On September 22, 2009 CDC updated its recommendations for the use of influenza antiviral medicines to provide additional guidance for clinicians in prescribing antiviral medicines for treatment and prevention (chemoprophylaxis) of influenza during the 2009-2010 flu season. These recommendations are intended to help clinicians prioritize use of antiviral drugs for treatment and prevention of influenza. As in earlier antiviral recommendations posted on May 6, 2009 and updated on September 8, 2009, the priority for use of antiviral medications this season continues to be in people with more severe illness, such as people hospitalized with influenza, and people at increased risk of influenza-related complications. This document has been updated to provide additional clarification on several issues, including the increased risk for complications in young children, particularly children younger than 2 years of age.
As with any medical decision making, clinical judgment is an essential factor in making decisions about treatment with antiviral medications.
How is the new guidance different from the guidance that was issued on September 8, 2009?
The priority use for antiviral medications during the upcoming influenza season remains generally the same as outlined in the antiviral recommendations first posted on May 6, 2009 and updated on September 8, 2009; that is to prioritize use of these drugs for those patients who are severely ill (such as those who are hospitalized) and those patients who are ill with influenza-like illness and who are at higher risk for influenza related complications. New information in the updated guidance dated September 22, 2009 includes:
1. Additional context and guidance for clinicians regarding the risk for complications and treatment considerations for young and very young children.
2. Information regarding the oral dosing dispenser included in the Tamiflu® for Oral Suspension packaging and instructions to insure the units of measure on the prescription instructions match the dosing device are also included.
3. More information about the possible underlying physiological conditions that may be associated with neuromuscular and neurocognitive disorders that might contribute to the increased risk for influenza complications in persons with these types of disorders.
The updated recommendations continue to balance between providing clinicians the information and guidance needed to reach those at greatest risk with appropriate and timely treatment; to reduce the chances of antiviral resistance through inappropriate or unnecessary chemoprophylaxis; and yet to still recognize the overarching importance of clinical judgment in making treatment and chemoprophylaxis decisions.
Who is prioritized for treatment with influenza antiviral drugs?
Most people ill with influenza will recover without complications.
Some people are at highest risk of influenza-related complications and are prioritized for treatment with influenza antiviral drugs this season. They include:
* People with more severe illness, such as those hospitalized with suspected or confirmed influenza
* People with suspected or confirmed influenza who are at higher risk for complications
o Children younger than 2 years old
o Adults 65 years and older
o Pregnant women
o People with certain chronic medical or immunosuppressive conditions
* People younger than 19 years of age who are receiving long-term aspirin therapy
Children 2 years to 4 years old are more likely to require hospitalization or urgent medical evaluation for influenza compared with older children, although the risk is much lower than for children younger than 2 years old. Children aged 2 years to 4 years without high risk conditions and who are not severely ill do not necessarily require antiviral treatment.
Children and adults presenting with suspected influenza who have symptoms of lower respiratory tract illness or clinical deterioration should also receive prompt empiric antiviral therapy, regardless of previous health or age.
Physicians may also decide not to treat some people in these groups and/or treat people who are not in these groups based on their clinical judgment.
Who is lower priority for treatment with influenza antiviral drugs?
Treatment with influenza antiviral drugs is generally not needed for people who are not at higher risk for complications or do not have severe influenza, such as those requiring hospitalization. However, any suspected influenza patient who presents with emergency warning signs (for example, difficulty breathing or shortness of breath) or signs of lower respiratory tract illness or worsening illness should seek medical care promptly receive antiviral therapy when indicated.
Doctors may treat some people who are not in a high risk group based on their clinical judgment. In addition, doctors also may decide that treatment is not needed for some who are in a high risk group based on their clinical judgment.
Which influenza antiviral drugs should be used for treatment this season?
At this time, treatment with oseltamivir (trade name Tamiflu®) or zanamivir (trade name Relenza®) is recommended for all people with suspected or confirmed influenza who require hospitalization.