practice and NHS England prescribing advice⃰.

¥please note that currently Paxlovid is a ‘Hospital Only – Red Drug’ on the Formulary and Referral website. Discussions with the Formulary Intervention Group and the LMC are ongoing, but a GP with appropriate knowledge may choose to prescribe ‘off formulary’.

The LMC’s current guidance for GP’s states:

‘The General Medical Council’s Good Medical Practice guidance is clear that ‘in providing clinical care, you must prescribe medicines only when you have adequate knowledge of the patient’s health and a re satisfied that the medicine serves the patients needs’, and ‘that the treatment you provide is compatible with any other treatments the patient is receiving’. ‘This therefore does not allow for most GPs to prescribe under this guidance'.

We therefore recommend that GPs do not agree to prescribe antiviral medication, such as Paxlovid, unless as part of an appropriate commissioned service. This may include where these medications have been through local medicines governance processes and local guidance to support prescribing with appropriate specialist input as required.

  • ⃰ please note that community pharmacies are unlikely to have Paxlovid in stock and will have to order it (which may be up to 24 hours). As long as the patient meets all the eligibility and exclusion criteria, this time delay is acceptable. If this time delay may push the patient outside the ‘treatment window’ of 5 days, then a referral to the local CMDU would be appropriate.
  • There is also prescribing training available the NHS Learning Hub here.

A list of those eligible for these treatments can be found on the referral form and on the national website here – under ‘Recommendations update: Box 1 and Box 2’. This list does change, so it is important to check when assessing a patient with a positive COVID-19 test.

South and West Devon Formulary

North and East Devon Formulary


  • See ‘Referral’ section for details on the referral process for Out of Hours (OOH) or NHS 111.

PANORAMIC study

Oral antivirals will be made available to a wider cohort of at-risk patients through a national study known as the PANORAMIC study. Further information is available here: PANORAMICtrial. Patients eligible for nMABs or oral antivirals under this guidance should be offered treatment in the community and not be referred to this study.

Referral

Referral Instructions:

a) In Hours Referral (access to e-RS):

If a patient meets the eligibility criteria, patients should be referred using the referral template to a CMDU by searching for the CMDU services on eRS:

e-Referral Service Selection

Specialty: Infectious Diseases

Clinic Type: Not Otherwise Specified

Service: There will be an option for a service that includes ‘CMDU’ in the name

Please do not email referrals to DRSS.

b) Out of Hours (OOH) / NHS111 (no access to e-RS)

If a patient meets the eligibility criteria, patients should be referred using the referral template to a CMDU and emailed to the appropriate CMDU:

Referral Form

Referral form nMAB community access - no merge fields

Referral form nMAB community access - EMIS

Referral form nMAB community access - S1

Supporting Information

Patient Information

Treatments for coronavirus (COVID-19) - NHS (www.nhs.uk)

Easy read and other language versions of this information are available from: https://www.england.nhs.uk/coronavirus/treatments

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: January 2022

Updated: September 2023

Last updated: 18-09-2023

 

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