Early Interventions Are Vital for Treating Influenza, Especially in Patients With Chronic Conditions

After a flu season that the CDC called one of the deadliest in recent memory, any information that can help clinicians avert patient morbidity and mortality is welcome. During a session at the Asembia Specialty Pharmacy Summit 2019, Marilyn N. Bulloch, PharmD, BCPS, FCCM, walked participants through the various treatment options for influenza. For many attendees, the clinical presentation of flu viruses was old news, but the review helped set the stage for the rest of Bulloch’s riveting presentation.

“Approximately 1 in 10 residents of the United States develops the flu every year, and those are the numbers in spite of our current level of vaccination, which is, of course, inadequate at just 39%,” Bulloch said.

Bulloch reviewed influenza’s various complications, which by now are also well known. She highlighted the patient populations who stand to suffer more serious consequences if they contract influenza, stressing that any patient with a chronic disorder has an elevated risk. These patients need to be vaccinated, but clinicians and patients both need to understand that last year’s vaccine had just a 40% efficacy rate. Therefore, even patients who received the vaccine could develop the flu.

In the past, a bout of the flu was equivalent to dropping out of society for at least a few days to recover. Fortunately, treatment options have improved over the past few years.

Bulloch reviewed the 2018 Infectious Diseases Society of America (IDSA) guidelines for treatment of active or suspected flu. The guidelines indicate that certain patients who have influenza, either documented or suspected, should be treated regardless of whether they were vaccinated. Those include all hospitalized patients, those with severe or progressive illnesses, high-risk patients, very young patients, the elderly population, pregnant women, and women who have recently delivered.

The IDSA guidelines urge clinicians to consider treating patients who have had the flu for 2 or fewer days or who are household contacts of high-risk patients. The guidelines also recommend treating health care providers who care for high-risk patients.

Pre- and postexposure prophylaxis have become buzzwords associated with influenza, and clinicians need to be more aggressive about using both. This means breaking down barriers so patients can access these medications quickly.

Bulloch reviewed the currently available agents for treatment and sometimes prophylaxis, which include oseltamivir, zanamivir, peramivir, and baloxavir marboxil. The newest of the agents, baloxavir marboxil is a unique capdependent endonuclease inhibitor, because it is a singledose oral medication. The agent was approved based on the CAPSTONE 1 and 2 trials, for which results showed that the median time to alleviation of symptoms was reduced compared with placebo.

Bulloch noted that although many clinicians are familiar with the basics of treatment, such as starting antiviral therapy as soon as possible with the FDA-approved dosing, they need to be aware that longer treatment durations can be lifesaving in patients with a severe illness. Importantly, pharmacists also need to be aware of the benefit of treatment beyond the 48-hour window in special populations.

Sheldon J. Rich, PhD, RPh, discussed the economic burdens associated with influenza. During the 2017-2018 season, influenza affected 49 million Americans, which is more than the combined populations of Texas and Florida. Influenza led to 960,000 hospitalizations and 79,000 deaths in the United States last year, resulting in more than $10 billion in health care spending.

Rich stressed the importance of educating patients about the benefits of flu vaccination. Using patient-friendly language, he described ways to help individuals understand that vaccination can prevent them from getting sick with the flu and reduces hospitalization.

“An area where significant improvement is needed is in helping parents understand that in children, a flu vaccination can be lifesaving,” Rich said. “Most of the children who died of influenza in the last flu season had not been vaccinated. It can often be difficult to convey the real value of influenza vaccination or any vaccination in this era of misinformation, but it’s essential that we try. Everyone should get a flu shot every year.”

Finally, Rich indicated that clinicians have to be familiar with the current CDC recommendation that any patient who has suspected or confirmed influenza be treated as soon as possible. The availability of vaccinations in pharmacies will also help get more people vaccinated. Many states have created pharmacist collaborative practice protocols allowing pharmacists to test for influenza and start treatment when following those protocols.