The Medical Letter on Drugs and Therapeutics
Antiviral Drugs for Influenza for 2022-2023
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Med Lett Drugs Ther. 2022 Nov 28;64(1664):185-90
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  • Mark Abramowicz, M.D., President has disclosed no relevant financial relationships.
  • Jean-Marie Pflomm, Pharm.D., Editor in Chief has disclosed no relevant financial relationships.
  • Brinda M. Shah, Pharm.D., Consulting Editor has disclosed no relevant financial relationships.
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  1. Discuss the 2022-2023 recommendations for antiviral treatment and prophylaxis of seasonal influenza.
 Select a term to see related articles  Amantadine   Antiviral drugs   baloxavir   FluMist   influenza   influenza vaccine   oseltamivir   peramivir   Rapivab   Relenza   Rimantadine   Tamiflu   Xofluza   zanamivir 

Influenza is generally a self-limited illness, but complications such as pneumonia, respiratory failure, and death can occur, especially in patients at increased risk for influenza complications (see Table 1). Antiviral drugs recommended for treatment and chemoprophylaxis of influenza this season are listed in Table 2. Updated information on influenza activity and antiviral resistance is available from the CDC at None of the drugs that are FDA-approved for treatment of influenza have clinically relevant antiviral activity against SARS-CoV-2.

TREATMENT RECOMMENDATIONS — Antiviral treatment is recommended as soon as possible for any patient with suspected or confirmed influenza who is hospitalized, has severe, complicated, or progressive illness, or is at increased risk for complications, even if it is started >48 hours after illness onset.1-3 False-negative results can occur with some influenza tests; patients in the above groups should receive antiviral treatment even if they test negative, especially when influenza viruses are known to be circulating in the community.4

Antiviral treatment can be considered for otherwise healthy symptomatic outpatients with suspected or confirmed influenza who are not at increased risk for influenza complications if it can be started within 48 hours after illness onset.

TREATMENT — A neuraminidase inhibitor (oral oseltamivir, IV peramivir, or inhaled zanamivir) or the oral cap-dependent endonuclease inhibitor baloxavir marboxil is recommended for treatment of suspected or confirmed uncomplicated influenza in nonpregnant outpatients this season. All of these drugs are active against influenza A and B viruses.

Oseltamivir is preferred for use in pregnant women, hospitalized patients, and outpatients with severe, complicated, or progressive illness.1

Effectiveness – Use of a neuraminidase inhibitor or baloxavir for treatment of acute uncomplicated influenza in adults shortens the duration of symptoms by about one day.5-8 In a meta-analysis of 26 randomized, placebo-controlled trials that included 11,897 healthy adults and children with influenza-like illness, zanamivir was associated with the shortest time to alleviation of influenza symptoms and baloxavir was associated with the lowest risk of influenza-related complications.9 In hospitalized patients, oral oseltamivir and IV peramivir appear to be similarly effective.10

A meta-analysis of randomized trials in children with influenza found that starting oseltamivir within 48 hours after illness onset reduced illness duration by about 18 hours (by about 30 hours when trials that enrolled children with asthma were excluded) and decreased the risk of otitis media.11 In children hospitalized with laboratory-confirmed influenza, antiviral treatment started within 48 hours after illness onset was associated with shorter lengths of hospital stay compared to no antiviral treatment.12

Although most controlled trials of antiviral drugs have not been powered to assess their efficacy in preventing serious influenza complications, experts have generally interpreted the combined results of controlled trials, observational studies, and meta-analyses as showing that early antiviral treatment of influenza in high-risk and hospitalized patients can reduce the risk of complications.6,13-16

Oseltamivir vs Baloxavir – Oseltamivir is FDA-approved for treatment of acute, uncomplicated influenza in patients ≥2 weeks old. Baloxavir is approved for use in otherwise healthy patients ≥5 years old or in patients ≥12 years old who are at high risk of developing influenza-related complications.

In a randomized, double-blind trial (miniSTONE-2) in 173 children 1-11 years old with influenza, the median time to improvement in symptoms was similar with a single dose of baloxavir or 5 days' treatment with oseltamivir (both started within 48 hours after illness onset; 138 vs 150 hours).17

In a randomized, double-blind trial (CAPSTONE-2) in 2184 adolescents and adults with uncomplicated influenza who were at high risk of developing complications, the median time to improvement of symptoms was similar with a single dose of baloxavir or 5 days' treatment with oseltamivir (both started within 48 hours after illness onset) in the overall population and in those infected with influenza A(H3N2), but was statistically significantly shorter with baloxavir in those infected with influenza B (median difference 27.1 hours). Use of either drug was associated with a lower incidence of influenza-related complications and fewer antibiotic prescriptions compared to placebo.5

In a randomized, double-blind trial (FLAGSTONE) in 366 patients ≥12 years old hospitalized with severe influenza, the time to clinical improvement was not statistically significantly different with a combination of a neuraminidase inhibitor (primarily oseltamivir) and baloxavir compared to a neuraminidase inhibitor alone (95.5 vs 100.2 hours).18

Timing – Neuraminidase inhibitors are most effective when started within 48 hours after illness onset, but the results of some observational studies in hospitalized and critically ill patients suggest that treatment started as late as 4-5 days after illness onset can shorten the length of hospitalization and reduce the risk of complications such as pneumonia, respiratory failure, and death.19-22 No data are available on the efficacy of baloxavir when it is started >48 hours after illness onset.

Adults with community-acquired pneumonia who test positive for influenza should receive antiviral treatment regardless of the duration of illness.23

CHEMOPROPHYLAXIS — Oseltamivir, zanamivir, and baloxavir are FDA-approved for post-exposure prophylaxis of influenza following close contact with an infected individual. Post-exposure prophylaxis should be considered for persons at increased risk of complications who have not received an annual influenza vaccine for the current season, received one within the previous 2 weeks, or might not respond to vaccination, or when the match between the vaccine and circulating strains is poor. It is not recommended for healthy persons exposed to influenza or when >48 hours have elapsed since exposure. Antiviral chemoprophylaxis with oseltamivir or zanamivir is also recommended to help control institutional influenza outbreaks.1

Effectiveness – Neuraminidase inhibitors have generally been about 70-90% effective in preventing influenza caused by susceptible strains of influenza A or B viruses.1 In a randomized, double-blind trial in 752 household contacts of patients with influenza, the efficacy of a single dose of baloxavir in preventing clinical influenza in household contacts was 86%.24

Timing – When indicated, chemoprophylaxis should be started no later than 48 hours after exposure and, with oseltamivir or zanamivir, it should be continued for 7 days after the last known exposure.

For institutional outbreaks, the CDC recommends chemoprophylaxis with oral oseltamivir or inhaled zanamivir for at least 2 weeks and continuing for up to 1 week after the end of the outbreak.

View a more detailed table

PREGNANCY AND LACTATION — Pregnant women are at increased risk for severe complications of influenza. Oseltamivir and zanamivir appear to be safe for use during pregnancy.25,26 Prompt treatment with oseltamivir is recommended for women with suspected or confirmed influenza who are pregnant or ≤2 weeks postpartum.27-29 Oseltamivir is preferred for treatment of women who are breastfeeding. No data are available on use of baloxavir in pregnant or breastfeeding women.

Antiviral chemoprophylaxis can be considered for pregnant women who have had close contact with someone likely to have influenza. Zanamivir may be preferred because of its limited systemic absorption, but oseltamivir is a reasonable alternative, especially in women at increased risk for respiratory problems.

RESISTANCE — Over 99% of the recently circulating influenza virus strains tested by the World Health Organization (WHO) have been susceptible to neuraminidase inhibitors.30 Reduced susceptibility of some influenza virus strains, particularly influenza A(H1N1), to oseltamivir or peramivir can emerge during or after treatment, especially in young children and immunocompromised patients with prolonged viral shedding.31-36 Resistant isolates have usually remained susceptible to zanamivir, but reduced susceptibility to zanamivir has been reported.37 In immunocompromised patients, a double dose of oseltamivir reduced the incidence of oseltamivir resistance compared to standard dosing, but it did not improve efficacy and caused more adverse effects.38

Baloxavir is active against neuraminidase inhibitor-resistant strains of influenza A and B viruses, including A(H1N1), A(H5N1), A(H3N2), and A(H7N9). Amino acid substitutions associated with reduced susceptibility to baloxavir have occurred following treatment with a single dose of the drug.8,39 Reduced susceptibility to baloxavir appears to be more frequent in persons infected with influenza A(H3N2) and A(H1N1)pdm09 viruses, particularly children.40,41 Baloxavir monotherapy is not recommended for severely immunosuppressed patients because of concerns that prolonged replication of the influenza virus in these patients could lead to emergence of resistance. Oseltamivir and peramivir may be active against influenza virus strains with reduced susceptibility to baloxavir.42

The adamantanes amantadine and rimantadine are active against influenza A viruses, but not influenza B viruses. As in recent past seasons, resistance to these drugs is high (>99%) among circulating influenza A(H3N2) and A(H1N1)pdm09 viruses; neither amantadine nor rimantadine is recommended for treatment or chemoprophylaxis of currently circulating influenza A viruses.

ADVERSE EFFECTS — Nausea, vomiting, and headache are the most common adverse effects of oseltamivir; taking the drug with food may minimize GI adverse effects. Oseltamivir has been associated with bradycardia in critically ill patients.43 Diarrhea, nausea, sinusitis, fever, and arthralgia have been reported with zanamivir. Inhalation of zanamivir can cause bronchospasm; the drug should not be used in patients with underlying airway disease. Diarrhea and neutropenia have occurred with peramivir.44

Baloxavir was well tolerated in clinical trials. It appears to cause less nausea and vomiting than oseltamivir.45

Neuropsychiatric events, including self-injury and delirium, have been reported in patients taking neuraminidase inhibitors or baloxavir, but a causal relationship has not been established, and neuropsychiatric dysfunction can be a complication of influenza illness itself.46 Hypersensitivity reactions, including anaphylaxis, have been reported with all of these drugs.

USE WITH THE LIVE-ATTENUATED VACCINE — Use of oseltamivir or zanamivir within 48 hours before, peramivir within 5 days before, or baloxavir within 17 days before administration of the intranasal live-attenuated influenza vaccine (FluMist Quadrivalent) could inhibit replication of the vaccine virus, reducing the vaccine's efficacy, and is not recommended.47 Persons who receive any of these antiviral drugs during these specified times and through 2 weeks after receiving the live-attenuated vaccine should be revaccinated with an inactivated or recombinant age-appropriate influenza vaccine.48

DRUG INTERACTIONS — Coadministration of dairy products, beverages, antacids, laxatives, multivitamins, or other products containing polyvalent cations (e.g., calcium, aluminum, iron, magnesium, selenium, or zinc) can reduce serum concentrations of baloxavir and should be avoided.


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