2020 symposia series 1 · • individualize influenza treatment in pediatric patients based on...
TRANSCRIPT
2020 Symposia Series 1
Weighing the Options: Prevention and
Management of Influenza in Patients at
High Risk for Complications
3
Learning Objectives
• Identify available and emerging options for prevention of influenza
• Select influenza treatment for adult patients at high risk of
complications based on current recommendations and evidence
• Individualize influenza treatment in pediatric patients based on
current recommendations
4
• Rates of serious illness and death from
seasonal influenza are highest in persons >65
years, in children <2 years, and in anyone with
medical conditions at increased risk for
complications
• In the 2017-2018 flu season, influenza killed
and hospitalized more people in the US than
any other year since 2010
Epidemiology and Burden of Seasonal Influenza in the US
*Data for 2017-2018 and 2018-2019 are preliminary estimates.
Centers for Disease Control and Prevention. cdc.gov/flu/about/burden/index.html. Accessed Apr 5, 2020; Centers for Disease Control and Prevention.
gis.cdc.gov/GRASP/Fluview/FluHospRates.html. Accessed Apr 5, 2020; Rolfes MA, et al. Influenza Other Respir Viruses. 2018;12:132-137.
Burden of Influenza: Annual Estimates by the CDC From 9 Influenza Seasons (2010-2011 through 2018-2019)*
9.3 to 45 million illnesses caused
140,000 to 810,000 hospitalizations
12,000 to 61,000 deaths
14.2 to 21 million outpatient medical visits
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Influenza-Positive Tests Reported to CDC: National Summary, 2019-2020 Season
Centers for Disease Control and Prevention. cdc.gov/flu/weekly/index.htm. Accessed Apr 5, 2020.
0
500
1000
1500
2000
2500
3000
3500
4000
2019-40 2019-42 2019-44 2019-46 2019-48 2019-50 2019-52 2020-02 2020-04 2020-06 2020-08 2020-10 2020-12 2020-14 2020-16 2020-18 2020-20
Num
ber
of P
ositiv
e S
pe
cim
en
s
Week
B (Yamagata Lineage) B (Victoria Lineage) B (lineage not performed) A (H3N2) A (H1N1)pmd09 A (subtyping not performed)
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Number of Specimens Tested and Percent Positive for SARS-CoV-2
SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
Centers for Disease Control and Prevention. cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. Accessed Apr 5, 2020.
0
1000
2000
3000
4000
2019-40 2019-42 2019-44 2019-46 2019-48 2019-50 2019-52 2020-02 2020-04 2020-06 2020-08 2020-10 2020-12 2020-14 2020-16 2020-18 2020-20
B (Yamagata Lineage) B (Victoria Lineage)
B (lineage not performed) A (H3N2)
A (H1N1)pmd09 A (subtyping not performed)
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
11000
12000
13000
14000
15000
16000
SARS-CoV-2
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Outpatient Visits for Influenza-like Illness Reported to CDC: National Summary, 2009-2020
ILI = influenza-like Illness.
Centers for Disease Control and Prevention. cdc.gov/flu/weekly/index.htm. Accessed Apr 5, 2020.
0
1
2
3
4
5
6
7
8
9
40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
% o
f V
isito
rs fo
r IL
I
Week
2018-19 season
2017-18 season
2015-16 season
2014-15 season
2011-12 season
2009-10 season
2019-20 National Baseline
2019-20 season
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Influenza Pandemics
*As of May 11, 2020; COVID-19 = Coronavirus disease 2019.
Dawood FS, et al. Lancet Infect Dis. 2012;12:687-695; Johnson NP, et al. Bull Hist Med. 2002;76:105-115; Saunders-Hastings PR, et al. Pathogens.
2016;5:e66; Simonsen L, et al. PLoS Med. 2013;10:e1001558; Taubenberger JK, et al. Emerg Infect Dis. 2006;12:15-22; COVID-19 Dashboard by
the Center for Systems Science and Engineering at Johns Hopkins University. coronavirus.jhu.edu/map.html. Accessed May 11, 2020; University of
Washington Institute for Health Metrics and Evaluations. www.covid19.healthdata.org Accessed May 11, 2020.
Common Name Year Virus Estimated No. of Deaths (range)
Spanish flu 1918 H1N1 50 million-100 million
Asian flu 1958 H2N2 1 million-2 million
Hong Kong flu 1968 H3N2 500,000-2 million
H1N1 pandemic 2009 H1N1 151,700-575,400
COVID-19 2020 SARS-CoV-2 137,184* (by Aug 4, 2020)
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• The family Orthomyxoviridae has 3 genera, or
types, that infect humans: influenza viruses A,
B, and C
• Influenza A virus subtypes are based on
specific HA and NA glycoproteins that they
express
− 18 HAs (H1-H18)
− 11 NAs (N1-N11)
− Potential for 144 HA and NA combinations
(some HAs and NAs cannot work together)
• Birds are reservoir for 16 HA and 9 NA
subtypes
Influenza Virus
HA = hemagglutinin; NA = neuraminidase; NS = nonstructural protein; ss = single stranded.
Clancy S. Nature Education. 2008;1:83; Vemula SV, et al. Viruses. 2016;8:96.
Hemagglutinin NA
NS2
Lipid
bilayer
Ion
channel
Matrix
protein
Negative-sense
ssRNA
10
Case Study: Joanne, a 52-year-old female
• Joanne visits your primary care practice in November for an annual checkup
• She is under the care of a rheumatologist for psoriatic arthritis and well managed with methotrexate and etanercept
• No other chronic medical problems
⎻ 5 ft 6 in; 249 lb; BMI: 40.2 kg/m2; blood pressure: 128/78 mm Hg
• Unvaccinated against influenza and skeptical about the vaccine
⎻ She received the vaccine last year and “got the flu” the day after
• You recommend influenza vaccination, but she refuses
10
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Focus on Patients at Higher Risk for Influenza Complications
Demographic factors
• Adults aged ≥65 years
• Children <5 years (highest risk in children
<2 years, especially if <6 months)
• Pregnant women (and women up to 2 weeks
postpartum)
• American Indians/Alaska Natives
• Residents of nursing homes and other
long-term care facilities
Centers for Disease Control and Prevention. cdc.gov/flu/highrisk/index.htm. Accessed Apr 5, 2020.
Chronic Medical Conditions
• Asthma
• Neurologic and neurodevelopmental conditions
• Blood disorders (eg, sickle cell disease)
• Chronic lung disease (eg, COPD, cystic fibrosis)
• Diabetes
• Kidney disorders
• Liver disorders
• Morbid obesity (BMI ≥40 kg/m2)
• <19 years and on long-term aspirin- or salicylate-
containing medications
• Compromised immune system or on
immunosuppressive therapies
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Influenza Vaccination: Effective but Underutilized
• Most effective means of preventing seasonal influenza virus infection
– Recommended in all persons ≥6 months in the United States
• 38% to 61% of population gets vaccinated*
• Because of changes in circulating influenza strains, vaccine reformulated every year
• Vaccination can prevent serious illness
⎻ CDC estimates that during the 2018-2019 season, flu vaccine prevented an estimated:
• 4.4 million illnesses
• 2.3 million medical visits; 58,000 hospitalizations
• 35,000 deaths
*Estimated from percentage of patients with acute respiratory illness who were vaccinated for the 2019-2020 flu season.
Dawood FS, et al. MMWR Morb Mortal Wkly Rep. 2020;69:177-182.
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• Vaccination does not guarantee protection
• Interim data for vaccine effectiveness during 2019-2020 flu season (adjusted):
– 55% against influenza B/Victoria
– 37% against influenza A(H1N1)pdm09
– 45% overall effectiveness against influenza A and B combined
• Despite overall vaccine effectiveness of 38% in 2017-2018 season, flu vaccine prevented:
‒ 7.1 million illnesses, 3.7 million medical visits
‒ 109,000 hospitalizations, 8000 deaths
Interim Data for Influenza Vaccine Effectiveness During the 2019-2020 Season
Dawood FS, et al. MMWR Morb Mortal Wkly Rep 2020;69:177-182; Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21.13
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Manufacturing
Process Age Indication Route Formulations
IIV4 standard dose Egg based† ≥6 months IM Prefilled syringe, MDV*
IIV4 standard dose Cell culture based ≥4 years IM Prefilled syringe, MDV*
IIV3 high dose Egg based† ≥65 years IM Prefilled syringe
IIV3 standard dose with
MF59 adjuvant
Egg based† ≥65 years IM Prefilled syringe
RIV4 Recombinant HA ≥18 years IM Prefilled syringe
LAIV4‡ Egg based† 2 to 49 years Intranasal Single-use intranasal spray
Influenza Vaccines: 2019-2020 Influenza Season
*MDV = multidose vials containing ≤25 ug/0.5 mL thimerosal; †Contraindicated only if history of severe allergic reaction (eg, anaphylaxis) to egg; ‡Precautions in individuals with asthma, or underlying medical conditions that may predispose to complications after wild-type influenza infection;
IIV3 = inactivated influenza vaccine, trivalent; IIV4 = inactivated influenza vaccine, quadrivalent; IM = intramuscular; LAIV4 = Live attenuated
influenza vaccine; RIV4 = recombinant influenza vaccine, quadrivalent.
Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21.
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• Vaccine composition:
‒ A/Brisbane/02/2018 (H1N1) pdm09-like virus
‒ A/Kansas/14/2017 (H3N2)-like virus
‒ B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage)
‒ B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage) [quadrivalent only]
• Clinicians may administer any licensed, age-appropriate influenza vaccine to all patients
‒ Includes those with egg allergy, except for history suggestive of anaphylaxis
ACIP Guideline Update for 2019-2020 Influenza Season
ACIP = Advisory Committee on Immunization Practices.
Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21.
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Influenza Vaccination in Children Aged 6 Months Through 8 Years
Grohskopf LA, et al. MMWR Recomm Rep. 2019;68:1-21.
Has the child received ≥2 doses of influenza vaccine previously
(excluding the current influenza season)?
2 doses of 2019-2020
influenza vaccine
(≥4 weeks apart)
1 dose of 2019-2020
influenza vaccine
Yes No or don’t know
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High-dose and MF59-adjuvanted Seasonal Influenza Vaccines in Patients ≥65 Years
RCT = randomized controlled trial.
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/acip/2019-2020/acip-table.htm. Accessed Apr 5, 2020; ClinicalTrials.gov.
clinicaltrials.gov/ct2/show/NCT03183908. Accessed Apr 5, 2020; Czaja CA, et al. Open Forum Infec Dis. 2019;6:ofz225; DiazGranados CA, et al.
N Engl J Med. 2014;371:635-645; Gravenstein S, et al. Lancet Respir Med. 2017;5:738-746; Grohskopf LA, et al. MMWR Recomm Rep.
2019;68:1-21; Izurieta HS, et al. Lancet Infect Dis. 2015;15:293-300; Lapi F, et al. Expert Rev Vaccines. 2019;18:663-670; Reed C, et al. PLoS
One. 2015;10:e0118369; Shay DK, et al. J Infect Dis. 2017;215:510-517; Van Buyunder PG, et al. Vaccine. 2013;31:6122-6128.
• Population accounts for up to 90% of seasonal flu-related deaths and 50% to 70% of hospitalizations
• High-dose vs standard-dose vaccine (RCTs and observational studies)
⎻ Higher immunogenic responses
⎻ Improved protection against influenza and related complications
• MF59-adjuvanted vaccine vs nonadjuvanted inactivated influenza vaccine (observational studies)
⎻ Greater vaccine efficacy for lab-confirmed influenza and influenza-related hospitalizations
⎻ Results of RCT comparing immunogenicity of MF59-adjuvanted to high-dose vaccines pending
(NCT03183908)
• ACIP recommends no preference for particular vaccine types
⎻ Vaccination should not be delayed if a specific product is not available
18
• Classic flu
– Abrupt onset of fever, chills, myalgia, headache, fatigue, nonproductive cough, sore throat, rhinitis
– Some people may have GI symptoms (eg, nausea, diarrhea)
– Typically resolves within 3 to 7 days
– Cough, malaise can persist for >2 weeks
• Mild illness without fever may also occur
• Atypical presentations may occur in elderly, immunocompromised hosts, infants
Influenza Symptoms and Clinical Course
CF = cystic fibrosis; CV = cardiovascular; MI = myocardial infarction.
Centers for Disease Control and Prevention. cdc.gov/flu/symptoms/symptoms.htm. Accessed Apr 5, 2020; Kwong JC, et al. N Engl J Med.
2018;378:345-353; Rolfes MA, et al. Clin Infect Dis. 2018;67:485-492; Uyeki TM, et al. Clin Infect Dis. 2019;68:895-902.
• Complications
– Sinusitis, otitis media
– Pneumonia—primary viral or secondary bacterial
– Coinfections with other bacterial/viral pathogens
– Exacerbation of underlying medical conditions
(eg, COPD, asthma, CF, diabetes)
– Associations with CV events (eg, MI, stroke),
parotitis
19
Case Study (cont’d): Joanne
• Joanne returns to your office in early December after sudden onset of symptoms the previous morning
⎻ Symptoms include fever (101.8°F), chills, body aches, intense headache, extreme fatigue, and cough
• Has missed work yesterday; unable to perform household chores
• Several coworkers have been sick with flu-like illness, and Joanne is concerned that she may have the flu
• Adult daughter and a grandchild (newborn) will be visiting soon, and she wants to avoid spreading her illness
• Husband, aged 60 years, has not been vaccinated
19
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Differential Diagnosis of Allergies, URIs, and Influenza in a Typical Influenza Season
Centers for Disease Control and Prevention. www.cdc.gov/flu.htm. Accessed Apr 5, 2020; National Institutes of Health. newsinhealth.nih.gov/2014/10/cold-flu-or-
allergy. Accessed Apr 5, 2020.
Symptom Allergy Acute URI (common cold) Influenza
Itchy, watery eyes Common Rare; conjunctivitis may occur with
adenovirus
Soreness behind eyes, sometimes
conjunctivitis
Nasal discharge Common Very common Common
Nasal congestion Common Very common Sometimes
Sneezing Very common Very common Uncommon
Sore throat Sometimes Very common Sometimes
Cough Sometimes Common Very common
Headache Sometimes Sometimes Common
Fever Never Rare in adults, possible in children Very common
Malaise Sometimes Sometimes Very common
Fatigue, weakness Sometimes Sometimes Very common
Myalgia Never Rare Very common
Duration of symptoms Weeks 3 to 14 days 3 to 10 days; several weeks of cough, fatigue
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Laboratory Diagnostic Methods to Detect Influenza A and B
Test Method Test Time Sensitivity Specificity
Rapid molecular assay Nucleic acid amplification 15 to 30
minutes
High High
RIDT Antigen detection <30 minutes Low/Moderate* High
Immunofluorescence assay Antigen detection 1 to 4 hours Moderate High
Molecular assays, including
RT-PCR
Nucleic acid amplification 1 to 8 hours High High
Multiplex molecular assays Nucleic acid amplification 1 to 2 hours High High
Rapid cell culture (shell vials,
cell mixtures)
Virus isolation 1 to 3 days High High
Viral cell culture Virus isolation 3 to 10 days High High
*Higher sensitivity with analyzer reader device. FDA now requires RIDTs to achieve 80% sensitivity.
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/diagnosis/overview-testing-methods.htm. Accessed Apr 5, 2020; Uyeki TM, et
al. Clin Infect Dis. 2019;68:895-902.
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RT-PCR RIDT
Diagnostic accuracy ✓ Higher sensitivity → fewer false
negatives
Specific → Limited false positives
Lower sensitivity → more false
negatives (newer tests have improved)
Specific → Limited false positives
Discriminate influenza
A subtypes ✓ Yes, if subtype primers used No
Time to results ≤30 minutes to several hours ✓ 10 to 15 minutes
Availability in office
setting More expensive and less available ✓ More likely to be available
RT-PCR Versus RIDT: Preferred Tests
✓ = preferred.
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/diagnosis/overview-testing-methods.htm. Accessed Apr 20, 2020; Merckx J,
et al. Ann Intern Med. 2017;167:394-409; Uyeki TM, et al. Clin Infect Dis. 2019;68:895-902.
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Interpreting Influenza Testing Results
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/diagnosis/algorithm-results-circulating.htm. Accessed Apr 5, 2020; Centers
for Disease Control and Prevention. cdc.gov/flu/professionals/diagnosis/overview-testing-methods.htm. Accessed Apr 5, 2020.
• Initiate antiviral treatment if indicated
• Implement infection prevention and control measures
• Consider additional influenza testing if subtype info is desired
• Use information on local influenza activity (eg, from health
department), patient history and travel, clinical signs/symptoms,
and physical examination to decide if treatment is indicated
• Initiate antiviral treatment if flu is suspected and patient is at high
risk for complications or is being admitted to the hospital
• Consider additional diagnostic testing for other pathogens
Cannot rule out flu,
especially if test does
not have high sensitivity
or if specimen was
collected >4 days after
illness onset
Negative
result
Influenza virus
infection likelyPositive result
(A or B)
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Confirmed or suspected influenza
• Initiate antiviral treatment as soon as possible for patients who:
⎻ Have severe, complicated, or progressive illness
⎻ Require hospitalization
⎻ Are at higher risk for complications due to age or underlying conditions
• Do not wait for test results in patients who have a serious illness or are otherwise at high risk
• Consider antiviral treatment for outpatients if treatment can be initiated within 48 hours of onset without known risk factors for severe illness
When to Treat Influenza: Complicated vs Uncomplicated
Uyeki TM, et al. Clin Infect Dis. 2019;68:895-902.
25
Why Is It Important to Treat Early?
• RCTs show that antiviral treatment within 2 days of illness onset can lessen symptoms, shorten disease course, and reduce complications and hospitalization risk
• Observational studies indicate that timely antiviral treatment can reduce complications and hospitalization risk, and decrease mortality in hospitalized patients (up to 4-5 days after symptom onset)
Dobson J, et al. Lancet. 2015;385:1729-1737; Jain S, et al. N Engl J Med. 2009;361:1935-1944; McGeer A, et al. Clin Infec Dis. 2007;45:1568-
1575. Muthuri SG, et al. Lancet Respir Med. 2014;2:395-404; Venkatesan S, et al. Clin Infect Dis. 2017;64:1328-1334.
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Influenza Antivirals: Mechanisms of Action
Finberg RW, et al. J Infect Dis. 2019;219:1026-1034; Li TC, et al. Viruses. 2015;7:4929-4944; Noshi T, et al. Antiviral Res. 2018;160:109-117.
Adsorption Packaging and budding Release
Cap snatching (baloxavir, pimodivir)
mRNA
RNA (+/-)
Endocytosis
and fusion Uncoating
Receptor
containing
sialic acid
NA inhibitors (oseltamivir, peramivir, zanamivir)
M2 inhibition
(adamantanes)Antibodies
RNA polymerase inhibition(favipiravir)
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FDA-approved Antiviral Agents for Influenza
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed Apr 28, 2020; Grohskopf LA, et
al. MMWR Recomm Rep. 2019;68:1-21; Wester A, et al. Infect Drug Resist. 2016;9:201-214
• Neuraminidase inhibitors: oseltamivir, peramivir, zanamivir
– Activity against both influenza A and B viruses
– Oseltamivir, zanamivir also used as prophylaxis
• Baloxavir
– Activity against both influenza A and B viruses
– Inhibits endonuclease, enzyme required for viral gene transcription
• Adamantanes: amantadine, rimantadine
– Activity against influenza A only
– Widespread resistance, not recommended
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Antivirals for Influenza: Age Indications and Dosage
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed Apr 20, 2020; Rapivab
[prescribing information]. BioCryst Pharmaceuticals; 2018; Relenza [prescribing information]. GlaxoSmithKline; 2018; Tamiflu [prescribing
information]. Genentech; 2019; Xofluza [prescribing information]. Genentech; 2019.
Antiviral Dosage
Age
Indication
Route of
Administration Precautions
Baloxavir Single oral dose
• 40 mg for patients 40 to 80 kg
• 80 mg for patients ≥80 kg
≥12 years Tablets Do not take with:
• Dairy products or calcium-fortified
beverages
• Polyvalent cation-containing
laxatives
Oseltamivir Twice daily for 5 days
• 75 mg (≥13 years)
• Weight based (1-12 years)
• 3 mg/kg (2 weeks-1 year)
≥2 weeks Capsule or oral
suspension
Peramivir Single dose of 600 mg over 15 min ≥2 years Intravenous
Zanamivir 10 mg twice daily for 5 days ≥7 years Oral inhalation Do not use in patients with:
• Underlying respiratory disease
• History of milk protein allergy
29
Drugs AEs
Baloxavir Diarrhea, bronchitis, nausea, sinusitis, headache
Postmarketing reports: Swelling of the face, eyelids or tongue; dysphonia; angioedema; anaphylactic reactions,
anaphylactic shock, anaphylactoid reactions; rash, urticaria, erythema multiforme; vomiting, bloody diarrhea,
melena, colitis; delirium, abnormal behavior, and hallucinations
Oseltamivir Nausea, vomiting, headache
Postmarketing reports: serious skin reactions; sporadic, transient neuropsychiatric events*
Peramivir Diarrhea
Postmarketing reports: serious skin reactions; sporadic, transient neuropsychiatric events*
Zanamivir Oropharyngeal or facial edema; skin rash; bronchospasm, especially in the setting of underlying airways
disease; sinusitis; dizziness; ear, nose, and throat infections
Postmarketing reports: sporadic, transient neuropsychiatric events*
Antivirals for Influenza: Adverse Events (AEs)
*Self-injury or delirium; mainly reported among Japanese adolescents and adults; may be due to viral infection itself.
Centers for Disease Control and Prevention. cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed Apr 20, 2020; Tamiflu
[prescribing information]. Genentech; 2019; Xofluza [prescribing information]. Genentech; 2019; Rapivab [prescribing information], BioCryst
Pharmaceuticals; 2018; Relenza [prescribing information]. GlaxoSmithKline; 2018.29
30
100
80
60
40
20
0
• Phase 3 study
‒ 1436 otherwise healthy patients
‒ 12 to 64 years of age
‒ Symptomatic uncomplicated flu
• Time to alleviation of symptoms
‒ Baloxavir group: 53.7 h
‒ Placebo group: 80.2 h (P <.001)
• Baloxavir generally well tolerated
‒ Diarrhea most common adverse event, but less frequent than with placebo
CAPSTONE-1: Time to Alleviation of Symptoms With Baloxavir Marboxil vs Placebo
Hayden FG, et al. N Engl J Med. 2018;379:913-923.
Pa
tie
nts
Wh
o D
id N
ot H
ave
Sym
pto
m A
llevia
tio
n (
%)
Hours From Start of Trial Regimen
0 30 60 90 120 150 180 210 240 270 300 330
Baloxavir
Placebo
+ +++
+++
+
+
+++
++
++
+
+
+ ++++++++
31
• Phase 3 Study in patients ≥12 years (N = 2184) presenting ≤48 hours of symptom onset and at high risk of influenza
complications (eg, asthma or chronic lung disease, age ≥65 years)
• Primary endpoint: Time to improvement of influenza symptoms in baloxavir vs placebo groups
• Adverse events were similar among groups
CAPSTONE-2: Baloxavir vs Placebo or Oseltamivir in Patients at High Risk for Influenza Complications
*All reported values are medians; **As determined by virus titer.
NA = not available; TTIIS = Median time to improvement of influenza symptoms.
Ison MG, et al. Abstract LB16, IDSA Week, Oct 6, 2018; Xofluza [prescribing information]. Genentech; 2019; Xofluza [approval letter], October 16,
2019. www.accessdata.fda.gov/drugsatfda_docs/nda/2019/210854Orig1s001.pdf. Accessed Apr 13, 2020; ClinicalTrials.gov.
clinicaltrials.gov/ct2/show/NCT02949011. Accessed Apr 5, 2020.
Measure* Baloxavir PlaceboP Value
(Baloxavir vs Placebo)Oseltamivir
P Value
(Baloxavir vs Oseltamivir)
Overall TTIIS 73.2 h 102.3 h <.0001 81.0 h .8347
Influenza A/H3N2 TTIIS 75.4 h 100.4 h .0141 NA NA
Influenza B TTIIS 74.6 h 100.6 h .0138 101.6 h .0251
Time to cessation of viral
shedding**
48 h 96 h <.0001 96 h <.0001
32
Joanne: Case Conclusion
• You prescribe baloxavir for Joanne, advising her not to take it with:
⎻ Dairy products, calcium-fortified beverages, polyvalent cation-containing laxatives, antacids, or oral supplements (eg, calcium, iron, magnesium, selenium, or zinc)
• She feels better within a few days; 12 days later she feels almost completely better, except for a slight lingering cough
• She’s looking forward to spending time with her daughter and new grandchild during their upcoming visit
• She has urged her husband and her college-aged children to get vaccinated and is committed to getting vaccinated herself early in the season each year
33
Case Study: Sarah, an 11-year-old Student
• Usually in excellent health
• Sudden onset of headache, pharyngitis, fever, chills, nasal congestion yesterday;
symptoms worse today and now include dry cough, fatigue, weakness
• Mother reports OTC meds providing limited relief
• Flu prevalent at her school and community
• Height: 5 ft, 4 in; weight: 105 lb (BMI: 18 kg/m2); blood pressure: 118/73 mm Hg
• Temperature: 103.5°F; heart rate: 95 beats/min; respiration rate: 14 breaths/min;
SpO2: 98% on room air
• Lungs: clear to auscultation
• Rapid strep test: negative
34
Case Study: Sarah
• Given Sarah’s symptoms and the fact that flu is currently circulating in the community, your clinical judgment is that a flu test is:
‒ Not necessary for diagnosis
‒ Would not change your approach to management
• You discuss antiviral treatment options with Sarah and her mother
35
Case Conclusion: Sarah
• You prescribe Sarah oseltamivir, 75 mg twice daily for 5 days, because
it is approved for children of Sarah’s age and has more than 20 years
of clinical use
• Her symptoms start to resolve over the next few days and by the
weekend she is feeling well enough to travel for her quiz bowl event
• You recommend she get vaccinated early in the next flu season
36
• Phase 3 multicenter in patients 1 to <12 years of age and influenza confirmed by RIDT
• Primary endpoint: Proportion of patients exhibiting AEs or severe AEs for up to day 29
• Patients randomized to baloxavir (single dose; N = 115) or oseltamivir (twice daily for 5 days; N = 58)
• No serious AE, deaths, adverse events of special interest, or new safety signals observed
MINISTONE-2: Baloxavir vs Oseltamivir in Pediatric Patients With Influenza-like Symptoms
*Determined via virus titer.
Baker J, et al. OPTIONS X 2019. Abstract 11756; ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT03629184. Accessed Apr 5, 2020; Roche.
www.roche.com/investors/updates/inv-update-2019-07-03.htm. Accessed Apr 5, 2020.
Measure Baloxavir Oseltamivir
Patients with at least 1 AE 46.1% 53.4%
Median time to cessation of viral shedding* (95% CI) 24.2 h (23.5 to 24.6) 75.8 h (68.9 to 97.8)
Median time to alleviation of influenza signs and
symptoms (95% CI)
138.1 h (116.6 to 163.2) 150.0 h (115.0 to 165.7)
37
• Phase 3 randomized study assessing post-exposure prophylaxis in unvaccinated household contacts of
influenza-infected patients (influenza confirmed by RIDT)
• Household contacts randomized to single-dose baloxavir vs placebo
• Primary endpoint: Proportion of participants testing positive for influenza (RT-PCR positive, with fever and ≥1
symptom[s]) during 10-day assessment period
• Serious AEs not observed
BLOCKSTONE: Baloxavir Prophylaxis vs Placebo in Subjects Living With Someone With Confirmed Influenza
Ikematsu H, et al. OPTIONS X 2019. Abstract 11718; Roche. www.roche.com/media/releases/med-cor-2019-09-02b.htm. Accessed Apr 5, 2020.
Measure Baloxavir (n = 374) Placebo (n = 375) P Value
Subjects developing flu 1.9% 13.6% <.0001
Subjects at high risk of flu-associated
complications developing flu
2.2% 15.4% .0435
Children <12 years of age 4.2% 15.5% .0339
Influenza A (H1N1) 1.1% 10.6% .0023
Influenza A (H3N2) 2.8% 17.5% <.0001
Incidence of AEs 22.2% 20.5% —
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• Current FDA-approved indication
⎻ Treatment of acute uncomplicated influenza in patients ≥12 years who have been symptomatic for ≤48 hours and who are:
• Otherwise healthy, or
• At high risk for influenza-related complications
• Convenience of single oral dose
• Offers another option if/when viruses become resistant to NA inhibitors
• Quicker reduction of influenza B symptoms than oseltamivir
• Faster clearance of virus than oseltamivir
• CDC does not recommend use of baloxavir in pregnant or breastfeeding women, outpatients with complicated or progressive illness, or hospitalized patients because of lack of data in these groups
Considerations Regarding Baloxavir
Centers for Disease Control and Prevention. www.cdc.gov/flu/treatment/baloxavir-marboxil.htm. Accessed Apr 5, 2020; ClinicalTrials.gov.
clinicaltrials.gov/ct2/show/NCT02949011. Accessed Apr 5, 2020; Hayden FG, et al. N Engl J Med. 2018;379:913-923; Ison MG, et al. IDSA Week,
Oct 6, 2018. Abstract LB16; Xofluza [prescribing information]. Genentech; 2019.
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Tell Your Patients to Be Proactive…Get Flu Vaccination, Not the Flu
Oct Nov Dec Jan Feb
Month
Ca
se
s
Optimal time for
vaccination
Height of flu
season
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PCE Action Plan
✓ Beware of potential for influenza complications, especially in higher risk patients
✓ Strongly recommend influenza vaccination for all patients older than 6 months and GET
YOURSELF VACCINATED
✓ Confirm influenza using rapid molecular assay if available; RIDT 2nd choice
✓ Consider clinical diagnosis without diagnostic lab testing for patients with signs and symptoms
consistent with flu, especially during periods of influenza activity in the community
✓ Initiate antiviral treatment as early as possible and preferably within 2 days to ensure best treatment
outcomes
✓ Treat influenza A and B with an NA inhibitor or baloxavir
PCE Promotes Practice Change
2020 Symposia Series 1