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PHYSICIAN ALERT:
♦
Current Antiviral Recommendations forInfluenza Treatment
October 16, 2009 Vol. 29, No. 7
WASHOE
COUNTY
DISTRICT
HEALTH
DEPARTMENT
•
P.O.
BOX
11130
•
RENO,
NEVADA
•
89520-0027
•
(775)
328-2447
This alert contains information on investigations in progress and/or diagnoses that may not yet be confirmed.The Physician Alert is intended primarily for the use of local health care providers, should be considered privileged, and should
NOT be distributed
further.
Current Antiviral Recommendations for Treatment of Influenza
WHOM TO TREAT:
♦
Any patients with suspected or confirmed influenza
requiringhospitalization
.
♦
Any patients with influenza-like-illness associated with
moresevere symptoms
, such as evidence of lower respiratory tractinfection or clinical deterioration, regardless of previous health or age, including pneumonia, dyspnea, tachypnea or hypoxia, even inthe outpatient setting.
♦
Any patients presenting with suspected or confirmed influenza
whoare at higher risk for complications
, including:
o
Children below the age of 5 years;
o
Pregnant women (oseltamivir & zanamavir are Category Cagents);
o
Persons with chronic lung disease, renal insufficiency, chronicheart disease, diabetes mellitus, chronic liver disease,hematologic malignancies, sickle cell disease, debilitatingneurologic disorders, immunodeficiency disorders, or who areon immunosuppressive therapy;
o
Obese persons with a BMI greater than 35;
o
Smokers:
o
Persons aged 65 and older;
o
Children on chronic aspirin therapy up to age 18;
o
Patients presenting with apparent exacerbations of asthma or chronic obstructive lung disease during an influenzaepidemic should be assumed to have influenza.
♦
Treatment should not wait for laboratory confirmation.
Anegative rapid test for influenza does not rule out influenzainfection.
*
♦
Treatment should be initiated for the above groups
even if more than 48 hours have lapsed since symptom onset.
**
♦
Treatment should also be considered for persons with influenza-like-illness who live with or care for an infant less than six monthsof age.
♦
If practitioners choose to treat patients at lower risk of complications (i.e. those not listed in the groups above), treatmentshould not be started more than 48 hours after symptom onset.
WHAT IS THE TREATMENT?
♦
Oseltamivir (Tamiflu®) or zanamivir (Relenza®) are the onlyantivirals recommended for treatment or chemoprophylaxis of theinfluenza strains currently circulating. Dosage recommendationsare included on the following page.
♦
Treatment with higher doses of antivirals (e.g., 150 mgoseltamivir BID for adults) and longer courses (e.g., >5days) may be considered in cases of severe disease or if there is evidence of clinical progression while ontreatment with standard doses.
Concerns that critically illpatients may have the potential for lower oseltamivir absorption, higher viral loads, and reduced delivery of oseltamivir to damaged tissue exist. No comparative studieshave assessed the effectiveness of higher doses or extendedtreatment, but such treatment has been suggested basedupon the above concerns.
♦
Treatment with higher doses of antivirals (e.g., 150 mgoseltamivir twice per day for adults) should also beconsidered for hospitalized patients with BMI > 35
because of concerns that standard dosage recommendationsmay be inadequate.
♦
If oseltamivir resistance emerges during this epidemic, thenzanamivir or a combination of oseltamivir and rimantadine maybecome recommended as empiric therapy for influenza in highrisk or severely ill patients with influenza. This information willbe updated in future editions of the Epi – News. Nationalsurveillance data on antiviral susceptibility of circulatinginfluenza viruses is updated weekly and can be accessed athttp://www.cdc.gov/flu/weekly/.
WHOM TO TEST:
♦
Only patients requiring hospitalization for suspectedinfluenza or patients who died of an acute illness in whichinfluenza was suspected should be tested for novel H1N1influenza through the Nevada State Public HealthLaboratory.
♦
Additional diagnostic tests for influenza are available throughcommercial labs or at point of care, including rapid antigentests, direct and indirect immunofluorescence (DFA and IFA)and viral isolation in tissue cell culture. Although most patientswith clinical illness consistent with uncomplicated influenza donot require diagnostic influenza testing for clinicalmanagement, use of these tests are up to the clinical judgmentof the health care provider.
Please remember that a negativerapid flu antigen test does not rule out influenza infection.
*
Treatment may be discontinued if testing for influenza is negative by RT-PCR, but the rapid flu antigen test should not be relied upon,because it is insensitive (10-70%) in the detection of the H1N1 strain of swine-origin influenza virus currently circulating.
**
Patients who are severely ill with influenza, or who are at high risk of severe or complicated influenza, may benefit from antiviral therapyinitiated later than 48 hours after onset. This is thought to be because these are patients in whom active viral replication is prolonged, so thatsuppressing influenza viral replication, even late in the course of illness, reduces mortality. Patients who received oseltamivir more than 48hours after onset in a Toronto study of persons hospitalized with severe influenza in the 2005-06 influenza season still experienced a mortalityrate that was only 24% of the mortality among those who did not receive oseltamivir.
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2009-10-16 Current Antiviral Recommendations for Influenza Treatment
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