2020 Symposia Series 1 - Practicing Clinicians Exchange
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2020 Symposia Series 1
Weighing the Options: Prevention and
Management of Influenza in Patients at
High Risk for Complications
Learning Objectives
• Identify available and emerging options for prevention of influenza
• Select influenza treatment for adult patients at high risk of
complications based on current recommendations and evidence
• Individualize influenza treatment in pediatric patients based on
current recommendations
3
Epidemiology and Burden of Seasonal Influenza in the US
Burden of Influenza: Annual Estimates by the CDC From 9 Influenza Seasons (2010-2011 through 2018-2019)*
• Rates of serious illness and death from
9.3 to 45 million illnesses caused seasonal influenza are highest in persons >65
years, in children
Influenza-Positive Tests Reported to CDC:
National Summary, 2019-2020 Season
4000
3500
Number of Positive Specimens
3000
2500
2000
1500
1000
500
0
2019-40 2019-42 2019-44 2019-46 2019-48 2019-50 2019-52 2020-02 2020-04 2020-06 2020-08 2020-10 2020-12 2020-14 2020-16 2020-18 2020-20
Week
B (Yamagata Lineage) B (Victoria Lineage) B (lineage not performed) A (H3N2) A (H1N1)pmd09 A (subtyping not performed)
Centers for Disease Control and Prevention. cdc.gov/flu/weekly/index.htm. Accessed Apr 5, 2020. 516000
Number of Specimens Tested and Percent Positive 15000
for SARS-CoV-2 14000
13000
12000
11000
10000
9000
B (Yamagata Lineage) B (Victoria Lineage) SARS-CoV-2 8000
B (lineage not performed) A (H3N2)
7000
A (H1N1)pmd09 A (subtyping not performed)
6000
5000
4000 4000
3000 3000
2000 2000
1000 1000
0
2019-40 2019-42 2019-44 2019-46 2019-48 2019-50 2019-52 2020-02 2020-04 2020-06 2020-08 2020-10 2020-12 2020-14 2020-16 2020-18 2020-20
SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
Centers for Disease Control and Prevention. cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. Accessed Apr 5, 2020. 6Outpatient Visits for Influenza-like Illness Reported to CDC:
National Summary, 2009-2020
9
2018-19 season
2017-18 season
8
2015-16 season
2014-15 season
7 2011-12 season
% of Visitors for ILI
2009-10 season
6 2019-20 National Baseline
2019-20 season
5
4
3
2
1
0
40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
Week
ILI = influenza-like Illness.
Centers for Disease Control and Prevention. cdc.gov/flu/weekly/index.htm. Accessed Apr 5, 2020. 7Influenza Pandemics
Common Name Year Virus Estimated No. of Deaths (range)
Spanish flu 1918 H1N1 50 million-100 million
Asian flu 1958 H2N2 1 million-2 million
Hong Kong flu 1968 H3N2 500,000-2 million
H1N1 pandemic 2009 H1N1 151,700-575,400
COVID-19 pandemic estimate (for comparison to influenza pandemics)
COVID-19 2020 SARS-CoV-2 143,357* (by Aug 4, 2020)
*As of May 18, 2020; COVID-19 = Coronavirus disease 2019.
Dawood FS, et al. Lancet Infect Dis. 2012;12:687-695; Johnson NP, et al. Bull Hist Med. 2002;76:105-115; Saunders-Hastings PR, et al. Pathogens.
2016;5:e66; Simonsen L, et al. PLoS Med. 2013;10:e1001558; Taubenberger JK, et al. Emerg Infect Dis. 2006;12:15-22; COVID-19 Dashboard by
the Center for Systems Science and Engineering at Johns Hopkins University. coronavirus.jhu.edu/map.html. Accessed May 11, 2020; University of
Washington Institute for Health Metrics and Evaluations. www.covid19.healthdata.org Accessed May 22, 2020. 8Influenza Virus
Hemagglutinin NA
• The family Orthomyxoviridae has 3 genera, or NS 2
types, that infect humans: influenza viruses A,
B, and C
• Influenza A virus subtypes are based on
specific HA and NA glycoproteins that they Lipid
bilayer
express
− 18 HAs (H1-H18)
Ion
− 11 NAs (N1-N11) channel
− Potential for 144 HA and NA combinations
(some HAs and NAs cannot work together) Matrix
protein
• Birds are reservoir for 16 HA and 9 NA
subtypes Negative-sense
ssRNA
HA = hemagglutinin; NA = neuraminidase; NS = nonstructural protein; ss = single stranded.
Clancy S. Nature Education. 2008;1:83; Vemula SV, et al. Viruses. 2016;8:96. 9Case Study: Joanne, a 52-year-old female
• Joanne visits your primary care practice in November for an annual checkup
• She is 5 ft 6 in; 249 lb (BMI = 40.2 kg/m2)
• Her blood pressure is 128/78 mm Hg
• Unvaccinated against influenza and skeptical about the vaccine
⎻ She received the vaccine last year and “got the flu” the day after
• You recommend influenza vaccination, but she refuses
10
10Focus on Patients at Higher Risk for Influenza Complications Demographic factors Chronic Medical Conditions • Adults aged ≥65 years • Asthma • Children
Influenza Vaccination: Effective but Underutilized
• Most effective means of preventing seasonal influenza virus infection
– Recommended in all persons ≥6 months in the United States
• 38% to 61% of population gets vaccinated*
• Because of changes in circulating influenza strains, vaccine reformulated every year
• Vaccination can prevent serious illness
⎻ CDC estimates that during the 2018-2019 season, flu vaccine prevented an estimated:
• 4.4 million illnesses
• 2.3 million medical visits; 58,000 hospitalizations
• 35,000 deaths
*Estimated from percentage of patients with acute respiratory illness who were vaccinated for the 2019-2020 flu season.
Dawood FS, et al. MMWR Morb Mortal Wkly Rep. 2020;69:177-182. 12Interim Data for Influenza Vaccine Effectiveness
During the 2019-2020 Season
• Vaccination does not guarantee protection
• Interim data for vaccine effectiveness during 2019-2020 flu season (adjusted):
– 55% against influenza B/Victoria
– 37% against influenza A(H1N1)pdm09
– 45% overall effectiveness against influenza A and B combined
• Despite overall vaccine effectiveness of 38% in 2017-2018 season, flu vaccine
prevented:
‒ 7.1 million illnesses, 3.7 million medical visits
‒ 109,000 hospitalizations, 8000 deaths
13
Dawood FS, et al. MMWR Morb Mortal Wkly Rep 2020;69:177-182; Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21. 13Influenza Vaccines: 2019-2020 Influenza Season
Manufacturing
Process Age Indication Route Formulations
IIV4 standard dose Egg based† ≥6 months IM Prefilled syringe, MDV*
IIV4 standard dose Cell culture based ≥4 years IM Prefilled syringe, MDV*
IIV3 high dose Egg based† ≥65 years IM Prefilled syringe
IIV3 standard dose with Egg based† ≥65 years IM Prefilled syringe
MF59 adjuvant
RIV4 Recombinant HA ≥18 years IM Prefilled syringe
LAIV4‡ Egg based† 2 to 49 years Intranasal Single-use intranasal spray
*MDV = multidose vials containing ≤25 ug/0.5 mL thimerosal; †Contraindicated only if history of severe allergic reaction (eg, anaphylaxis) to egg;
‡Precautions in individuals with asthma, or underlying medical conditions that may predispose to complications after wild-type influenza infection;
IIV3 = inactivated influenza vaccine, trivalent; IIV4 = inactivated influenza vaccine, quadrivalent; IM = intramuscular; LAIV4 = Live attenuated
influenza vaccine; RIV4 = recombinant influenza vaccine, quadrivalent.
Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21. 14ACIP Guideline Update for 2019-2020 Influenza Season • Vaccine composition: ‒ A/Brisbane/02/2018 (H1N1) pdm09-like virus ‒ A/Kansas/14/2017 (H3N2)-like virus ‒ B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) ‒ B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage) [quadrivalent only] • Clinicians may administer any licensed, age-appropriate influenza vaccine to all patients ‒ Includes those with egg allergy, except for history suggestive of anaphylaxis ACIP = Advisory Committee on Immunization Practices. Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21. 15
Influenza Vaccination in Children Aged 6 Months Through 8 Years
Has the child received ≥2 doses of influenza vaccine previously
(excluding the current influenza season)?
Yes No or don’t know
2 doses of 2019-2020
1 dose of 2019-2020
influenza vaccine
influenza vaccine
(≥4 weeks apart)
Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21. 16High-dose and MF59-adjuvanted Seasonal Influenza Vaccines
in Patients ≥65 Years
• Population accounts for up to 90% of seasonal flu-related deaths and 50% to 70% of hospitalizations
• High-dose vs standard-dose vaccine (RCTs and observational studies)
⎻ Higher immunogenic responses
⎻ Improved protection against influenza and related complications
• MF59-adjuvanted vaccine vs nonadjuvanted inactivated influenza vaccine (observational studies)
⎻ Greater vaccine efficacy for lab-confirmed influenza and influenza-related hospitalizations
⎻ Results of RCT comparing immunogenicity of MF59-adjuvanted to high-dose vaccines pending
(NCT03183908)
• ACIP recommends no preference for particular vaccine types
⎻ Vaccination should not be delayed if a specific product is not available
RCT = randomized controlled trial.
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/acip/2019-2020/acip-table.htm. Accessed Apr 5, 2020; ClinicalTrials.gov.
clinicaltrials.gov/ct2/show/NCT03183908. Accessed Apr 5, 2020; Czaja CA, et al. Open Forum Infec Dis. 2019;6:ofz225; DiazGranados CA, et al.
N Engl J Med. 2014;371:635-645; Gravenstein S, et al. Lancet Respir Med. 2017;5:738-746; Grohskopf LA, et al. MMWR Recomm Rep.
2019;68:1-21; Izurieta HS, et al. Lancet Infect Dis. 2015;15:293-300; Lapi F, et al. Expert Rev Vaccines. 2019;18:663-670; Reed C, et al. PLoS
One. 2015;10:e0118369; Shay DK, et al. J Infect Dis. 2017;215:510-517; Van Buyunder PG, et al. Vaccine. 2013;31:6122-6128. 17Influenza Symptoms and Clinical Course
• Classic flu • Complications
– Abrupt onset of fever, chills, myalgia, – Sinusitis, otitis media
headache, fatigue, nonproductive cough, sore
throat, rhinitis – Pneumonia—primary viral or secondary bacterial
– Some people may have GI symptoms (eg, – Coinfections with other bacterial/viral pathogens
nausea, diarrhea) – Exacerbation of underlying medical conditions
– Typically resolves within 3 to 7 days (eg, COPD, asthma, CF, diabetes)
– Cough, malaise can persist for >2 weeks – Associations with CV events (eg, MI, stroke),
parotitis
• Mild illness without fever may also occur
• Atypical presentations may occur in elderly,
immunocompromised hosts, infants
CF = cystic fibrosis; CV = cardiovascular; MI = myocardial infarction.
Centers for Disease Control and Prevention. cdc.gov/flu/symptoms/symptoms.htm. Accessed Apr 5, 2020; Kwong JC, et al. N Engl J Med.
2018;378:345-353; Rolfes MA, et al. Clin Infect Dis. 2018;67:485-492; Uyeki TM, et al. Clin Infect Dis. 2019;68:895-902. 18Case Study (cont’d): Joanne
• Joanne returns to your office in early December after sudden onset of
symptoms the previous morning
⎻ Symptoms include fever (101.8°F), chills, body aches, intense headache,
extreme fatigue, and cough
• Has missed work yesterday; unable to perform household chores
• Several coworkers have been sick with flu-like illness, and Joanne is concerned
that she may have the flu
• Adult daughter and a grandchild (newborn) will be visiting soon, and she wants
to avoid spreading her illness
• Husband, aged 60 years, has not been vaccinated
19
19Differential Diagnosis of Allergies, URIs, and Influenza in a Typical
Influenza Season
Symptom Allergy Acute URI (common cold) Influenza
Itchy, watery eyes Common Rare; conjunctivitis may occur with Soreness behind eyes, sometimes
adenovirus conjunctivitis
Nasal discharge Common Very common Common
Nasal congestion Common Very common Sometimes
Sneezing Very common Very common Uncommon
Sore throat Sometimes Very common Sometimes
Cough Sometimes Common Very common
Headache Sometimes Sometimes Common
Fever Never Rare in adults, possible in children Very common
Malaise Sometimes Sometimes Very common
Fatigue, weakness Sometimes Sometimes Very common
Myalgia Never Rare Very common
Duration of symptoms Weeks 3 to 14 days 3 to 10 days; several weeks of cough, fatigue
Centers for Disease Control and Prevention. www.cdc.gov/flu.htm. Accessed Apr 5, 2020; National Institutes of Health. newsinhealth.nih.gov/2014/10/cold-flu-or-
allergy. Accessed Apr 5, 2020. 20Laboratory Diagnostic Methods to Detect Influenza A and B
Test Method Test Time Sensitivity Specificity
Rapid molecular assay Nucleic acid amplification 15 to 30 High High
minutes
RIDT Antigen detectionRT-PCR Versus RIDT: Preferred Tests
RT-PCR RIDT
Diagnostic accuracy ✓ Higher sensitivity → fewer false Lower sensitivity → more false
negatives negatives (newer tests have improved)
Specific → Limited false positives Specific → Limited false positives
Discriminate influenza
A subtypes ✓ Yes, if subtype primers used No
Time to results ≤30 minutes to several hours ✓ 10 to 15 minutes
Availability in office
setting More expensive and less available ✓ More likely to be available
✓ = preferred.
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/diagnosis/overview-testing-methods.htm. Accessed Apr 20, 2020; Merckx J,
et al. Ann Intern Med. 2017;167:394-409; Uyeki TM, et al. Clin Infect Dis. 2019;68:895-902. 22Interpreting Influenza Testing Results
• Use information on local influenza activity (eg, from health
Cannot rule out flu, department), patient history and travel, clinical signs/symptoms,
Negative especially if test does and physical examination to decide if treatment is indicated
result not have high sensitivity • Initiate antiviral treatment if flu is suspected and patient is at high
or if specimen was risk for complications or is being admitted to the hospital
collected >4 days after • Consider additional diagnostic testing for other pathogens
illness onset
• Initiate antiviral treatment if indicated
Positive result Influenza virus
• Implement infection prevention and control measures
(A or B) infection likely
• Consider additional influenza testing if subtype info is desired
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/diagnosis/algorithm-results-circulating.htm. Accessed Apr 5, 2020; Centers
for Disease Control and Prevention. cdc.gov/flu/professionals/diagnosis/overview-testing-methods.htm. Accessed Apr 5, 2020. 23When to Treat Influenza: Complicated vs Uncomplicated Confirmed or suspected influenza • Initiate antiviral treatment as soon as possible for patients who: ⎻ Have severe, complicated, or progressive illness ⎻ Require hospitalization ⎻ Are at higher risk for complications due to age or underlying conditions • Do not wait for test results in patients who have a serious illness or are otherwise at high risk • Consider antiviral treatment for outpatients if treatment can be initiated within 48 hours of onset without known risk factors for severe illness Uyeki TM, et al. Clin Infect Dis. 2019;68:895-902. 24
Why Is It Important to Treat Early? • RCTs show that antiviral treatment within 2 days of illness onset can lessen symptoms, shorten disease course, and reduce complications and hospitalization risk • Observational studies indicate that timely antiviral treatment can reduce complications and hospitalization risk, and decrease mortality in hospitalized patients (up to 4-5 days after symptom onset) Dobson J, et al. Lancet. 2015;385:1729-1737; Jain S, et al. N Engl J Med. 2009;361:1935-1944; McGeer A, et al. Clin Infec Dis. 2007;45:1568- 1575. Muthuri SG, et al. Lancet Respir Med. 2014;2:395-404; Venkatesan S, et al. Clin Infect Dis. 2017;64:1328-1334. 25
Influenza Antivirals: Mechanisms of Action
Adsorption Packaging and budding Release
Receptor
containing
sialic acid
M2 inhibition
Antibodies (adamantanes)
Endocytosis mRNA NA inhibitors
Cap snatching (oseltamivir,
and fusion Uncoating (baloxavir, peramivir,
RNA (+/-) zanamivir)
pimodivir)
RNA polymerase
inhibition
(favipiravir)
Finberg RW, et al. J Infect Dis. 2019;219:1026-1034; Li TC, et al. Viruses. 2015;7:4929-4944; Noshi T, et al. Antiviral Res. 2018;160:109-117. 26FDA-approved Antiviral Agents for Influenza • Neuraminidase inhibitors: oseltamivir, peramivir, zanamivir – Activity against both influenza A and B viruses – Oseltamivir, zanamivir also used as prophylaxis • Baloxavir – Activity against both influenza A and B viruses – Inhibits endonuclease, enzyme required for viral gene transcription • Adamantanes: amantadine, rimantadine – Activity against influenza A only – Widespread resistance, not recommended Centers for Disease Control and Prevention. cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed Apr 28, 2020; Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21; Wester A, et al. Infect Drug Resist. 2016;9:201-214 27
Antivirals for Influenza: Age Indications and Dosage
Age Route of
Antiviral Dosage Indication Administration Precautions
Baloxavir Single oral dose ≥12 years Tablets Do not take with:
• 40 mg for patients 40 to 80 kg • Dairy products or calcium-fortified
• 80 mg for patients ≥80 kg beverages
• Polyvalent cation-containing
laxatives
Oseltamivir Twice daily for 5 days ≥2 weeks Capsule or oral
• 75 mg (≥13 years) suspension
• Weight based (1-12 years)
• 3 mg/kg (2 weeks-1 year)
Peramivir Single dose of 600 mg over 15 min ≥2 years Intravenous
Zanamivir 10 mg twice daily for 5 days ≥7 years Oral inhalation Do not use in patients with:
• Underlying respiratory disease
• History of milk protein allergy
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed Apr 20, 2020; Rapivab
[prescribing information]. BioCryst Pharmaceuticals; 2018; Relenza [prescribing information]. GlaxoSmithKline; 2018; Tamiflu [prescribing
information]. Genentech; 2019; Xofluza [prescribing information]. Genentech; 2019. 28Antivirals for Influenza: Adverse Events (AEs)
Drugs AEs
Baloxavir Diarrhea, bronchitis, nausea, sinusitis, headache
Postmarketing reports: Swelling of the face, eyelids or tongue; dysphonia; angioedema; anaphylactic reactions,
anaphylactic shock, anaphylactoid reactions; rash, urticaria, erythema multiforme; vomiting, bloody diarrhea,
melena, colitis; delirium, abnormal behavior, and hallucinations
Oseltamivir Nausea, vomiting, headache
Postmarketing reports: serious skin reactions; sporadic, transient neuropsychiatric events*
Peramivir Diarrhea
Postmarketing reports: serious skin reactions; sporadic, transient neuropsychiatric events*
Zanamivir Oropharyngeal or facial edema; skin rash; bronchospasm, especially in the setting of underlying airways
disease; sinusitis; dizziness; ear, nose, and throat infections
Postmarketing reports: sporadic, transient neuropsychiatric events*
*Self-injury or delirium; mainly reported among Japanese adolescents and adults; may be due to viral infection itself.
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed Apr 20, 2020; Tamiflu
29 [prescribing information]. Genentech; 2019; Xofluza [prescribing information]. Genentech; 2019; Rapivab [prescribing information], BioCryst
Pharmaceuticals; 2018; Relenza [prescribing information]. GlaxoSmithKline; 2018. 29CAPSTONE-1: Time to Alleviation of Symptoms
With Baloxavir Marboxil vs Placebo
100 ++ • Phase 3 study
+
+
+ + ‒ 1436 otherwise healthy patients
Patients Who Did Not Have
Symptom Alleviation (%)
80 +
+ Placebo ‒ 12 to 64 years of age
60 ‒ Symptomatic uncomplicated flu
40
Baloxavir +
+
• Time to alleviation of symptoms
20
++
+ +
‒ Baloxavir group: 53.7 h
++ + + + +++++++
‒ Placebo group: 80.2 h (PCAPSTONE-2: Baloxavir vs Placebo or Oseltamivir
in Patients at High Risk for Influenza Complications
• Phase 3 Study in patients ≥12 years (N = 2184) presenting ≤48 hours of symptom onset and at high risk of influenza
complications (eg, asthma or chronic lung disease, age ≥65 years)
• Primary endpoint: Time to improvement of influenza symptoms in baloxavir vs placebo groups
• Adverse events were similar among groups
P Value P Value
Measure* Baloxavir Placebo Oseltamivir
(Baloxavir vs Placebo) (Baloxavir vs Oseltamivir)
Overall TTIIS 73.2 h 102.3 hJoanne: Case Conclusion
• You prescribe baloxavir for Joanne, advising her not to take it with:
⎻ Dairy products, calcium-fortified beverages, polyvalent cation-containing
laxatives, antacids, or oral supplements (eg, calcium, iron, magnesium,
selenium, or zinc)
• She feels better within a few days; 12 days later she feels almost completely
better, except for a slight lingering cough
• She’s looking forward to spending time with her daughter and new grandchild
during their upcoming visit
• She has urged her husband and her college-aged children to get vaccinated
and is committed to getting vaccinated herself early in the season each year
32Case Study: Sarah, an 11-year-old Student
• Usually in excellent health
• Sudden onset of headache, pharyngitis, fever, chills, nasal congestion yesterday;
symptoms worse today and now include dry cough, fatigue, weakness
• Mother reports OTC meds providing limited relief
• Flu prevalent at her school and community
• Height: 5 ft, 4 in; weight: 105 lb (BMI: 18 kg/m 2); blood pressure: 118/73 mm Hg
• Temperature: 103.5°F; heart rate: 95 beats/min; respiration rate: 14 breaths/min;
SpO2: 98% on room air
• Lungs: clear to auscultation
• Rapid strep test: negative
33Case Study: Sarah
• Given Sarah’s symptoms and the fact that flu is currently circulating
in the community, your clinical judgment is that a flu test is:
‒ Not necessary for diagnosis
‒ Would not change your approach to management
• You discuss antiviral treatment options with Sarah and her mother
34Case Conclusion: Sarah
• You prescribe Sarah oseltamivir, 75 mg twice daily for 5 days, because
it is approved for children of Sarah’s age and has more than 20 years
of clinical use
• Her symptoms start to resolve over the next few days and by the
weekend she is feeling well enough to travel for her quiz bowl event
• You recommend she get vaccinated early in the next flu season
35MINISTONE-2: Baloxavir vs Oseltamivir in Pediatric Patients With Influenza-like Symptoms • Phase 3 multicenter in patients 1 to
BLOCKSTONE: Baloxavir Prophylaxis vs Placebo in Subjects Living
With Someone With Confirmed Influenza
• Phase 3 randomized study assessing post-exposure prophylaxis in unvaccinated household contacts of
influenza-infected patients (influenza confirmed by RIDT)
• Household contacts randomized to single-dose baloxavir vs placebo
• Primary endpoint: Proportion of participants testing positive for influenza (RT-PCR positive, with fever and ≥1
symptom[s]) during 10-day assessment period
• Serious AEs not observed
Measure Baloxavir (n = 374) Placebo (n = 375) P Value
Subjects developing flu 1.9% 13.6%Considerations Regarding Baloxavir
• Current FDA-approved indication
⎻ Treatment of acute uncomplicated influenza in patients ≥12 years who have been symptomatic for
≤48 hours and who are:
• Otherwise healthy, or
• At high risk for influenza-related complications
• Convenience of single oral dose
• Offers another option if/when viruses become resistant to NA inhibitors
• Quicker reduction of influenza B symptoms than oseltamivir
• Faster clearance of virus than oseltamivir
• CDC does not recommend use of baloxavir in pregnant, breastfeeding mothers, outpatients with
complicated or progressive illness, severely immunosuppressed people, or hospitalized patients because
of lack of data in these groups
Centers for Disease Control and Prevention. www.cdc.gov/flu/treatment/baloxavir-marboxil.htm. Accessed May 18, 2020; ClinicalTrials.gov.
clinicaltrials.gov/ct2/show/NCT02949011. Accessed Apr 5, 2020; Hayden FG, et al. N Engl J Med. 2018;379:913-923; Ison MG, et al. IDSA Week,
Oct 6, 2018. Abstract LB16; Xofluza [prescribing information]. Genentech; 2019. 38Tell Your Patients to Be Proactive…Get Flu Vaccination, Not the Flu
Cases
Height of flu
season
Optimal time for
vaccination
Oct Nov Dec Jan Feb
Month
39PCE Action Plan
✓ Beware of potential for influenza complications, especially in higher risk patients
✓ Strongly recommend influenza vaccination for all patients older than 6 months and GET
YOURSELF VACCINATED
✓ Confirm influenza using rapid molecular assay if available; RIDT 2nd choice
✓ Consider clinical diagnosis without diagnostic lab testing for patients with signs and symptoms
consistent with flu, especially during periods of influenza activity in the community
✓ Initiate antiviral treatment as early as possible and preferably within 2 days to ensure best treatment
outcomes
✓ Treat influenza A and B with an NA inhibitor or baloxavir
PCE Promotes Practice Change
402020 Symposia Series 1
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