Regarding Tamiflu, Doctors and Patients Face a Question of When to Act

When Dr. Matt Thompson, a pediatrician at the Kids Clinic in Spokane, Wash., found about a month ago that his six children had come down with H1N1, or swine flu, he did not give them the antiviral medication that might have made their sickness a bit shorter.
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“They don’t have asthma; they’re not immune-compromised; they don’t work in a health care setting,” Dr. Thompson said. “I don’t tell that story to minimize concern about this virus, but here was a case where my kids weren’t that sick.”
Dr. Thompson is on the conservative side of the question of when to give patients Tamiflu, the most frequently prescribed antiflu medicine, saying he fears creating a resistant strain of the virus. 
According to the Centers for Disease Control and Prevention, antivirals should be given in the most severe cases of the flu, or when a patient is in a high-risk group, which includes pregnant women and children under 2.
But that leaves a large gray area for mild or moderate cases or people who have simply been exposed to the virus and want to prevent its taking hold. For the moderately ill, the drug may shorten the duration of symptoms by about a day. But it is expensive, costing about $100 for a 10-pill adult course, and it can have side effects like stomach aches, nausea and, more rarely, confusion and nightmares. 
In part because of evolving advice about when to give the drug, there has been some confusion among doctors about whether to prescribe the antivirals for less severe cases. 
It comes down to a judgment call for doctors and parents, said Dr. Andrew T. Pavia, chief of the division of pediatric infectious diseases at the University of Utah and chairman of the pandemic influenza task force of the Infectious Diseases Society of America.
“There is no group for whom treatment is inappropriate if they are ill with influenza,” Dr. Pavia said. But, he cautioned, “in mild to moderate illness, treatment has to be begun within 48 hours to have substantial benefit.”
The guidance “leaves room for clinical judgment,” said Dr. Anne Moscona, a professor of pediatrics and microbiology at the Weill Cornell Medical Center. “And it leaves room to decide on a case-by-case basis, thank God, but humans want to be told exactly what to do. If the C.D.C. gave more specific guidance than that, they would be making it up.”
Among those who should definitely take an antiviral are flu patients with symptoms severe enough, or nearly severe enough, for hospitalization, who develop a lower respiratory infection, who have a chronic condition like AIDS or lung disease, or who are pregnant, over 65 or under 2 years old, said Dr. Anthony Fiore, an influenza expert with the disease control centers.
The centers now discourage prescribing Tamiflu to healthy people as a preventive measure except in limited situations — for instance, to people with an underlying condition who have had significant exposure to the virus. Even then, agency guidance says, doctors can wait and treat such people only if symptoms begin to appear. People who live in a household with a flu victim have only a 15 percent to 25 percent chance of becoming infected even without antivirals, Dr. Pavia said.
In Britain, there has been a full-fledged debate about the propriety of prescribing Tamiflu to children, particularly after Andrew Castle, a tennis-player-turned-television presenter, announced that his 16-year-old daughter had “almost died” after receiving the drug (she also had been experiencing flu-like symptoms).
At the time, some healthy children in Britain were given the drug as a guard against getting sick, which also happened in isolated instances in the United States. In one British study, more than half the healthy children who took Tamiflu reported adverse effects.
Some British researchers have warned that the side effects could cause dehydration or other complications, but health officials there have said that those studies were done on people with influenza that is not swine flu, and that for high-risk groups the dangers of H1N1 outweigh the side effects. 
Dr. Fiore said that there had been few reports of side effects in the United States, and that only a few cases of drug-resistant H1N1 had been recorded. 
Dr. Thompson says he warns parents of the potential downside to Tamiflu, even though the side effects can be difficult to distinguish from the symptoms of flu itself.
“We tell them,” he said, “ ‘It’s medicine; this isn’t without risk. They can have stomachaches; they can act a little goofy. Let us know if that happens.’ And nobody’s called me.”