Transcript

Lee Tetreault:

Hello and welcome to Frequently Asked Questions from the session, Seasonal Influenza: When, Who and How to Manage. We are joined today by Dr. Robert Hopkins and Dr. Charles Vega. First off, Dr. Hopkins could you go into a little bit of key pointers from today's session for our audience? 

Dr. Hopkins:  

Absolutely. First and foremost, we need to remember that influenza vaccination is critical to prevent influenza in our patients across the age spectrum from 6 months of age and older. Second is that influenza primarily needs to be a clinical diagnosis, but there are appropriate times when testing is important to make a definitive diagnosis and to appropriately treat patients. Third is that antiviral medications are underutilized in the treatment of influenza. And finally, we need to at least recognize that some patients may benefit from prophylaxis or treating with antiviral medications to prevent influenza in particular settings.

Lee Tetreault:

Let's get into some of these frequently asked questions. First, are there any pointers around influenza prevention that clinicians need to know? 

Dr. Hopkins:  

Well, first and probably most important in my mind is that we need to be vaccinating all of our patients 6 months of age and older with influenza vaccine every year. Many people in the past have talked about egg allergy or other reasons to not vaccinate. We now know that egg allergy is no longer a contraindication to flu vaccination, and that almost everyone can be vaccinated safely. Our older adults have a number of options for special vaccines that provide additional protection, but everyone needs a flu shot. Second is that handwashing and using a respiratory mask and staying healthy are all also additional tools to help prevent people from getting the flu. So, those also need to be important in our preventive considerations.

Lee Tetreault:

When should influenza antiviral testing be considered as opposed to making a clinical diagnosis of flu? 

Dr. Hopkins:  

Well, generally in an outpatient setting, when flu is widespread in the community, there's no reason to test for influenza. But, if it's early in the season and there hasn't been much in the way of influenza detected in the community, or if you're uncertain based on clinical criteria that a patient may have influenza, as opposed to something else, or somebody is sick enough that you feel like you need to put them in the hospital, those patients all need to be tested to make sure that they have influenza. But I think it's critically important to recognize that if you're gonna test somebody for influenza, you probably should couple that with going ahead and empirically treating, because we don't wanna wait on the results of the test and potentially miss the opportunity to treat early.

Lee Tetreault:

What are the options for antiviral treatments in outpatients? 

Dr. Hopkins:  

In outpatients, we have a number of important options for treatment of influenza. First is oseltamivir or Tamiflu that's been around for many years. It's a very effective oral medication for influenza. Another one which is Relenza, which is an inhaled neuraminidase inhibitor that's helpful in treating influenza, but it shouldn't be used in people that have lung disease or other pulmonary compromise. And finally, we have a new agent, baloxavir, that is an oral agent that can be very effective in helping to reduce the severity of influenza. Baloxavir has the advantage of being a one-time pill.

Lee Tetreault:

And how about for inpatients? 

Dr. Hopkins:  

For inpatients we do not currently have data on baloxavir in the inpatient setting or in severely ill patients. But oseltamivir or Tamiflu is still a first-line option for treatment. You could also use the inhaled agent, Relenza. And then finally, for severely ill patients in the intensive care unit, you could use peramivir which is an injectable one-time agent for treatment of influenza. Remember also that patients that are hospitalized need to be on respiratory isolation to reduce the likelihood of spread of influenza in the hospital setting.

Lee Tetreault:

What are some potential advantages in the use of baloxavir as opposed to oseltamivir for the treatment of influenza? 

Dr. Hopkins:  

Well, baloxavir is a single-dose treatment regimen for influenza. The fact that you can give a one-pill one time and reduce the spread of influenza by dropping the viral load, by effectively treating influenza, as opposed to having to take something twice a day for five days, I think is a major advantage. This newer agent, we're certainly seeing good successes to this point and we will have more data on that baloxavir over the next few years or few seasons, that will tell us whether it's also an effective options for sicker patients who may need to be hospitalized, and for younger children, as it's only approved for folks 12 and older at this point.

Lee Tetreault:

What do you do for a non-high risk patient in terms of their treatment? 

Dr. Vega:  

So, most of the patients in my practice are high risk. The CDC defines high risk fairly broadly: Very young, the very old, and particularly those with a lot of chronic illness which is most of my patients with chronic kidney disease, COPD, and asthma, particularly diabetes and severe obesity really common in my practice. And for those patients, it's a fairly straightforward choice. It's how do I get them antiviral treatment? So working with the patient to get antiviral treatment on board with the idea of improving symptoms but also preventing complications.

For the rare average risk patient who presents within 48 hours with influenza symptoms, that could be more of a shared decision-making process. I find that exploring patients' motivations for getting better oftentimes will yield an answer as to whether they want treatment that can improve their symptoms by about a day, by reducing the course of illness by about a day. So that might be a big deadline at work, or an important event over the weekend that they want to attend, or maybe they're just so darn miserable they just want it... It's worth it to get better in one or maybe even two days earlier. And so that's a shared decision-making process that is different than the high-risk patient. And then there are certain patients who absolutely just don't want to take any kind of antiviral drug. Maybe they're there just to make sure they didn't have a more severe bacterial infection. In that case, of course, it's fine just to treat with supportive care, lots of analgesics, antipyretics, maybe something for cough, and give them information on the course of illness.

Lee Tetreault:

How do you get treatment to influenza patients on time within 48 hours? 

Dr. Vega:  

That's traditionally one of the great limitations of influenza therapy is that it's really ideally initiated within 24 hours, but 48 hours is the standard window for effective therapy. And I don't necessarily talk to everybody about symptoms of influenza, but my high-risk patients who are say, immunosuppressed or on dialysis, or any of the high-risk group, maybe while we're giving the flu shot in the fall, I'll mention, "Hey, by the way, the flu shot isn't 100% effective. If you develop the rapid onset of fever and myalgias and getting really tired, then call our office and we can maybe arrange for you to be seen and initiate antiviral therapy that much earlier." So, just preloading those high-risk patients with a warning and giving the education upfront before the influenza season really hits, I think is one way we can mitigate the negative effects of influenza.

Lee Tetreault:

This is great information, thank you both so much for your time today.