mdebord Posted January 23, 2014 Author Share Posted January 23, 2014 Very good! Exact tx plan will vary by provider preference, but here's what I did: Steroid shot in office, Rx tamiflu and azithromycin 500 x 5 days (could not with confidence exclude PNA so I treated with the caveat that if he worsened to go to ER). Rec Mucinex (my favorite if they have sputum) and AVOID DECONGESTANTS because of the BP. Start taking lisinopril again daily and f/u with me in 2 weeks. Rest, fluids, alternate tylenol and motrin every 3 hours for fever/aches. Also Rx Tamiflu prophylactic for wife and 2 year old daughter (don't forget this for the vulnerable!) There were a few reasons I wanted to discuss this. First, flu is common but many in the public don't realize how sick it can make you. Had this guy been elderly or even just LOOKED bad (he really didn't) I would have sent him to the ER. I had a 20 year old that ended up there with PNA last week; looked fine when I saw him and even had Tamiflu - so keep your guard up. Also, in thinking back on it, I didn't see much flu in PA school (just depends what season your IM rotations fall during), so I thought it would make for a good discussion. Thanks for the assist E! (I think the alternative he was referring to is the zanamavir). Thanks for playing guys! Link to comment Share on other sites More sharing options...
AREID Posted January 23, 2014 Share Posted January 23, 2014 For the students: What organism is mostly likely to cause pneumonia post influenza. Think carefully.. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
patachok Posted January 23, 2014 Share Posted January 23, 2014 For the students: What organism is mostly likely to cause pneumonia post influenza. Think carefully.. Sent from my iPhone using Tapatalk Strep pneumo? Link to comment Share on other sites More sharing options...
Will352ns Posted January 23, 2014 Share Posted January 23, 2014 Strep pneumo? Concur Link to comment Share on other sites More sharing options...
cinntsp Posted January 23, 2014 Share Posted January 23, 2014 Treatment included oseltamivir or zanamivir. So many people forget it's not just supportive care. Treatment exists lol Sent from my iPhone using Tapatalk It seems the data for tamiflu is very weak at best. There was a good discussion about it in the Dec or Jan EMRAP. Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 23, 2014 Share Posted January 23, 2014 Here's what I told my patients: "Medication (Tamiflu specifically) is available and studies have demonstrated that it may lessen the overall severity of your symptoms (don't know how one would measure this to know the difference in the same patient) and shorten the duration of the illness by approximately one day, thus going from an average of six days to five days. Your co-pay will be $50 at the pharmacy. Here are the serious potential side-effects of the medication (as I show them on iPhone from Epocrates). Do you wish to take the medication?" Once they see the side-effects most deferred on planning on filling the prescription (suicide warning based on Japanese rash of adolescent/teen suicides years back). IF the patient was a high risk (elderly with co-morbid conditions such as CVD, DM, COPD) then I would encourage them to fill it, understanding that the benefit was questionable. While systemic steroids may make them feel better temporarily I would question the risk/benefit as a result of the primary concern of pneumococcal pneumonia and the increased risk of same from immune system suppression (highest rate of mortality of pneumonias). Link to comment Share on other sites More sharing options...
Will352ns Posted January 23, 2014 Share Posted January 23, 2014 GMOTM pretty much summed up my thinking on antivirals for flu. It's good to hear different thoughts from folks who have been practicing a while. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 23, 2014 Moderator Share Posted January 23, 2014 Relenza is an inhaled antiviral. I had a pt on bipap recently who couldn't swallow pills and the hospitalist used this. Link to comment Share on other sites More sharing options...
AREID Posted January 23, 2014 Share Posted January 23, 2014 Strep pneumo? Yea strep it is! A lot of students say staph. There's an association with staph post influenza, but overall strep is most common Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 23, 2014 Moderator Share Posted January 23, 2014 I only rx tamiflu if less than 48 hrs since onset of sx and one of the following: age less than 5 age>60 pregnant immunocompromised(bad dm, hiv, ca, etc) pt being admitted due to severity of dz pt lives with others in above categories. I wrote it last weekend for a 45 yr old guy who was truly miserable who had multiple small kids and an elderly parent at home, more for the family than for the pt. I don't write it for the run of the mill otherwise healthy 30 yr old who just feels like crap. they can just suck it up. I don't think I would take it myself unless admission quality sick. Link to comment Share on other sites More sharing options...
Epangerl Posted January 23, 2014 Share Posted January 23, 2014 Would you have tested for flu if the pt had been vaccinated? My family was vaccinated last year and still ended up with tamiflu. Daughter 1's best friend/cousin/sharer of all germs tested positive, so when Daughter 1's temp started creeping up the same day, I had her tested immediately. Rapid flu test positive despite vaccination. Physician prescribed tamiflu for Daughter 1 (then age 4), prophylactic tamiflu for Daughter 2 (then age 2), and me (then pregnant with Daughter 3 and still nursing Daughter 2, frequent contact with elderly parents). Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 23, 2014 Moderator Share Posted January 23, 2014 yup, if it looks like flu and I would consider treating I test. the shot is not 100% effective. if I know it's flu and I wouldn't treat with tamiflu as they are not high risk and I have ruled out other stuff I just tell them it is most likely influenza and prescribe symptomatic tx. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 23, 2014 Share Posted January 23, 2014 Immunity conferred in only ~65% of children and adults (best case), less in older adults thus the separate vaccination for them. Link to comment Share on other sites More sharing options...
cbrsmurf Posted January 24, 2014 Share Posted January 24, 2014 Note that the rapid influenza test sensitivity is poor, at only 50-60%, although it has good specificity. With influenza, always be ready to make a clinical diagnosis, which probably should've been in one's top 2 or 3 differential with just the complaints, vitals, and time of year. In addition to prophylaxis, I would recommend their family members to get vaccinated as well. Good case. Link to comment Share on other sites More sharing options...
cinntsp Posted January 25, 2014 Share Posted January 25, 2014 Some of the points from the EMRAP discussion: - Oseltamivir's supporting data is partly based on a Roche-produced meta-analysis of unpublished studies(that they would not release) - Cochrane reviewers asked for the data and Roche would not provide it initially. They finally released some of the data after public pressure. - The Cochrane reviewers and another independent group reviewed it and found: 1. Symptoms - oseltamivir reduced flu-like symptoms by a little less than a day if administered within 48hrs of symptom onset BUT increased nausea and vomiting. It's basically a trade. 2. Complications - No effect. Does not reduce complications vs. placebo. Doesn't reduce hospitalizations, M&M, etc They state that two of the trials reviewed contained elderly and chronically ill patients only, which is who we often believe need this drug. This group actually doesn't even get the symptom reduction benefit! 3. Spread of disease - Contacts get sick just as often as those near influenza patients given placebo, but have reductions in "culture proven" influenza. Conclusion: Oseltamivir is not helpful or useful. Link to comment Share on other sites More sharing options...
mdebord Posted January 26, 2014 Author Share Posted January 26, 2014 It depends who you ask... If I tell a patient that he has to take 2 unpaid days off work instead of 3 - he certainly deems it worthwhile to take the Tamiflu. Sometimes the risk/benefit analysis is not so clear. Link to comment Share on other sites More sharing options...
wisemakl Posted February 19, 2014 Share Posted February 19, 2014 Here's my question.. and maybe I completely missed something in the last 16 months of my life. You talk about giving a steroid shot, one of my classmates who is rotation at an Urgent Care said they do this a lot. I totally do not understand the reasoning? My personal PCP has never done this, and I've never heard of it. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 19, 2014 Moderator Share Posted February 19, 2014 Here's my question.. and maybe I completely missed something in the last 16 months of my life. You talk about giving a steroid shot, one of my classmates who is rotation at an Urgent Care said they do this a lot. I totally do not understand the reasoning? My personal PCP has never done this, and I've never heard of it. some folks give a steroid injection to help prevent or treat seasonal allergies in pts who suffer from severe sx during allergy season, typically in the spring. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2014 Share Posted February 19, 2014 Or you could be giving it to, uh, generate, cough, $. Look at the half-lives of one 10 mg. dexamthasone injection versus nine days of tapered generic prednisone (60-40-20 mg). Oh, don't forget to include a cost comparison. Everyone likes a door prize (and pain). Damn you Jerry Hoffman, MD for making me think this way. I should have taken the other colored pill and lived in bliss. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 19, 2014 Moderator Share Posted February 19, 2014 lots of places do kenalog 40 mg/day once/yr at beginning of spring for "allergies". not a fan of this practice. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2014 Share Posted February 19, 2014 Don't understand the long-term pharmacological benefit of this practice. Just put them on a nasal steroid spray. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 19, 2014 Moderator Share Posted February 19, 2014 Don't understand the long-term pharmacological benefit of this practice. Just put them on a nasal steroid spray. yup, flonase is the bomb. started using this stuff 2 yrs ago and no longer need claritin, zyrtec, or allegra. it's just 6 weeks/yr that something blooms that I am sensitive so qd use during that time and I am golden without any antihistamine side effects. definitely beats drowning in snot every spring. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2014 Share Posted February 19, 2014 Even better that it's one of few in generic. I'm a longtime user/believer. Link to comment Share on other sites More sharing options...
PACdan Posted February 19, 2014 Share Posted February 19, 2014 yup, flonase is the bomb. started using this stuff 2 yrs ago and no longer need claritin, zyrtec, or allegra. it's just 6 weeks/yr that something blooms that I am sensitive so qd use during that time and I am golden without any antihistamine side effects. definitely beats drowning in snot every spring. Most definitely. I have nasty tree/grass pollen allergies during the spring. Starting Flonase at the first sign of trouble reduces symptoms drastically. Also, Costco has 365 pill count bottles of Cetirizine for $11.99, compared to the 30 Zyrtec pills you get at the grocery store for 20 bucks. Talk about being raked over the coals... Sent from the Satellite of Love using Tapatalk Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2014 Share Posted February 19, 2014 Shhh, you're cutting into the profit margin ;). Don't forget to refill your K-cups with their Pacific Bold coffee while there. Link to comment Share on other sites More sharing options...
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