Antivirals

Antiviral medications for influenza

Antiviral medications are available and effective for the treatment and prevention of influenza, however they do not replace influenza vaccination as the recommended strategy for the control of influenza.(1)

The neuraminidase inhibitors are the preferred class of antivirals approved for use in New Zealand. They include TAMIFLU® (oseltamivir) and RELENZA® (zanamivir) which are active against influenza A and B viruses.

Antiviral resistance to both oseltamivir and zanamivir in circulating influenza viruses is currently low, however resistance may emerge in some patients (e.g. the immune-compromised) in association with treatment.

Guidance on influenza prevalence can be obtained from regional influenza surveillance reports, these are updated weekly and available at http://www.surv.esr.cri.nz/virology/influenza_weekly_update.php during the season. Antiviral resistance data is included in the report at the end of October and the annual report in March the following year.

Antiviral treatment

TAMIFLU® is approved for the treatment of persons 1 year and older. RELENZA® is approved for the treatment of persons 5 years and older; however it is not recommended for people with underlying respiratory disease (e.g. asthma, COPD).

Limited information regarding the use of TAMIFLU in children from birth to <1 year old is available, although it was approved for use during the 2009 pandemic.

Clinical benefit is greatest when antiviral treatment is commenced EARLY, especially within 2 days of influenza illness onset. Clinical trials show that early antiviral treatment can shorten the duration of fever and influenza symptoms, reduces viral shedding and may reduce the risk of complications from influenza including otitis media in children, pneumonia and respiratory failure.(2-3) Observational studies during the 2009 pandemic have shown that antiviral treatment commenced within 2–4 days in comparison with 5 or more days may still be beneficial in patients with severe or complicated influenza. Reductions in hospitalisation, respiratory failure, intensive care admission, and mortality have been demonstrated.(4-5-6)

Treatment indications

Treatment is recommended as early as possible for patients with suspected or confirmed influenza who are hospitalised, have severe influenza, progressive illness or are at higher risk of severe outcomes.

  • Persons at higher risk for influenza complications include those ≥65 years, all ages with chronic respiratory disease, immunosuppression, women who are pregnant or postpartum and residents of nursing homes or chronic care facilities
  • Treatment should start immediately, rather than wait for the results of a virology test 

Seek specialist advice as appropriate, especially for patients with severe or deteriorating influenza.

TAMIFLU® is recommended as the first-line antiviral treatment. Standard adult treatment courses are:

  • TAMIFLU® 1 x 75mg capsule twice daily for 5 days
  • RELENZA® 2 x 5mg, two inhalations twice a day (a total daily dose of 20mg) for 5 days

Recomendations for the second-line use of RELENZA® are:

  • An inability to take or tolerate TAMIFLU® e.g. due to nausea or vomiting
  • Moderate to severe renal impairment

TAMIFLU® is a Prescription Medicine and must be prescribed by a doctor. However, during the influenza season (April to November) Tamiflu may be prescribed by a pharmacist for the treatment of influenza, provided the patient is ≥12 years old and has been assessed by a pharmacist.

www.medsafe.govt.nz/profs/class/classification.asp

Antiviral chemoprophylaxis

TAMIFLU® is approved for the prophylaxis of persons 1 year and older and RELENZA® for the prophylaxis of persons 5 years and older; however RELENZA® is not recommended for people with underlying respiratory disease (e.g. asthma, COPD).

While annual influenza vaccination, given well before the influenza season, is the recommended strategy/approach to prevention and control of influenza, clinical trials have reported that both TAMIFLU® and RELENZA® were effective in preventing influenza illness in persons following exposure to a household member or other close contact with laboratory confirmed influenza (TAMIFLU® 68%-89%; RELENZA® 72%-82%).(1)

Post-exposure indications for use

Routine use of antivirals for pre-exposure or post exposure chemoprophylaxis is not recommended, however there are situations where post-exposure use is indicated.

  • On a case by case basis e.g. for pregnant or postpartum women who have had close contact with an influenza case or other persons at high risk of severe illness
  • For outbreak control among high risk persons in institutional settings e.g. hospitals, residents of nursing homes and other closed institutions(7)

Chemoprophylaxis should occur within 48 hours of exposure to an influenza infected person.

Standard adult chemoprophylaxis courses are:

  • TAMIFLU® 1 x 75mg capsule daily for 10 days
  • RELENZA® 2 x 5mg, two inhalations a day (a total daily dose of 10mg) for 10 days
References
  1. Fiore, M., et al., Antiviral agents for the treatment and chemoprophylaxis of influenza. Centers for Disease Control and Prevention, 2011.
  2. Wang, K., et al., Neuraminidase inhibitors for preventing and treating influenza in children (published trials only). Cochrane Database of Systematic Reviews, 2012(4).
  3. Jefferson, T., et al., Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children. Cochrane Database Syst Rev, 2012. 1: p. CD008965.
  4. Siston, A.M., et al., Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA, 2010. 303(15): p. 1517 25.
  5. Yu, H., et al., Risk factors for severe illness with 2009 pandemic influenza A (H1N1) virus infection in China. Clin Infect Dis, 2011. 52(4): p. 457-65.
  6. Hsu, J., et al., Antivirals for treatment of influenza: a systematic review and meta-analysis of observational studies. Ann Intern Med, 2012. 156(7): p. 512-24.
  7. Booy, R., et al., Treating and preventing influenza in aged care facilities: a cluster randomised controlled trial. PLoS One, 2012. 7(10): p. e46509.