TREATMENT OF PIG FLU (SWINE FLU)

 Treatment is largely supportive and consists of bedrest, increased fluid consumption, cough suppressants, and antipyretics and analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) for fever and myalgias. Severe cases may require intravenous hydration and other supportive measures. Antiviral agents may also be considered for treatment or prophylaxis

Laboratory testing has found the swine influenza A (H1N1) virus susceptible to the prescription antiviral drugs oseltamivir and zanamivir, and the CDC has issued interim guidance for the use of these drugs to treat and prevent infection with swine influenza viruses. As part of its preparation for the emergency, the US Department of Homeland Security is releasing 25% of stockpiled antiviral agents (ie, oseltamivir [Tamiflu], zanamivir [Relenza]).

The usual vaccine for influenza administered at the beginning of the flu season is not effective for this viral strain. Also, other antiviral agents (eg, amantadine, rimantadine) are not recommended because of recent resistance to other influenza strains documented over the past several years.

Basic supportive care (ie, hydration, analgesics, cough suppressants) should be prescribed. Empiric antiviral treatment should be considered for confirmed, probable, or suspected cases of swine influenza. Treatment of hospitalized patients and patients at higher risk for influenza complications should be prioritized.

Initiation of antiviral agents within 48 hours of symptom onset is imperative for providing treatment efficacy against influenza virus. In studies of seasonal influenza, evidence for benefits of treatment is strongest when treatment is started within 48 hours of illness onset. However, some studies of treatment of seasonal influenza have indicated benefit, including reductions in mortality or duration of hospitalization, even in patients in whom treatment was started more than 48 hours after illness onset. The recommended duration of treatment is 5 days.

  • Prophylaxis with antiviral agents should also be considered in the following individuals (pre-exposure or postexposure):
    • Close household contacts of a confirmed or suspected case who are at high risk for complications (eg, chronic medical conditions, persons >65 y or <5 y, pregnant women)
    • School children at high risk for complications who have been in close contact with a confirmed or suspected case
    • Travelers to Mexico who are at high risk for complications (eg, chronic medical conditions, persons >65 y or <5 y, pregnant women)
    • Health care providers or public health workers who were not using appropriate personal protective equipment during close contact with a confirmed or suspected case
  • Pre-exposure prophylaxis can be considered in the following persons:
    • Any health care provider who is at high risk for complications (eg, chronic medical conditions, adults >65 y, pregnant women)
    • Individuals not considered to be at high risk but who are nonetheless traveling to Mexico, first responders, or border workers who are working in areas with confirmed cases

Antiviral Agents

Drugs indicated for treatment of swine influenza A (H1N1) virus include neuraminidase inhibitors (ie, oseltamivir and zanamivir).

Oseltamivir (Tamiflu)

Oseltamivir inhibits neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell’s receptor for viral hemagglutinin. By inhibiting viral neuraminidase, this agent decreases the release of viruses from infected cells and, thus, viral spread. Oseltamivir is effective in the treatment of influenza A or B and must be administered within 48 hours of symptom onset. The sooner the drug is administered after symptom onset, the better the likelihood of a good outcome. Oseltamivir reduces the length of illness by an average of 1.5 days. (In a subgroup of high-risk patients, illness was reduced by 2.5 d.) In addition, the severity of symptoms is also reduced.

Oseltamivir is available as 30-mg, 45-mg, and 75-mg oral capsules and as a powder for suspension that contains 12 mg/mL after reconstitution.

  • Adult dose
    • Treatment for acute illness: 75 mg PO bid for 5 d
    • Prophylaxis: 75 mg PO qd
  • Pediatric dose
    • Treatment for acute illness and age <1 year
      • ❤ months: 12 mg PO bid
      • 3-5 months: 20 mg PO bid
      • 6-11 months: 25 mg PO bid
    • Treatment for acute illness and age >1 year
      • <15 kg: 30 mg PO bid
      • 15-23 kg: 45 mg PO bid
      • 23-40 kg: 60 mg PO bid
      • >40 kg: Administer as in adults
    • Prophylaxis and age <1 year
      • ❤ months: Data limited; not recommended unless situation judged critical
      • 3-5 months: 20 mg PO qd
      • 6-11 months: 25 mg PO qd
    • Prophylaxis and age >1 year
      • <15 kg: 30 mg PO qd
      • 15-23 kg: 45 mg PO qd
      • 23-40 kg: 60 mg PO qd
      • >40 kg: Administer as in adults

Zanamivir (Relenza)

Zanamivir inhibits neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell’s receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Zanamivir is effective against both influenza A and B. The preparation of zanamivir is in powder form for inhalation via the Diskhaler oral inhalation device. Circular foil discs that contain 5-mg blisters of drug are inserted into the supplied inhalation device. Individuals with asthma or other respiratory conditions that may decrease ability to inhale drug should be given oseltamivir.

  • Adult dose
    • Treatment for acute illness: 10 mg inhaled orally bid for 5 d
    • Prophylaxis of household contact: 10 mg inhaled orally qd for 10 d (initiate within 36 h)
    • Prophylaxis for community outbreak: 10 mg inhaled orally qd for 28 d (initiate within 5 d of outbreak)
  • Pediatric dose
    • Treatment for acute illness
      • <7 years: Not established
      • >7 years: Administer as in adults
    • Prophylaxis in household contact
      • <5 years: Not established
      • >5 years: Administer as in adults
    • Prophylaxis in community outbreak
      • Adolescents 12-16 years: Administer as in adults

Additional pediatric considerations

Aspirin or aspirin-containing products (eg, bismuth subsalicylate [Pepto Bismol]) should not be included in the treatment of confirmed or suspected viral infection in persons aged 18 years or younger because of the risk of Reye syndrome. For relief of fever, other antipyretic medications (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) are recommended.

Pregnant women

Oseltamivir and zanamivir are “Pregnancy Category C” medications, indicating that no clinical studies have been conducted to assess the safety of these medications in pregnant women. Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, oseltamivir or zanamivir should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus; the manufacturers’ package inserts should be consulted. However, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to women who have received oseltamivir or zanamivir. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Because zanamivir is an inhaled medication and has less systemic absorption, some experts prefer zanamivir over oseltamivir for use in pregnant women, when feasible.

 

Reference :

  1. CDC. Swine Influenza (Flu). Centers for Disease Control and Prevention. Available at http://www.cdc.gov/swineflu/index.htm. Accessed April 28, 2009.
  2. CDC. Guidance for Clinicians & Public Health Professionals. http://www.cdc.gov/swineflu/guidance/. Available at http://www.cdc.gov/swineflu/guidance/. Accessed April 27, 2009.
  3. CDC. Interim Guidance on Antiviral Recommendations for Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection and Close Contacts. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/swineflu/recommendations.htm. Accessed April 28, 2009.
  4. WHO. Swine Influenza Frequently Asked Questions. World Health Organization. Available at http://www.who.int/csr/swine_flu/swine_flu_faq_26april.pdf. Accessed April 27, 2009.

 

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Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

email : judarwanto@gmail.com

 

 

 

 

 

 

 

Copyright © 2009, Clinic For Children Information Education Network. All rights reserved.

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