Influenza in Children: Is Treat Early, Treat Often the Best Strategy?

Weijen Chang, MD; Matthew Garber, MD; Ricardo A. Quinonez, MD

Disclosures

February 25, 2015

Editorial Collaboration

Medscape &

In This Article

What Is the Role of Professional Societies?

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.

(In a post-interview exchange, Dr Quinonez added: "A more recent meta-analysis published since this original interview took place suggests increased benefit of oseltamivir compared with the Cochrane investigators' review. It is highly important to note that this most recent review was sponsored by the manufacturers of oseltamivir and conducted by a group of investigators called the Multiparty Group for Advice on Science (MUGAS), and was funded by an unrestricted grant from Roche. This might lead the reader to conclude significant conflict of interest. Of note, the results for benefits in this newer review are presented as relative risks while the results for adverse effects are presented as absolute risk. This, of course, makes the risk-benefit ratio artificially inflated in favor of benefit.")

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.

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