How should we diagnose and treat the
flu?
Finally what I have been
telling my paitients for years is shown by more modern studies on treating
the flu:
http://www.smh.com.au/federal-politics/political-news/antiviral-drug-stockpile-a-waste-of-money-says-study-20140410-zqt3i.html
The average
accuracy of the Rapid Flu Tests is 50%. See:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6143a3.htm
CDC Quote:
RIDTs (Rapid Tests) may be used to help with diagnostic and
treatment decisions for patients in clinical settings, such as whether to
prescribe antiviral medications. However, due to the limited sensitivities
and predictive values of RIDTs, negative results of RIDTs do not exclude
influenza virus infection in patients with signs and symptoms suggestive of
influenza. Therefore, antiviral treatment should not be withheld from
patients with suspected influenza, even if they test negative. Testing is
not needed for all patients with signs and symptoms of influenza to make
antiviral treatment decisions. Once influenza activity has been documented
in the community or geographic area, a clinical diagnosis of influenza can
be made for outpatients with signs and symptoms consistent with suspected
influenza, especially during periods of peak influenza activity in the
community.
So basically the CDC said to
approach the patient as if they have the flu regardless of the test.
Therefore many cases where I am sure they clinically have the flu I do not
test them. The test will not change what I do for the patient.
Do
you need to be treated with Tamiflu?
The
medication has to be started in the first 24-48 hours since it only shortens
the illness by one day. Studies showed that the medication only
shortened the illness by 12 - 24 hours. Resistance can be a worry. In a study from April
2012 from the National Institute, 27 cancer patients who were hospitalized
for the flu. They found 2 of the viruses were resistant to Tamiflu before
treatment and 4 developed resistance at the end of therapy with Tamiflu.
Not
everyone should be treated with Tamiflu. Here is a quote from the CDC:
"It’s
very important that antiviral drugs are used early to treat hospitalized
patients, people with severe flu illness, and people who are at higher risk
for flu complications based on their age or underlying medical conditions.
Other people also may be treated with antiviral drugs by their doctor this
season. Most otherwise-healthy people who get the flu, however, do not
need to be treated with antiviral drugs."
Following is a list of all the health and age factors that are known to
increase a person’s risk of getting serious complications from the flu:
·
Asthma
·
Neurological and neurodevelopmental conditions
·
Blood disorders (such as sickle cell disease)
·
Chronic lung disease (such as chronic obstructive pulmonary
disease [COPD] and cystic fibrosis)
·
Endocrine disorders (such as diabetes mellitus)
·
Heart disease (such as congenital heart disease, congestive
heart failure and coronary artery disease)
·
Kidney disorders
·
Liver disorders
·
Metabolic disorders (such as inherited metabolic disorders
and mitochondrial disorders)
·
Morbid obesity (body mass index [BMI] of 40 or higher)
·
People younger than 19 years of age on long-term aspirin
therapy
·
Weakened immune system due to disease or medication (such as
people with
HIV or AIDS(http://www.cdc.gov/flu/protect/hiv-flu.htm),
or
cancer, or those on chronic steroids)
Other people at high risk
from the flu:
·
Adults 65 years and older
·
Children younger than 5 years old, but especially children
younger than 2 years old
·
Pregnant women and women up to 2 weeks after the end of
pregnancy
·
American Indians and Alaska Natives
Study showing Tamiflu did not decrease the mortality of flu in children.
When I tell the patient I am not treating their child since
they are not high risk, they look worried at me. So I ask them do you want
to shorten your child’s illness by one day and then grandma dies of the flu
in the years to come when the medication does not work? Too many clinics
give out Tamiflu like bubble gum to everyone and they are not supposed to do
that.
Another study came out in
Spring of 2014 showing Tamiflu had very little affect on hours of fever and
did not change hospitalizations or secondary pneumonias.
http://pipeline.corante.com/archives/2014/05/16/the_real_numbers_on_tamiflu.php
Should you get Tamiflu to prevent the flu?
Again we worry about resistance. If someone in the family
has the flu, we could give Tamiflu to everyone in that house in order to try
and prevent others from getting
it. The first person in the family who developed the flu did not catch it
from a family member. They caught it from someone outside the home. So if we give
the Tamiflu to others in the family for a few days, they will still be exposed to
the flu for the
rest of the winter at school, friends, church, and stores. Are you going to
give them Tamiflu the whole winter? I recommend Tamiflu to prevent the flu
for a pregnant mommy who is at bed rest and not going out, a small infant
who is not going out in public, or
elderly relatives with cancer and other diseases and they are not going out
in public. I do not think the average child who is going to school needs
medication to prevent the flu.
Whether you get Tamiflu or not, watch out for fever after day
5 of the illness. Fever is during the first 3-4 days and pretty much gone
by day 5. Fever after that is bronchitis, sinus or pneumonia bacterial
infections that can be deadly. Please call if that occurs.
Dr. Knapp
p.s. Opinions expressed here
are my personal ones and does not take the place of recommendations from
your doctor.
Discussions on
Flu and treatment 2015
Weijen Chang, MD: Recently, Thomas Frieden, MD,
director, US Centers for Disease Control and Prevention (CDC), in response
to criticism about the reduced efficacy of this season's influenza
vaccination, has been prominently
advocating use of antiviral medications (oseltamivir [Tamiflu®]
and zanamivir [Relenza®]) for the treatment of influenza infections in
adults and children. In short, his philosophy can be paraphrased as, "Treat
early, treat late, treat often." This treatment recommendation, however,
seems to be swimming upstream against a growing river of evidence that
questions the efficacy of influenza antiviral medications, especially in
light of an unfavorable adverse effect profile.[1]
The current CDC recommendations advocate treatment with
antivirals for all children hospitalized with influenza infection, despite
recent studies showing lack of efficacy in otherwise healthy children.
Based on my concerns as a pediatric hospitalist with
the recommendations and the lack of evidence, I decided to touch base with
two other pediatric hospitalists, Matthew Garber, MD, and Ricardo Quinonez,
MD, and I asked them about the use of antiviral medications in the treatment
of pediatric influenza infections.
Drs Garber and Quinonez, what do you think is driving
Dr Frieden's strong, perhaps non-evidence-based, recommendations for
antiviral treatments in influenza infection?
Matthew Garber, MD: This is a
difficult question, especially because I don't know Dr Frieden and am
unaware of his life experiences, general approach to medicine, how he
understands and deals with risk, or various outside pressures he may be
under.
I can speak to some underlying psychological biases that
most of us share and other issues in evidence-based medicine that may be at
play. First you have the original CDC,[2]
World Health Organization (WHO),[3]
and American Academy of Pediatrics (AAP)[4]
recommendations that advocate use of antivirals pretty broadly. If you were
to take those recommendations at face value, without critically looking at
the evidence and the Cochrane review,[1]
you could logically conclude that because this season is predicted to be
severe, and the vaccine is not very effective, we need to rely even more
heavily on these medicines.
As you know, the best evidence we have—systematic reviews
and meta-analyses of randomized controlled trials—including data from
methodologically sound, industry-sponsored trials that were withheld from
the Cochrane respiratory group for 5 years[5]
and tells us that these medications reduce symptoms by about 1 day if given
very early in the course of infection. However, there is no evidence that
they prevent complications, hospitalizations, or deaths from influenza.
Furthermore, even though prophylaxis with antivirals can prevent symptomatic
disease in a contact, prophylaxis has not been shown to decrease
transmission of the virus (the main impetus for stockpiling these medicines
in order to halt an epidemic).
So did the Cochrane review prove that antivirals do not
prevent complications, hospitalizations, and death? That is the
evidence-based medicine issue I'm talking about. It is very hard to prove a
negative. Except in extreme extenuating circumstances, we generally require
proof that a drug works before using it—we do not require proof that a drug
does not work to avoid using it.
Then there are the psychological issues to take into
consideration. People, and perhaps especially doctors, like to help other
people. Doctors have been trained that when a patient is sick, we find out
what is wrong with him/her and then find the best treatment and administer
it. It is very hard for us to say, "Thank you for coming to see me and
paying for this visit, but there is really no effective therapy for this
condition other than symptomatic relief." We'd much prefer to say, "Aha! You
have the flu, and here is the drug that will make you better." Then of
course, especially in pediatrics, the patients do get better, which
reinforces our behavior. The placebo effect is large, especially in
children,[6]
which also encourages this type of behavior.
Finally, unfairly, we treat errors of omission differently
from errors of commission. If someone complains of nausea and vomiting after
receiving oseltamivir, we say, "Well yes, that is a known side effect of
that drug." Basically it is the cost of doing business. If we don't give an
antiviral and the person becomes very sick, we are often faulted for failing
to provide the right treatment and may even be sued. Even our language
contributes to overtesting and overtreatment saying things like, "To be
conservative you better get that chest x-ray. And just to be safe, let's
start that antibiotic or antiviral." When in fact one could argue that the
conservative path in the face of uncertainty would be to intervene less, not
more. This is partly explained by our failure to consider the harms of our
interventions (finding an innocent lesion on the chest x-ray that leads to
an invasive procedure; Clostridium difficile infection following
antibiotics).[7]
Dr Chang: Given the recent Choosing Wisely® campaign
started by the American Board of Internal Medicine (ABIM) and joined by
major professional societies (AAP, Society for Hospital Medicine [SHM],
etc), should one of the major societies balance the voice of the CDC with
their own recommendations?
Ricardo A. Quinonez, MD: The
short answer is yes, particularly those societies that use strong
evidence-based decisions for their own guidelines. My view is that they
should adhere to the highest standard both when they write their own
guidelines and endorse others' recommendations. I really think that is not
the case currently. To be fair, though, it is going to be extraordinarily
difficult for a medical society to contradict decisions made by one of the
highest medical authorities in the land, such as the CDC.
Where it really should start is with those medical experts
within our government to have a measured response to ongoing health crisis
and not swing the pendulum so far that they are ignoring science. I
understand they want to seem proactive given the initial criticism the CDC
received for handling of the Ebola crisis. However, the failure of this
year's vaccine to completely cover the flu represented yet another crisis.
The unmeasured response was to support, in an extraordinary way, medications
for which evidence is not just lacking but also has a clear track record of
manipulation of data by its industry supporters.
I would direct readers to well-documented instances of
this behavior with oseltamivir by the British Medical Journal.[8]
I think the CDC and others should take an unbiased approach to
recommendations even in times of crisis. The US Preventive Services Task
Force (USPSTF) framework for making recommendations is a great example to
follow. If evidence is not there to support a particular therapy or test, no
recommendation is made. It allows clinicians to use their judgment to make
clinical decisions in those instances in which the evidence is equivocal or
highly biased, as is the case for antivirals in influenza. The CDC's strong
stance on this has really put conscientious physicians in a difficult spot.
Dr Chang: The reality of practicing hospital-based
pediatrics is that it is a team effort and, as physicians, we are not immune
to the "peer pressure" of others when it comes to treatment selection. How
much antiviral use by hospitalists is due to a fear of being second-guessed
(especially if the patient subsequently "crashes")?
Dr Quinonez: This is a
fantastic point, and I could not agree more with your assessment. I think
pediatricians and other physicians have been placed in an extraordinarily
difficult situation. Those of us who like to make decisions based on
evidence when treating children feel extremely uncomfortable with the CDC's
recommendations. On the one hand, the latest meta-analysis of neuraminidase
inhibitors not only found insufficient evidence to support an effect on
complications in patients with influenza but also found that the harm has
been severely understated. These medications may actually put children at
risk of developing important neuropsychiatric symptoms and significant
emesis.
CDC defends its decisions by pointing to single studies
showing decreased complications and mortality but ignores the higher-level
evidence (meta-analysis) that should drive recommendations. The US Food and
Drug Administration (FDA), an agency that has indeed reviewed the full study
data on Tamiflu® during its approval process, has actually contradicted the
CDC's recommendations and has forced the makers of oseltamivir to include in
its labeling language that effectively states that Tamiflu has not been
shown to prevent complications like serious bacterial infections.
On the other hand, not following the CDC recommendation
puts practitioners at a very significant risk for legal exposure. It is not
hard to imagine that a patient who presents with influenza-like symptoms and
is not started on antivirals and later develops a complication (which,
again, the evidence does not support antivirals being able to prevent) could
result in the physician being dragged into a painful legal proceeding based
solely on the strong recommendation from the CDC that seems to be using
antivirals as the solution to the inefficacy of this year's flu vaccine.
Dr Chang: Does the severity of the current influenza
season, coupled with the lower-than-expected efficacy of the seasonal
vaccine, warrant increased antiviral usage by hospitalists?
Dr Garber: I don't think it
does. But to be fair, this argument is not completely without merit. As I
discussed before, it's hard to disprove a negative, but with the large
number of patients studied, I think we can rule out a large effect size of
the antivirals. While antivirals may have a small effect size to prevent
complications in a limited group of patients, there is currently no
high-quality evidence supporting this. The clinician must weigh several
factors when considering interventions for her patients.
Let's pretend, just for the sake of argument, that a
particular antiviral was shown to have absolutely no side effects and was
free (maybe it's derived from a pesky weed that homeowners would be happy
for us to pluck and ingest). Let's also pretend that this year's influenza
season is much worse than the 1918 Spanish flu epidemic (imagine Ebola that
spreads like the flu). In this imaginary scenario, prescribing the antiviral
makes sense. No side effects and it's free. It may help some people avoid
complications, but even if it doesn't, what's the harm? Unfortunately, no
such medicine exists. They all have side effects, and current recommended
antivirals are quite pricey. We know that oseltamivir has a significant rate
of emesis and, though rare, occasionally causes severe neuropsychiatric
symptoms, even suicide. So those need to be added into the equation, and the
more prescriptions we write, the more potential harm we cause.
While harms resonate with doctors and patients more than
costs, we also must consider costs. Because the United States does not have
unlimited resources, money spent in one area of healthcare will not be
available in another. That is the reasoning behind the statement, "Waste is
unethical." We need to be good stewards of our country's healthcare dollars
and should not allocate large resources to unproven therapies as there will
undoubtedly be patients who will be denied effective therapy as a result.
So there is a balancing act. We must weigh the severity of
the disease and the evidence supporting the potential of the therapy to
improve important outcomes (such as mortality) against potential harms and
costs of the therapy. Right now we do not have strong evidence that
antivirals improve important outcomes, but they do have significant side
effects and high costs. So at this time I don't think the severity of the
season coupled with the poor efficacy of the vaccine warrant increased use
of antivirals by hospitalists.
