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?”
“…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.” Continue reading