September 21, 2020

Background: Previous evidence has found that oseltamivir reduces median time to alleviation of influenza symptoms over placebo by about 1 day.  The benefits were greater when treatment was initiated within 24 to 48 hours of symptoms onset. Many previous trials have been criticized for under-recruiting, selective reporting of outcomes, and not including enough children/older patients. Additionally, use of oseltamivir is known to cause side effects such as headaches, nausea/vomiting and, in some cases, neuropsychiatric illness. The CDC currently recommends treatment with oseltamivir in patients with confirmed or suspected influenza who are hospitalized, severely ill, or have higher risk for influenza complications as well as consideration of treatment for symptomatic outpatients if treatment can be initiated within 48 hours.

September 17, 2020

Background: Baloxavir (trade name Xofluza) was approved for the treatment of acute, uncomplicated influenza in patients > 12 years of age in October 2018. However, high-quality data has been underwhelming at best for its efficacy in treatment. Back in November of 2018, REBEL EM concluded:

Clinical Take Home Point: Consistent with every other study on anti-viral medications for influenza, baloxavir appears to decrease duration of symptoms, especially in patients treated within 24 hours of symptoms, BUT a massive exclusion list, cost of the medication, increased resistance after initiation, results only applicable to H3N2 (88% of patients with flu), no comparison to standard care (i.e. symptom based therapy), pharma sponsored study, and no patient oriented outcomes, it is hard to make an argument for the use of baloxivir in patients with confirmed influenza. This trial should be a reminder as to why an industry funded trial, without full release of data, and cherry picked endpoints should not be used to change practice.

Continued research on effective anti-influenza drugs is critically important particularly with the potential for a “double pandemic” in the coming months. While treatment results are modest at best, baloxavir has potential as a prophylactic medication as well.

January 14, 2019

Article: Uyeki TM 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. PMID: 30566567

Background: Influenza is an Emergency Department scourge that we deal with every year. The vast majority of patients recover from uncomplicated influenza without anything more than supportive care but, influenza can cause serious complications. Young children, older adults, pregnant and postpartum women, people with neurologic disorders and patients with certain chronic medical conditions (i.e. COPD, CAD, Diabetes, Immunocompromised states) are at increased risk for these complications. Annual vaccination is the best method to reduce the impact of influenza on morbidity and mortality. Though antiviral medications for influenza are far from perfect, the indications for their use must be understood.

November 19, 2018

Background: On October 24th, 2018, Roche, the maker of oseltamivir, announced that the US Food and Drug Administration (FDA) approved Xofluza (baloxavir marboxil) for the treatment of acute, uncomplicated influenza in people 12 years of age and older. Historically, there have been two classes of influenza treatment, the M2 ion-channel inhibitors, and the neuraminidase inhibitors, however circulating influenza viruses have become largely resistant to M2 ion-channel inhibitors and the emergence of newer strains of influenza (H1N1) could threaten the utility of neuraminidase inhibitors as well. I have written previously about the Tamiflu Debacle and why this is a medication we should not prescribe to immunocompetent patients. In this post, we attempt to answer a different question: Is baloxavir approval another debacle or does it actually improve patient oriented outcomes?
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