The Medical Letter on Drugs and Therapeutics
Antiviral Drugs for Influenza for 2023-2024
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Med Lett Drugs Ther. 2023 Nov 13;65(1689):177-82   doi:10.58347/tml.2023.1689a
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  • Mark Abramowicz, M.D., President has disclosed no relevant financial relationships.
  • Jean-Marie Pflomm, Pharm.D., Editor in Chief has disclosed no relevant financial relationships.
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Upon completion of this activity, the participant will be able to:
  1. Discuss the 2023-2024 recommendations for antiviral treatment and prophylaxis of influenza.
  2. Compare the antiviral drugs available for treatment of influenza based on their efficacy, dosage and administration, and potential adverse effects.
 Select a term to see related articles  antivirals   baloxavir   influenza   oseltamivir   peramivir   Rapivab   Relenza   Tamiflu   Xofluza   zanamivir 
Revised 11/1/23: In the clinical studies section, a meta-analysis of 15 randomized trials in 6295 outpatients was added.

Influenza is generally a self-limited illness, but pneumonia, respiratory failure, and death can occur, especially in patients at increased risk for influenza complications (see Table 1). Antiviral drugs recommended for treatment and chemoprophylaxis of influenza for the 2023-2024 season are listed in Table 2. Updated information on influenza activity and antiviral resistance is available from the CDC at

TREATMENT RECOMMENDATIONS — Antiviral treatment is recommended as soon as possible for any patient with suspected or confirmed influenza who is hospitalized, has severe, complicated, or progressive illness, or is at increased risk for complications, even if it is started >48 hours after illness onset.1-3 False-negative results can occur with influenza tests; patients in the above groups should receive antiviral treatment despite a negative test, especially when influenza viruses are known to be circulating in the community.4

Antiviral treatment can be considered for otherwise healthy symptomatic outpatients with suspected or confirmed influenza who are not at increased risk for influenza complications if it can be started within 48 hours after illness onset.

TREATMENT — A neuraminidase inhibitor (oral oseltamivir, IV peramivir, or inhaled zanamivir) or the oral cap-dependent endonuclease inhibitor baloxavir marboxil is recommended for treatment of suspected or confirmed uncomplicated influenza in nonpregnant outpatients this season. All of these drugs are active against influenza A and B viruses.

Oseltamivir is preferred for pregnant women, hospitalized patients, and outpatients with severe, complicated, or progressive illness.1

Effectiveness – Use of a neuraminidase inhibitor or baloxavir for treatment of acute uncomplicated influenza in adults shortens the duration of symptoms by about one day.5-8 Although most controlled trials of antiviral drugs have not been powered to assess their efficacy in preventing serious influenza complications, experts have generally interpreted the combined results of controlled trials, observational studies, and meta-analyses as showing that early antiviral treatment of influenza in high-risk and hospitalized patients can reduce the risk of complications.5,9-12

In a meta-analysis of 26 randomized, placebo-controlled trials that included 11,897 healthy children and adults with influenza-like illness, zanamivir was associated with the shortest time to alleviation of influenza symptoms and baloxavir was associated with the lowest risk of influenza-related complications.13

In a randomized, double-blind trial (CAPSTONE-2) in 2184 outpatients ≥12 years old with uncomplicated influenza who were at high risk of developing complications, the median time to symptom improvement was similar with a single dose of baloxavir or 5 days' treatment with oseltamivir (both started within 48 hours after illness onset) in the overall population and in those infected with influenza A(H3N2), but was statistically significantly shorter with baloxavir in those infected with influenza B (median difference 27.1 hours). Use of either drug was associated with a lower incidence of influenza-related complications and fewer antibiotic prescriptions compared to placebo.8

In one meta-analysis of 15 randomized trials that included 6295 outpatient adolescents and adults with influenza, use of oseltamivir did not reduce the risk of hospitalization in the overall population or in those ≥65 years old compared to placebo or standard of care.48

In a randomized, double-blind trial (miniSTONE-2) in 173 otherwise healthy children 1-11 years old with influenza, the median time to alleviation of symptoms was similar with a single dose of baloxavir or 5 days' treatment with oseltamivir (138 vs 150 hours; both started within 48 hours after illness onset).14

A meta-analysis of 5 randomized trials in children with influenza found that starting oseltamivir within 48 hours after illness onset reduced illness duration by about 18 hours (by about 30 hours when trials that enrolled children with asthma were excluded) and decreased the risk of otitis media.15

In a retrospective cohort study in 542 hospitalized adults, oral oseltamivir and IV peramivir were similarly effective in time to defervescence, duration of hospital and intensive care unit stay, and mortality.16 In children hospitalized with laboratory-confirmed influenza, antiviral treatment started within 48 hours after illness onset was associated with shorter durations of hospitalization compared to no antiviral treatment.17

In a randomized, double-blind trial (FLAGSTONE) in 366 patients ≥12 years old hospitalized with severe influenza, the median time to clinical improvement was not statistically significantly different with a combination of a neuraminidase inhibitor (primarily oseltamivir) and baloxavir compared to a neuraminidase inhibitor alone (95.5 vs 100.2 hours).18

Timing – Neuraminidase inhibitors are most effective when started within 48 hours after illness onset, but the results of some observational studies in hospitalized and critically ill patients suggest that treatment started as late as 4-5 days after illness onset can shorten the duration of hospitalization and reduce the risk of complications such as pneumonia, respiratory failure, and death.11,19-21 No data are available on the efficacy of baloxavir treatment that is started >48 hours after illness onset.

Guidelines for treatment of community-acquired pneumonia (CAP) recommend antiviral treatment for patients who test positive for influenza regardless of the duration of illness before diagnosis.22

CHEMOPROPHYLAXIS — Oseltamivir, zanamivir, and baloxavir are FDA-approved for chemoprophylaxis of influenza. Post-exposure prophylaxis should be considered within 48 hours of exposure for persons at increased risk of complications who have not received an annual influenza vaccine for the current season, received one within the previous 2 weeks, or might not respond to vaccination, or when the match between the vaccine and circulating strains is poor. It is not recommended for healthy persons exposed to influenza or when >48 hours have elapsed since exposure.

Antiviral chemoprophylaxis with oral oseltamivir or inhaled zanamivir is recommended by the CDC for control of institutional influenza outbreaks.1

Effectiveness – Neuraminidase inhibitors have generally been about 70-90% effective in preventing influenza caused by susceptible strains of influenza A or B viruses.1 In a randomized, double-blind trial in 752 household contacts of patients with influenza, a single dose of baloxavir was 86% effective in preventing clinical influenza in household contacts.23

Timing – When indicated, chemoprophylaxis with oseltamivir or zanamivir should be started no later than 48 hours after exposure and continued for 7 days after the last known exposure. A single dose of baloxavir within 48 hours after exposure is also an option.

For institutional influenza outbreaks, the CDC recommends chemoprophylaxis with oral oseltamivir or inhaled zanamivir for at least 2 weeks; prophylaxis should be continued for up to 1 week after the end of the outbreak.

View the Comparison Chart: Antiviral Drugs for Influenza for 2023-2024

PREGNANCY AND LACTATION — Pregnant women are at increased risk for severe complications of influenza. Oseltamivir and zanamivir appear to be safe for use during pregnancy.24,25 Prompt treatment with oseltamivir is recommended for women with suspected or confirmed influenza who are pregnant or ≤2 weeks postpartum.26-28 Oseltamivir is preferred for treatment of women who are breastfeeding. No data are available on the use of baloxavir in pregnant or breastfeeding women.

Antiviral chemoprophylaxis can be considered for pregnant women who have had close contact with someone suspected or confirmed to have influenza. Zanamivir may be preferred because of its limited systemic absorption, but oseltamivir is a reasonable alternative, especially in women at increased risk for respiratory problems.

RESISTANCE — Over 99% of the recently circulating influenza virus strains tested by the World Health Organization (WHO) have been susceptible to neuraminidase inhibitors.29 Reduced susceptibility of some influenza virus strains, particularly influenza A(H1N1) viruses, to oseltamivir or peramivir can emerge during or after treatment, especially in young children and immunocompromised patients with prolonged viral shedding.30-35 Resistant isolates have usually remained susceptible to zanamivir, but reduced susceptibility to zanamivir has been reported.36 In immunocompromised patients, a double dose of oseltamivir reduced the incidence of oseltamivir resistance compared to standard dosing, but it did not improve efficacy and caused more adverse effects.37

Amino acid substitutions associated with reduced susceptibility to baloxavir have occurred following treatment with a single dose of the drug.7,38 Reduced susceptibility to baloxavir appears to be more frequent in persons infected with influenza A(H3N2) and A(H1N1)pdm09 viruses, particularly children.39,40 Baloxavir monotherapy is not recommended for severely immunocompromised patients because of concerns that prolonged viral replication in such patients could lead to emergence of resistance. Oseltamivir and peramivir may be active against influenza virus strains with reduced susceptibility to baloxavir.41 Baloxavir is active against neuraminidase inhibitor-resistant strains of influenza A and B viruses, including A(H1N1), A(H5N1), A(H3N2), and A(H7N9).

The adamantanes amantadine and rimantadine are active against influenza A viruses, but not influenza B viruses. As in recent past seasons, resistance to these drugs is high (>99%) among circulating influenza A(H3N2) and A(H1N1)pdm09 viruses; neither amantadine nor rimantadine is recommended for treatment or chemoprophylaxis of influenza.

ADVERSE EFFECTS — Nausea, vomiting, and headache are the most common adverse effects of oseltamivir; taking the drug with food may minimize GI adverse effects. Oseltamivir has been associated with bradycardia in critically ill patients.42 Diarrhea, nausea, sinusitis, fever, and arthralgia have been reported with zanamivir. Inhalation of zanamivir can cause bronchospasm; the drug should not be used in patients with underlying airway disease. Diarrhea and neutropenia have occurred with peramivir.43

Baloxavir appears to cause less nausea and vomiting than oseltamivir.44

Neuropsychiatric events, including self-injury and delirium, have been reported in patients taking neuraminidase inhibitors or baloxavir, but a causal relationship has not been established, and neuropsychiatric dysfunction can be a complication of influenza itself.45 Hypersensitivity reactions, including anaphylaxis, have been reported with all of these drugs.

USE WITH THE LIVE-ATTENUATED VACCINE — Use of oseltamivir or zanamivir within 48 hours before, peramivir within 5 days before, or baloxavir within 17 days before administration of the live-attenuated intranasal influenza vaccine (FluMist Quadrivalent) could inhibit replication of the vaccine virus, reducing the vaccine's effectiveness, and is not recommended.46 Persons who receive any of these antiviral drugs during these specified times and through 2 weeks after receiving the live-attenuated vaccine should be revaccinated with an inactivated or recombinant age-appropriate influenza vaccine.47

DRUG INTERACTIONS — Coadministration of dairy products, beverages, antacids, laxatives, multivitamins, or other products containing polyvalent cations (e.g., calcium, aluminum, iron, magnesium, selenium, zinc) can reduce serum concentrations of baloxavir and should be avoided.


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