lets talk flu

[Simplify]

Curious about your practice-- are you treating high risk patients with tamiflu even if they are more than 48 hours from onset off illness?   High risk being defined by CDC guidelines (pregnant, >65, <5 but especially less than 2, significant comorbidities).  I have scoured the CDC guidelines and they seem vague about this.  They state that treatment should be given as soon as possible in high risk patients but do not define a 48 hour window, they also state there may be some benefit up to 5 days.    Obviously tamiflu has side effects, limited benefit, cost issues etc.     So, hypothetical-- what would you do with an 8 month old with + flu lets say 4 days from onset of illness who otherwise looks decent and wouldn't be admitted.   

[sas5814]

Always a tough call. Risk benefit both from the perspective of the patient and from the always 20-20 retrospectrograph used if there is a bad outcome.

If that kid was looking good and didn't have any other red flags I'd manage symptomatically with very explicit (and well documented) follow up instructions. I am not a Tamiflu fan.

[GetMeOuttaThisMess]

Agree with above, however, I ALWAYS warn patients about the numero uno bad guy of flu, that being a secondary opportunistic bacterial pneumonia. That’s the primary area of focus so in this example I take a moment to explain nasal flaring as well as supra/intercostal retractions. It’s the lungs that are going to take someone out. Not the snot, sore throat, or fever.

 

 

[lkth487]

Yeah I personally don't like tamiflu either, for kids.  I've given it on very rare occasions - mostly in kids with other significant comorbidities.  

[LT_Oneal_PAC]

Only given tamilfu once in 3 years. Granted I missed most of last flu season while on deployment. If they look good, do not care about high risk. I don’t even test unless they look like I would give tamiflu. Always give good return precautions and document them

[MCHAD]

Tamiflu sucks, is expensive, and has more potential side effects than it’s worth in my opinion. 

[GetMeOuttaThisMess]

Tamiflu sucks, is expensive, and has more potential side effects than it’s worth in my opinion. 

Out of curiosity, what are your particular concerns regarding side effects?


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[LT_Oneal_PAC]

For me it’s the below. While small, still more likely than making the patient feel any better.

Adverse Reactions

>10%:

Central nervous system: Headache (adolescents and adults: 2% to 17%)

Gastrointestinal: Vomiting (2% to 16%)

1% to 10%:

Central nervous system: Pain (adolescents and adults: 4%)

Gastrointestinal: Nausea (adolescents and adults: 8% to 10%)

<1%, postmarketing, and/or case reports: Abnormal behavior, abnormal hepatic function tests, accidental injury, agitation, anaphylactoid reaction, anaphylaxis, anxiety, cardiac arrhythmia, confusion, delirium, delusions, dermatitis, eczema, erythema multiforme, exacerbation of diabetes mellitus, facial edema, gastrointestinal hemorrhage, hallucination, hemorrhagic colitis, hepatitis, hypersensitivity reaction, hypothermia, impaired consciousness, nightmares, seizure, skin rash, Stevens-Johnson syndrome, swollen tongue, toxic epidermal necrolysis, urticaria

 

[Guest JMPA]

33 minutes ago, LT_Oneal_PAC said:

For me it’s the below. While small, still more likely than making the patient feel any better.

Adverse Reactions

>10%:

Central nervous system: Headache (adolescents and adults: 2% to 17%)

Gastrointestinal: Vomiting (2% to 16%)

1% to 10%:

Central nervous system: Pain (adolescents and adults: 4%)

Gastrointestinal: Nausea (adolescents and adults: 8% to 10%)

<1%, postmarketing, and/or case reports: Abnormal behavior, abnormal hepatic function tests, accidental injury, agitation, anaphylactoid reaction, anaphylaxis, anxiety, cardiac arrhythmia, confusion, delirium, delusions, dermatitis, eczema, erythema multiforme, exacerbation of diabetes mellitus, facial edema, gastrointestinal hemorrhage, hallucination, hemorrhagic colitis, hepatitis, hypersensitivity reaction, hypothermia, impaired consciousness, nightmares, seizure, skin rash, Stevens-Johnson syndrome, swollen tongue, toxic epidermal necrolysis, urticaria

 

Headache and vomiting!!!! Hey, isn't that a symptom of the flu?

[LT_Oneal_PAC]

1 hour ago, JMPA said:

Headache and vomiting!!!! Hey, isn't that a symptom of the flu?

Exactly.

[thinkertdm]

I wish that I wouldn't nearly have a stroke when someone states they "don't get flu shots".  One lady didn't trust the vaccine makers, but smelled so strongly of cigarettes I had to wear a mask.

[MCHAD]

5 hours ago, GetMeOuttaThisMess said:

 

Out of curiosity, what are your particular concerns regarding side effects?


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What lt_oneal_pac said

[GetMeOuttaThisMess]

The response to the inquiry that I made is what I was I was anticipating. I would say that you could find similar adverse effects from just about any medication. Now, if one wishes to question the efficacy I’m there with you. Anyone here old enough to remember why the package insert mentions “self injury, sometimes fatal”?

 

One additional thought. When one argues about the efficacy of the medication which in real terms ideally results in shortened duration of sx by about a day and potentially lessen the severity of the illness, how the heck does one objectively make such a determination? Frankly, how is this any different from treating an ear infection or throat infection with antibiotics?

 

[LT_Oneal_PAC]

58 minutes ago, GetMeOuttaThisMess said:

The response to the inquiry that I made is what I was I was anticipating. I would say that you could find similar adverse effects from just about any medication. Now, if one wishes to question the efficacy I’m there with you. Anyone here old enough to remember why the package insert mentions “self injury, sometimes fatal”?

 

One additional thought. When one argues about the efficacy of the medication which in real terms ideally results in shortened duration of sx by about a day and potentially lessen the severity of the illness, how the heck does one objectively make such a determination? Frankly, how is this any different from treating an ear infection or throat infection with antibiotics?

 

I still give abx for ear infections if not improved in 48 hours or clearly suppurative. I’m pretty sure you remember my opinion on abx for pharyngitis.

[LT_Oneal_PAC]

3 hours ago, thinkertdm said:

I wish that I wouldn't nearly have a stroke when someone states they "don't get flu shots".  One lady didn't trust the vaccine makers, but smelled so strongly of cigarettes I had to wear a mask.

Suspect it’s going to be worse after this year. Flu vaccine only 10% effective in Australia this year, which means we can see more of the same here.

[sas5814]

8 hours ago, LT_Oneal_PAC said:

Suspect it’s going to be worse after this year. Flu vaccine only 10% effective in Australia this year, which means we can see more of the same here.

Early signs are bad. We have seen more flu in the UC in the last 3 weeks than we did last flu season. I finished my 12 yesterday and went home and burned my scrubs. I felt like I was locked in a Petri dish all day.

[d2305]

http://www.nejm.org/doi/full/10.1056/NEJMp1714916?query=featured_home&

[thinkertdm]

4 hours ago, d2305 said:

http://www.nejm.org/doi/full/10.1056/NEJMp1714916?query=featured_home&

Yeah, it's called a "z-pack", solves universally everything.  Including press-Ganey scores!

[Cideous]

Every year some kid dies of Influenza and it is all over the news.  Recently a teen girl a few towns over from us.  I feel terrible for her and the family, but I admit one of the first things that came to mind was.....did she get put on Tamiflu?  She was seen at an UC 2 days prior to dying.  Just said she was seen at UC, sent home and died two days later....

I generally use Tamiflu.

[TWR]

Ever notice that the side effects of just about everything we write for is twice as long as the benefit????

[thinkertdm]

I saw a fellow yesterday who was prescribed tamiflu last year by his PCP for a cold for five days.  She also prescribed levocetirizine and ordered a boatload of labs, from CBC to flu swabs (negative) to esr.  I'm not sure what she was looking for, as both the history and A/P sections were templated from the EMR.  But it was an MD so no one reviewed her charts, and whatever goofy medicine she was practicing was A-ok because MD.  

[GetMeOuttaThisMess]

52 minutes ago, thinkertdm said:

I saw a fellow yesterday who was prescribed tamiflu last year by his PCP for a cold for five days.  She also prescribed levocetirizine and ordered a boatload of labs, from CBC to flu swabs (negative) to esr.  I'm not sure what she was looking for, as both the history and A/P sections were templated from the EMR.  But it was an MD so no one reviewed her charts, and whatever goofy medicine she was practicing was A-ok because MD.  

You're sure it was "just a cold"?

[thinkertdm]

Well, it wasn't the flu as the swabs were negative. I didn't see vitals in the note, and the a/p didn't say "influenza" or "influenza like syndrome".  If the note doesnt convey to other providers what you did or why you did it, you lost.  I was just as baffled the third time as I was the first as to why this was chosen.

[Guest UVAPAC]

https://www.cdc.gov/flu/professionals/diagnosis/algorithm-results-circulating.htm

 

CDC says to treat with Tamiflu... even if rapid is negative and symptoms consistent with influenza...

[camoman1234]

19 minutes ago, UVAPAC said:

https://www.cdc.gov/flu/professionals/diagnosis/algorithm-results-circulating.htm

 

CDC says to treat with Tamiflu... even if rapid is negative and symptoms consistent with influenza...

So why swab them? The contradict the makers of Tamiflu, CDC states: "if specimen was collected > 4 days after illness onset." Then per they are out of the range for Tamiflu... How about we do one better and do the maintenance dose of Tamiflu for everyone....I do not prescribe Tamiflu for numerous reasons.