Pharmacists remixing adult doses so kids can receive Tamiflu

A worldwide shortage of children's Tamiflu to treat H1N1 infections has the federal government dipping into its national emergency stockpile and pharmacists preparing doses the old-fashioned way – with a mortar and pestle.
Meanwhile, the Canadian spokeswoman for Hoffman-La Roche, the Swiss maker of the antiviral drug, said the order for more of the children's liquid doses won't be ready for another month or so – likely after the pandemic virus has passed its peak.
“We're actively working to bring more product into the country,” Laura Pagnotta said yesterday. “We can't provide a specific date but we are definitely in the queue. And we do anticipate having additional [supplies] available in the next month or so.”
The second wave of the H1N1 virus has not only led to more hospitalizations and additional deaths, it has resulted in more Canadians walking into pharmacies with prescriptions for antiviral medication. In the last week of October, more than 28,000 prescriptions were written for Tamiflu, the highest number since the virus first appeared in April, according to data from the Public Health Agency of Canada.
Oseltamivir – Tamiflu's generic name – can keep the virus in check if taken within days of symptoms appearing. Zanamivir, which is sold under the brand name Relenza, is another antiviral, but it is not approved for children under age 7.
The federal government dispensed 17,000 doses of pediatric Tamiflu in September from its emergency stockpile. (The government was unable to provide data on its current pediatric stockpile by deadline yesterday.) But pharmacists say the sheer volume of prescriptions, along with a shortage of the children's oral suspension, has them manually mixing doses.
Donnie Edwards, former chair of the Ontario Pharmacists' Association and a community pharmacist in Ridgeway, Ont., said about a week ago he was filling out, on average, four to eight children's Tamiflu prescriptions a day. To make the dosage, he empties the adult capsule, grinds the powder with a mortar and pestle, measures the correct amount and adds liquids and sweeteners.
“The whole time that all of this has been happening in the news, pharmacists have been out there scrambling and making sure that they are playing the critical-care role … to make sure children are being treated properly,” Mr. Edwards said.
Ms. Pagnotta of Roche said the company prioritized the manufacture of adult capsules, because they are used to treat seasonal flu, which affects primarily the elderly. The adult capsule can also be produced 25 times faster than the children's liquid Tamiflu and it can be repurposed for pediatric patients.
“By having those 75-milligram capsules, we're better able to meet the needs of a broader base of patients,” she said. Roche produces 30- and 45-milligram capsules for children, but the liquid version is preferred for young children who cannot swallow tablets.
One health expert said the shortage of liquid Tamiflu during the pandemic will serve as a lesson when preparing for the next one.
Upton Allen, chief of the division of infectious diseases at the Hospital for Sick Children, said that while his hospital has been actively compounding the correct dosage for children, more preparation in guaranteeing adequate supplies and further studies will be needed in the years ahead.
“Prior to the 2009 pandemic, we didn't have a lot of data that told us the correct doses of Tamiflu that we ought to use in very young children, particularly infants under one year of age,” Dr. Allen said.
“So there are two issues. First is the need to ensure that supplies are there as we move forward in time. And second, to ensure that the supplies are accompanied by the appropriate research that tells us what is the best dose to use to treat different individuals.”