Influenza Antiviral Therapy 

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Antiviral agents may be prescribed as treatment to potentially shorten the duration and decrease the severity of influenza infection. Antivirals may also be prescribed for chemoprophylaxis to prevent/attenuate a potential influenza infection following contact with an infected individual or in vulnerable individuals during a community outbreak (eg, nursing homes).

Amantadine and rimantadine are antiviral drugs in a class of medications known as adamantanes that were once prescribed for influenza treatment or prophylaxis. These medications are active against influenza A viruses, but not influenza B viruses. In recent past seasons, there has been a high prevalence (>99%) of influenza A(H3N2) and influenza A(H1N1)pdm09 (2009 H1N1) viruses resistant to adamantanes. Therefore, amantadine and rimantadine are not recommended for antiviral treatment or chemoprophylaxis of currently circulating influenza A viruses. [1]

When used as treatment, initiation of antiviral agents should not be delayed and ideally should be started within 48 hours of the onset of symptoms.

Infectious Disease Society of America guidelines for antiviral therapy for influenza

The Infectious Disease Society of America (IDSA) guidelines for influenza antiviral therapy are as follows: [2]

High-risk individuals

Clinicians should initiate antivirals as soon as possible for adults and children with documented or suspected influenza, irrespective of influenza vaccination history, in the following cases:

Individuals not at high risk

Clinicians may consider antivirals for individuals with documented or suspected influenza, irrespective of influenza vaccination history, in the following cases:

Treatment regimens for patients with influenza A and influenza B are outlined below. The regimens are based on patient age and weight. [3, 4, 5, 6, 7, 2]

Baloxavir marboxil (Xofluza)

Adolescents and adults aged 12 years or older

Dose based on body weight, as follows:

Oseltamivir (Tamiflu, generic)

Adolescents and adults

Children aged 1-12 years

Oseltamivir treatment varies by weight, as follows:

Children aged 2 weeks to younger than 1 year

Zanamivir (Relenza DIskhaler)

Adults and children aged ≥7 years

Peramivir (Rapivab)

Infuse diluted IV over 15-30 minutes

Adolescents and adults

Children aged 2-12 years

Antivirals should not be used for routine or widespread chemoprophylaxis outside of institutional outbreaks; antiviral chemoprophylaxis can be considered in the following cases: [2]

Adolescents and adults

Children aged 1-12 years

Oseltamivir treatment varies by weight, as follows:

Zanamivir prophylaxis (aged ≥5 y) consists of 10 mg (two 5-mg inhalations) inhaled PO once daily for 7 days.

Children younger than 1 year

Oseltamivir prophylaxis (aged 3 months to 1 year) consists of 3 mg/kg/dose PO once daily for 5 days.

In children younger than 3 months, oseltamivir prophylaxis is not recommended unless the situation is judged critical, owing to limited data in this age group.

Duration of chemoprophylaxis

Postexposure prophylaxis: 10 days when administered after a household exposure, or for high-risk patients, 7 days after the most recent known exposure when prophylaxis can be initiated within 48 hours of exposure

Pre-exposure prophylaxis: Dependent on duration of community outbreak as the antiviral needs to be taken every day during the outbreak to be maximally effective

Outbreaks in long-term care facilities and hospitals: Prophylaxis for ≥14 days and up to 7 days after the most recent known case was identified (CDC recommendation)

Oseltamivir: Up to 6 weeks

Zanamivir: Up to 4 weeks

Inpatient

Antiviral therapy should be initiated as early as possible in hospitalized patients with suspected or confirmed influenza, preferably within the first 48 hours of illness. However, antiviral therapy may still improve outcomes in hospitalized patients or outpatient high-risk individuals if started after the initial 48 hours of illness. Zanamivir disc inhaler administration is not possible for intubated patients or very young children, and is not appropriate in patients with underlying airway disease (eg, asthma, COPD). Depending on the severity of illness, hospitalized patients may require more than 5 days of antiviral therapy.

Outpatient

Certain populations are at higher risk for complications from influenza, as a result, initiation of antiviral treatment is recommended as early as possible for suspected or confirmed influenza in the following patient populations:

Overview

What is the dosage of oseltamivir (Tamiflu) for the treatment of influenza?

What are the antiviral regimens for chemoprophylaxis in children aged 1-12 years with suspected influenza?

How are antiviral drugs used in the treatment of influenza?

What is the role of adamantanes in the treatment of influenza?

What are the guidelines for antiviral therapy in the treatment of influenza A and B?

What is the dosage of baloxavir marboxil (Xofluza) for the treatment of influenza?

What is the dosage of zanamivir (Relenza Diskhaler) for influenza treatment in adults and children aged ?7 years for the treatment of influenza?

What is the dosage of peramivir (Rapivab) for the treatment of influenza?

What are the antiviral regimens for chemoprophylaxis in adolescents and adults with suspected influenza?

What are the antiviral regimens for chemoprophylaxis in children younger than 1 year with suspected influenza?

What is the duration of chemoprophylaxis for suspected influenza?

When is influenza antiviral therapy indicated for inpatient populations?

Which high-risk patient groups should receive influenza antiviral therapy?

Influenza Antiviral Medications: Summary for Clinicians. Center for Disease Control and Prevention (CDC). Available at http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed: October 25, 2018.

Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM Jr, Fry AM, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis. 2018 Dec 19. [Medline]. [Full Text].

Bearman GM, Shankaran S, Elam K. Treatment of severe cases of pandemic (H1N1) 2009 influenza: review of antivirals and adjuvant therapy. Recent Pat Antiinfect Drug Discov. 2010 Jun 1. 5(2):152-6. [Medline].

Saladino R, Barontini M, Crucianelli M, Nencioni L, Sgarbanti R, Palamara AT. Current advances in anti-influenza therapy. Curr Med Chem. 2010. 17(20):2101-40. [Medline].

Dutkowski R. Oseltamivir in seasonal influenza: cumulative experience in low- and high-risk patients. J Antimicrob Chemother. 2010 Apr. 65 Suppl 2:ii11-ii24. [Medline].

CDC. Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza — Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Surveill Summ. 2011 Jan 21. 60(1):1-28. [Medline].

Hayden FG, Sugaya N, Hirotsu N, Lee N, de Jong MD, Hurt AC, et al. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. N Engl J Med. 2018 Sep 6. 379 (10):913-923. [Medline].

Christian E Sandrock, MD, MPH, FCCP Associate Professor of Clinical Medicine, Division of Pulmonary/Critical Care Medicine, Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis Medical Center

Christian E Sandrock, MD, MPH, FCCP is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Infectious Diseases Society of America

Disclosure: Received honoraria from Pfizer for speaking and teaching; Received honoraria from Pfizer for consulting; Received honoraria from therevance for consulting; Received honoraria from GSK for speaking and teaching.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Influenza Antiviral Therapy 

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