About the Author
Sandra J. Grillo, MBA, RPh, is a retired independent community pharmacist with more than 40 years of experience. She is currently a student in the University of Connecticut Medical Writing Program.
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Evaluating Options for Respiratory Syncytial Virus Prophylaxis
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Key Takeaways
- RSV is a seasonal virus causing mild to severe respiratory symptoms, with high hospitalization rates in older adults and infants.
- Current RSV management focuses on supportive care, highlighting the need for effective prevention strategies to reduce disease burden.
Curbing RSV and its complications can reduce health care costs associated with its treatment.
Respiratory syncytial virus (RSV) causes infectious symptoms that range from mild to severe. It is a seasonal disease, typically occurring during the cold weather months (October-March/April), with maximum activity during December and January. It is a common childhood illness, with most children reaching their second birthday having already had some form of RSV disease. Individuals who are immunocompromised and older adults are also prone to developing RSV infection (Table 1).1
Image credit: Peter Hansen | stock.adobe.com
Symptoms of mild disease are runny nose and cough, while more involved RSV cases can include difficulty breathing, wheezing, and respiratory distress. The disease in infants and young children can sometimes progress to bronchiolitis and require more intense care and/or hospitalization. Secondary bacterial infection and cardiovascular or neurological complications can occur as a sequela of severe RSV, putting enormous strain on patients, caregivers and hospitals. Those aged 75 years and older experience the highest rates of hospitalization.1
Table 1: Predisposing Conditions for RSV
According to the CDC, individuals with severe cases of RSV could require additional oxygen, intravenous fluids, or intubation. However, in most of these cases hospitalization only lasts a few days before symptoms subside.2
Despite the considerable incidence of RSV across a broad group of patient populations, there are presently no drugs that cure this disease. Patients diagnosed with RSV are given supportive measures with diuretics, corticosteroids, and supportive oxygen, as symptoms dictate. Strategies for prevention of the disease are thereby essential to decrease its occurrence and lessen the severe consequences to patients while also diminishing the burdens to health care systems.1
Annals of Pharmacotherapy published a review on the efficacy of the currently available agents for the prophylaxis of RSV. The researchers compared prevailing modalities for the prevention of RSV by evaluating information found in a PubMed literature search (January 2020 through February 2024) and utilization data submitted to TriNetX for the 2023 and 2024 RSV season.1
The researchers analyzed studies of 2 vaccines, RSVPreF3 (Arexvy; GSK) and RSVpreF (Abrysvo; Pfizer), in adults 60 years of age or older. Additionally, they included pregnant women who received Abrysvo at 24 to 36 weeks of gestation. They also reviewed studies of the monoclonal antibody nirsevimab in both healthy preterm infants born at 29 to 34 weeks of gestation and healthy full-term infants born at or beyond 35 weeks of gestation, comparing its effectiveness to the current therapy with palivizumab.1
RSV is an RNA virus with 2 surface proteins, F and G, and 2 subtypes, A and B.Abrysvo is made of stabilized F protein antigen subunits, A and B. It contains 60 mcg of RSV-A and 60 mcg of RSV-B prefusion F antigens. Abrysvo is indicated for active immunization in adults aged 60 and older and is given in a single injection. It may also be used to induce passive immunization to pregnant women and preborn infants, when administered to expectant mothers in weeks 24 through 36 of gestation.1
Arexvy contains 120 mcg of only 1 prefusion F antigen, RSV-A, in combination with an adjuvant, AS01. Arexvy may be given to all patients aged 60 years and older. Additionally, it is indicated for active immunization in adults aged 50 and older who are at increased risk for lower respiratory tract disease (LRTD) from RSV and requires only 1 dose for efficacy.1
The third agent studied was nirsevimab (Beyfortus; AstraZeneca,Sanofi), which is a recombinant human immunoglobulin (Ig) G1 monoclonal antibody. Nirsevimab induces protection against illness by preventing RSV cellular access via its ability to bind to prefusion proteins. Its long half-life makes it a good choice for prophylactic therapy and requires a single administration during the RSV season. It may be given to any child up to 24 months of age who would be encountering their first RSV season and is available in 2 strengths.1
Palivizumab (Synagis; Sobi) acts similarly to nirsevimab but must be given to patients monthly during the RSV season, due to its short half-life. Infant growth during the RSV season complicates the use of palivizumab because weight-based dosage adjustments are necessary. Palivizumab may only be given to infants aged 6 months or less who were born prematurely, or those aged up to 24 months who have congenital heart disease (CHD) or bronchopulmonary dysplasia (BPD), which could lead to RSV and severe lower respiratory tract disease (LRTD). Because of palivizumab’s narrow indication, the newer agent nirsevimab has the potential to protect many more children from RSV.1
Abrysvo was used in the RENOIR study (2023) and the MATISSE study (2023). In the RENOIR study, prophylaxis with a single dose of Abrysvo exhibited an efficacy from 62% to 85% in decreasing RSV-associated illness and RSV-associated LRTD when given to patients 60 years and older. The MATISSE study involved vaccinating pregnant women at 24 to 36 weeks and evaluated their infants from 90 to 180 days after birth. Abrysvo had an efficacy from 51% to 81% at decreasing the incidence of medically attended (MA) RSV-associated LRTD and severe MA RSV-associated LRTD.1
The AReSVi-006 study used Arexvy in a single dose, administered to adults who were 60 years and older. It was shown to be effective at reducing RSV-related LRTD from 83% to 94%.1
Nirsevimab was employed in 2 studies, MELODY and Griffin 2020. MELODY assessed its efficacy in prevention of MA RSV-associated LRTD and/or hospitalization of the same, in infants born at or greater than 35 weeks gestational age. Griffin 2020 looked at similar disease end points in healthy preterm infants born between 29 and 34 weeks. Both studies exhibited efficacy from 62% to 78%.1
The American Academy of Pediatrics, the American College of Obstetrics and Gynecologists, and the Advisory Committee of Immunization Practice (ACIP) updated the indications for suitable prophylaxis for RSV using nirsevimab in 2023 and 2024. Many of the updates were for infants and children who may or may not have had exposure to RSV prophylaxis through their mothers, while in utero, or if they were at higher risk to develop the disease.1
Patients aged 60 to 74 years who were at increased risk of severe RSV disease were also recommended to receive RSV prophylaxis, per ACIP. (Table 2.)1 Additionally, all persons aged 75 years and older were strongly suggested to receive RSV prophylaxis.1
Table 2: Risk Factors for Patients aged 60-74 years at Greater Risk of Severe RSV Disease
This review provides clinicians with a useful resource for making recommendations to increase acceptance of prevention strategies for RSV in vulnerable populations. Curbing RSV and its complications can reduce health care costs associated with its treatment, as fewer patients would experience the severe consequences of the disease.
REFERENCES
1. Howard N, Pudim E 3rd. Evolving Strategies for Respiratory Syncytial Virus (RSV): A Review Article of Preventive Agents and Vaccines for RSV. Ann Pharmacother. Published January 2, 2025. doi:10.1177/10600280241302085
2. About RSV. CDC. News release. Published August 30, 2024. Accessed February 21, 2025. https://www.cdc.gov/rsv/about/index.html.
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