Tuesday, January 21, 2014

Tamiflu and Influenza in Children

     So far this 2013-2014 influenza season, the H1N1 influenza strain is what is circulating in the United States. That was included in both the flu shot and the FluMist (flu spray) vaccine this year. It has also been circulating the last few years. This means that between having had the vaccine or the illness in the recent past, many folks will be protected against the major strain this year. Despite that protection, many kids and adults will get influenza, some worse than others.
     What our grandparents would have said about influenza years ago is still true: you need rest, plenty of fluids, eat bland foods as you can, and treat the fever. Those things are still what I tell families battling influenza. A late fever (especially if there was an initial fever, none for a day or two, and now there is a fever again), a worsening cough a few days into the illness, or poor intake with less than three times urinating in 24 hours are worrisome signs or symptoms for the two most common complications of influenza in children: pneumonia and dehydration. And remember that the fever with influenza is often higher than many other illnesses: 106-107 degrees. Even with those high temperatures, what is important is whether your child perks up when the fever is coming down.
     I am certainly all for children 6 months to 18 years of age (that do not have some reason they cannot get the vaccine) receiving the flu vaccine each year. Since the recommendation changed a few years back (now saying everyone would benefit from the vaccine each year), we have routinely had my three sons vaccinated. One of my twins had influenza in first grade (he is now in 8th grade) before he ever received the flu vaccine. He felt like he got run over by a truck (very achy), had a fever up to 106.3 for 4-5 days, a sore throat, and a cough. Luckily, he did not get dehydrated or a case of pneumonia. He recovered well with rest, plenty of fluids, and fever reducers.
     So what about the antiviral medications, including Tamiflu? (a). These medications can shorten the course of influenza from 5-6 days to 4-5 days (shortens the illness by 1-2 days) if started in the first 48 hours of the illness. They also can prevent someone with a direct exposure to influenza from developing it, if it is given early after the exposure. (b). They are fairly expensive prescriptions -- we recently had a family that decided against filling the prescription for Tamiflu as the co-pay was over $100. (c). The supply of the Tamiflu liquid was in short supply early this flu season. The supply is better at this point (1-21-14). (d). Almost 40% (2 out of 5) of children taking Tamiflu will have stomachaches and nausea from the medication. Every year, we have people ask if they can stop the Tamiflu early because of the stomach symptoms. (e). There are no new promising antiviral medications under development that will be available soon. That means that when the influenza strains evolve and become resistant to the Tamiflu, we will have limited or no options for treating or preventing influenza. Since I began medical school in 1987, at least two prominent antiviral medications are no longer used because the influenza strains are resistant to the medications. (f). Tamiflu can lessen the chances of an ear infection, pneumonia, hospitalization, or death from influenza. (g). Very few people experience these issues, but some adolescents and adults have had self-injury or delirium while being on Tamiflu. These issues, interestingly, have been most prominent in persons in Japan with influenza who have been treated with Tamiflu.
     So when do I recommend Tamiflu in children? 1. A confirmed case (with the rapid influenza test which can be done in the office or at urgent care or emergency department) of influenza in a high risk (asthma, diabetes, heart disease, and some others) patient AND in the first 48 hours of the illness. 2. A confirmed case of influenza with severe symptoms that suggest someone is so ill they may require hospitalization for dehydration or pneumonia, especially if in the first 48 hours of the illness. 3. The rare case when a very high risk patient could not receive the flu vaccine (because of a severe egg allergy, for instance) but has a known direct exposure to influenza (such as a family member having the virus).
     I actually only prescribe Tamiflu a few times each year. I want to use it when it is appropriate. However, I also want to have an effective, safe antiviral medication for real emergencies and urgencies when the medication is truly needed. Now and in the future.

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