Amantadine, Oseltamivir and Zanamivir for the Treatment of Influenza (TA168 [Review])

Technology Appraisal Guidance No. 168

Source: National Institute for Health and Care Excellence

This guidance replaces ‘NICE technology appraisal guidance 58’ issued in February 2003.

The review and re-appraisal of amantadine, oseltamivir and zanamivir for the treatment of influenza has resulted in a change in the guidance. Specifically:

  • people with chronic neurological conditions and people with chronic liver disease are now considered ‘at risk’
  • zanamivir is now recommended as a treatment option for children between the ages of 5 and 12 years in ‘at-risk’ groups if influenza is circulating and they can start treatment within 36 hours of first symptoms
  • oseltamivir and zanamivir are now recommended as treatment options for ‘at-risk’ people in long-term and residential nursing homes during localised outbreaks (when influenza is not circulating), if there is a high level of certainty that the causative agent is influenza.

This guidance has been prepared in the expectation that vaccination against influenza is undertaken in accordance with national guidelines. Vaccination has been established as the first-line intervention to prevent influenza and its complications, and the use of drugs described in this guidance should not in any way detract from efforts to ensure that all eligible people receive vaccination.

This guidance does not cover the circumstances of a pandemic, impending pandemic, or a widespread epidemic of a new strain of influenza to which there is little or no community resistance.

1. Guidance

1.1 Oseltamivir and zanamivir are recommended, within their marketing authorisations, for the treatment of influenza in adults and children if all the following circumstances apply:

  • national surveillance schemes indicate that influenza virus A or B is circulating1
  • the person is in an ‘at-risk’ group as defined in 1.2
  • the person presents with an influenza-like illness and can start treatment within 48 hours (or within 36 hours for zanamivir treatment in children) of the onset of symptoms as per licensed indications.


1.2 For the purpose of this guidance, people ‘at risk’ are defined as those who have one of more of the following:

  • chronic respiratory disease (including asthma and chronic obstructive pulmonary disease)
  • chronic heart disease
  • chronic renal disease
  • chronic liver disease
  • chronic neurological conditions
  • diabetes mellitus.

People who are aged 65 years or older and people who might be immunosuppressed are also defined as ‘at-risk’ for the purpose of this guidance.

1.3 The choice of either oseltamivir or zanamivir in the circumstances described in 1.1 should be made after consultation between the healthcare professional, the patient and carers. The decision should take into account the patient’s preferences regarding drug delivery and potential adverse effects and contraindications. If all other considerations are equal, the drug with the lowest acquisition cost should be offered.

1.4 During localised outbreaks of influenza-like illness (outside the periods when national surveillance indicates that influenza virus is circulating in the community), oseltamivir and zanamivir may be offered for the treatment of influenza in ‘at-risk’ people who live in long-term residential or nursing homes. However, these treatments should be offered only if there is a high level of certainty that the causative agent in a localised outbreak is influenza (usually based on virological evidence of influenza infection in the initial case).

1.5 Amantadine is not recommended for the treatment of influenza.

1The Health Protection Agency in England (and the equivalent bodies in Wales and Northern Ireland) uses information from a range of clinical, virological and epidemiological influenza surveillance schemes to identify periods when there is a substantial likelihood that people presenting with an influenza-like illness are infected with influenza virus.

The guidance shown above constitutes Section 1 of the full document. A copy of the full document and a summary of the evidence is available on the Internet at NICE.

An abridged version of this guidance (a 'quick reference guide') is also available. Printed copies of the quick reference guide can be obtained by contacting 0845 003 7783 or emailing and quoting reference number N1804. It is also available on the Internet at NICE.

This guidance represents the view of the Institute which was arrived at after careful consideration of the available evidence. Health professionals are expected to fully take it into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

© Copyright National Institute for Health and Care Excellence. All rights reserved. This material may be freely reproduced for educational and not for profit purposes within the NHS. No reproduction by or for commercial organisations is permitted without the express written permission of the Institute.

Enquiries concerning the guidance should be addressed to: National Institute for Health and Care Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA. email:

Amantadine, Oseltamivir and Zanamivir for the Treatment of Influenza
Issue Date: February 2009

Review Date: November 2013

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