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Quick, Take Tamiflu? Maybe Not A Slamdunk If You're Young And Healthy

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As I listened to CDC director Dr. Tom Frieden issue a ringing endorsement of the prescription antiviral drug Tamiflu last week, I was also hearing a confused "But...but....but..." in my own head.

The crux of my confusion: I had the decided impression that the data on Tamiflu as a flu-fighter were underwhelming. That it just isn't all that effective. That doctors prescribe it because they have nothing better, but without a lot of hope that it will do a lot of good.

Among the factors that formed that impression:

• A MedPage Today post last month headlined "Why Is Tamiflu Still Around?" with the subhead, "Tamiflu doesn't help, so why are docs still prescribing it?"

• The data-driven doctors who run the Slow Medicine series had written last week that they accepted the updated CDC guidelines recommending quick antiviral therapy for high-risk patients. But....

"...as for patients who were previously healthy with less severe disease, we are more skeptical. The CDC recommends consideration of antivirals among such patients if the medications can be started within 48 hours of symptom onset. However, we suspect the side effects of antiviral medications are greater than the pharmaceutical companies have let on (identification of adverse effects for short term medications is particularly difficult). In most cases, good supportive care with close follow up will be more helpful than a marginally effective medication with uncertain side effects with attendant risks of future resistance."

• And Dr. Ben Kruskal, chief of infectious diseases at Harvard Vanguard Medical Associates, had recently responded to my email query about Tamiflu with this:

"My enthusiasm about antivirals for flu is mixed. They’re the best tool we have, but the evidence for the most hoped-for benefits is scanty indeed."

Bottom line? Dr. Frieden's bottom line was simply that antivirals are under-used and if a member of his family got the flu, he'd want them treated with Tamiflu. But the chief of the CDC has to think at the level of a whole population; what about those of us who think at the level of an individual?

You may prefer a more nuanced take from the likes of the Slow Medicine analysts and Dr. Kruskal, to wit:

Maybe the real Tamiflu bottom line here is that there's no simple bottom line.

Yes, if the patient is elderly or a baby or severely ill or otherwise at high risk of flu complications for any number of underlying health conditions — asthma, diabetes, cancer — quick prescription of antivirals (Tamiflu, Relenza and a new intravenous form, peramavir) makes sense. The potential dangers of flu complications in such high-risk patients are especially scary, so the potential benefits from the antivirals loom larger.

But if the patient is otherwise healthy, Dr. Kruskal says, while it's a reasonable decision to take Tamiflu, "I wouldn't call it entirely a slam-dunk."

If you're a young and otherwise healthy patient calling to ask about Tamiflu, he said, "I would say to you: 'These are medicines that, like all medicines, have some risk. What's the context of your illness right now? There are so many things about your situation that might push me one way or another in a fairly balanced situation like this."

"The point is that it's not meant to be a pat prescription," he adds. "It is meant to be a suggestion to consult with somebody who ideally knows you and your medical history, and knows you and your values, and can help you make a reasoned decision." (Though it's hard, Dr. Kruskal acknowledges, for doctors to have the time for this kind of discussion.)

As you consider, here's another potentially helpful data point from Slow Medicine's Dr. Michael Hochman, medical director for innovation at AltaMed Health Services in southern California, the biggest independent community health center in the nation.

AltaMed guides its clinicians to refrain from treating most otherwise healthy people with Tamiflu unless there is a compelling reason, he says. “Our organization said, ‘We really believe in the data in complicated sicker patients,'” but in otherwise healthy people, “‘We don’t think it’s the right thing and we fear we will cause more harm than good.'”

"I wish we could say that we have a really effective medicine for the flu," he said. "The unfortunate thing is that Tamiflu just isn't that effective and it does have some side effects."

A 2014 review by the Cochrane Collaboration and the medical journal BMJ simply didn't find much benefit from Tamiflu, Dr. Hochman noted; the drug seemed to reduce flu duration by several hours but the data were inconclusive, and did not show a clear reduction in complications or hospitalizations in otherwise healthy patients.

"It definitely is a mixed picture," he said.

And then there are the side effects: nausea and vomiting are not uncommon drug side effects, he said, but there have also been some disturbing reports of psychiatric side effects, including self-harm and delirium in children. Such rare side effects don't tend to turn up in the clinical trials that drug-makers perform to get drugs licensed.

From the Cochrane/BMJ review:

Compared with a placebo, taking Tamiflu led to a quicker alleviation of influenza-like symptoms of just half a day (from 7 days to 6.3 days) in adults, but the effect in children was more uncertain. There was no evidence of a reduction in hospitalisations or serious influenza complications; confirmed pneumonia, bronchitis, sinusitis or ear infection in either adults or children. Tamiflu also increased the risk of nausea and vomiting in adults by around 4 percent and in children by 5 percent. There was a reported increased risk of psychiatric events of around 1 percent when Tamiflu was used to prevent influenza. Evidence also suggests that Tamiflu prevented some people from producing sufficient numbers of their own antibodies to fight infection.

So if you're an otherwise healthy person, Dr. Hochman said, it could be a choice to "get better a few hours faster versus a medicine that has side effects we don't fully understand. It's a close call."

Maybe the real Tamiflu bottom line here is that there's no simple bottom line.

Dr. Andrew Buelt, co-founder of the Questioning Medicine podcast, who wrote the MedPage today post "Why Is Tamiflu Still Around?," said in an email that he tries to maximize shared decision-making on Tamiflu.

He tells his patients that he can write them a prescription for a medication that will cost about $100 and help them get better 18 hours faster at best. He adds:

Thus, instead of it taking seven days to recover from your illness you will feel better at the end of six days. It doesn't prevent hospitalization or death and the side effects are that for every 28 patients I treat, one will get nausea from the drug; and for every 22 patients that I treat, one will get vomiting from the drug. If the cost is worth it to you and this is something you are interested in, then I have no problem writing you a script but I want you to know the benefits and harms and not have unrealistic expectations. (Obviously, I always encourage good nutrition, sleep, and over-the-counter symptom control)

Whatever they decide, I'm OK.

Readers, how are you leaning personally on Tamiflu?

Hat-tip to Tom Anthony for the MedPage Today post.

Carey Goldberg Twitter Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth section.

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