Therapeutics of Flu, Pertussis, Covid, and RSV

all

Symptom management is appropriate in _______ patients.

rest and hydration

What should you recommend for muscle aches or general malaise?

-warm liquids

-gargle warm salt water

What can you recommend for sore throat?

-saline nasal spray or rinse

-humidifier or warm showers

-nasal strips

What can you recommend for congestion?

Dextromethorphan

-only single cough suppressant agent available

-no recommended < 4 yrs old

all

What cough suppressants have abuse potential?

Guaifenesin

-only single agent available for expectorant

-not recommended in < 4 yrs old

-ER forms not recommended in <12 yrs old

no

Are expectorants effective in nonproductive "dry" coughs?

analgesics/antipyretics

-OCTs NSAIDs, tylenol, aspirin

aspirin

should be avoided in peds

ibuprofen

should be avoided in < 6 months of age

NSAIDs

should be avoided in the 3rd trimester of pregnancy

decongestants

-Causes vasoconstriction (caution in cardiovascular disease)

-Phenylephrine has poor oral absorption

-Avoid in children < 2 years of age

throat spray/lozenge

-Can minimize sore throat symptoms

-Throat sprays often contain anesthetics with numbing properties (avoid in children < 6 years of age)

-Lozenges avoid in children < 5 years of age (choking hazard)

anti-histamines

-Can be effective if typical allergy symptoms (e.g. itchy eyes, runny nose) are present

-First generation (diphenhydramine, doxylamine) or second generation (cetirizine, loratadine, fexofenadine)

-Avoid first generation agents in geriatric populations

risk factors for severe disease in covid

• ≥ 65 years of age

• male

• presence of at least one underlying medical condition

• unvaccinated individuals

s/s of covid

sore throat, headache, runny nose, cough, fever and/or chills, fatigue, muscle/body aches, gastrointestinal distress, shortness of breath, loss of taste or smell, sputum production

mild to moderate covid

SpO2 ≥ 94% on room air and not needing supplemental oxygen with risk factors for progression to severe disease, hospitalization or death

severe but not critical covid

SpO2 < 94% on room air or needing low flow supplemental oxygen

critical covid

-needing high flow oxygen/or non invasive ventilation

-needing mechanical ventilation or ECMO

Paxlovid (Nirmatrelvir and Ritonavir)

for ambulatory adults and peds pts (≥ 12 yrs old and more than 40 kg) with mild to moderate covid at high risk for progression

within 5 days.

When do you have to give paxlovid?

300mg/100mg po q12h for 5 days

What is the dosing of paxlovid?

yes

Does paxlovid have renal dose adjustments?

Paxlovid AEs

-dysgeusia

-diarrhea

DDIs with paxlovid

-strong CYP3A4

-P-gp inhibitor

statins

What drugs should you hold when starting paxlovid?

lagevrio (molnupiravir)

for ambulatory adults with mild-to-moderate COVID-19 at high risk for progression without other therapy options

within 5 days

When do you have to start lagevrio?

800 mg po bid for 5 days

What is the dosing of lagevrio?

Lagevrio AEs

diarrhea and nausea

may halt bone growth

Why is lagevrio not authorized in pregnancy and children?

veklury

for ambulatory or hospitalized adults and pediatric patients ≥ 12 years of age & ≥ 40 kg with mild-to-moderate COVID-19 at high risk for progression

within 7 days of symptom onset

When do you have to start veklury?

200 mg IV on day 1, following by 100 mg IV once daily

What is the dosing of veklury for adults?

5 mg/kg IV on day 1, then 2.5 mg/kg IV once daily

What is the dosing of Veklury for peds?

3-5 days

How long is the Veklury course of therapy?

Veklury (Remdesivir) AEs

-elevated LFTs

-infusion reactions

-bradycardia

-hypotension

dexamethasone

for severe or critically ill hospitalized pts with covid

6 mg daily for 10 days or until discharge

What is the dosing of dexamethasone for covid?

AEs of Dexamethasone

fluid retention, hyperglycemia, hypertension, behavioral changes, increased appetite and weight gain

with food

What should you take with oral formulations of dexamethasone?

JAK Inhibitors: Olumiant® (baricitinib)& Xeljanz® (tofacitinib)

hospitalized adults with severe COVID-19 in combination with steroids (if you cant take steroids then take remdesivir with it)

4 mg po qd

What is the dosing of baricitinib?

10 mg po bid

What is the dosing of tofacitinib?

up to 14 days or until hospital discharge

What is the duration of dosing for JAK Inhibitors: Olumiant® (baricitinib) & Xeljanz® (tofacitinib)?

renal and hepatic

Are there dose adjustments for JAK Inhibitors: Olumiant® (baricitinib)& Xeljanz® (tofacitinib)?

BBW of JAK Inhibitors: Olumiant® (baricitinib)& Xeljanz® (tofacitinib)

Serious infections, all-cause mortality, malignancies (lung and lymphoma), major adverse cardiovascular events (MACE), and thrombosis

GI perforation and pregnancy

What type of pts should you AVOID use of JAK Inhibitors: Olumiant® & Xeljanz®?

AK Inhibitors: Olumiant® & Xeljanz® AEs

increased LFTs, thrombocytosis, thrombosis, neutropenia, urinary tract infections, and creatinephosphokinase elevations

do not initiate Olumiant or Xelijanz

• ANC < 1,000/mm3

• Lymphocytes <500/mm3

• Hemoglobin < 9 g/dL (Xeljanz®) or <8 g/dL (Olumiant®)

IL-6 Inhibitors: Actemra® (tocilizumab)& Kevzara® (sarilumab)

Among hospitalized adults with progressive severe or critical COVID-19 who have elevated markers of systemic inflammation in combination with steroids

8 mg/kg IV once (maxdose 800 mg); can consider 2nd dose 8 hours+ after initial

What is the dosing of Tocilizumab?

400 mg IV once

What is the dosing of Sarilumab?

inflammatory markers of IL-6

Systemic inflammation: C-reactive protein ≥ 75 mg/dL

BBW of Actemra andKevzara

serious infections

GI perforation

You should avoid Actemra and Kevzara in pts with what?

Actemra

should be avoided in pregnancy

AEs of IL-6 inhibitors (Actemra and Kevzara)

increased LFTs, neutropenia, urinary tract infections, and injection site reactions

do not initiate IL-6 inhibitors

• ANC < 2,000/mm3

• Platelets <150,000/mm3

• ALT/AST > 1.5 times ULN

Pemgarda (pemivibart)

-used for PREVENTION of covid in moderately or severely immunocompromised patients ≥12 years of age and ≥ 40 kg

-pts who have high risk of progression to severe covid without exposure

4.5 g IV as a single dose; may repeat dose every 3 months

What is the dosing of Pemgarda (pemivibart)?

at least 2 weeks after vaccine is recieved

When is pemgarda (pemivibart) given?

AEs of pemgarda (pemivibart)

infusion reactions, fatigue, headache, nausea, upper respiratory tract infection

Pemgarda (Pemivibart) BBW

anaphylaxis - monitor for at least 2 hours after infusion

risk factors for severe flu

-older adults (≥65 years)

-children < 2 years

-those with underlying conditions

s/s of flu

-rapid onset of fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis

-children - nausea, vomiting, otitis media

ppl who get flu tx

-Hospitalized patients

- Severe or progressive illness

- High risk of complications

- Immunosuppressed

- Multiple chronic conditions

- Pregnant women or within 2 weeks postpartum

- Children < 2 years of age

-Adults ≥65 years

ppl who should get chemoprophylaxis for flu

-Unvaccinated individuals with high risk of complications

- Severely immunocompromised

- Short-term for unvaccinated individuals in close contact with high risk individuals

neuraminidase inhibitors

-Oseltamivir (Tamiflu®)

-Zanamivir (Relenza®)

-Peramivir (Rapivab®)

polymerase acidic endonuclease inhibitors

baloxavir (Xofluza)

within 48 hours of symptom onset

When should flu meds be started?

Oseltamivir tx dose

75 mg PO BID x 5 daysIndicated for patients ≥14 days old

Oseltamivir prophylaxis dose

75 mg PO daily x 10 days Indicated for patients ≥3 months old

zanamivir tx dose

2 puffs BID x 5 days Indicated for patients ≥7 years old

zanamivir prophylaxis dose

2 puffs daily x 10 days Indicated for patients ≥5 years old

peramivir dosing

600 mg IV dose once over 15-30 minutes Indicated for patients ≥5 years old

AEs of Oseltamivir

-nausea/vomiting

-post-marketing:serious skin reactions & neuropsychiatric events

AEs of Zanamivir

sore throat, bronchospasm, sinusitis

Peramivir AEs

-diarrhea

-post-marketing: serious skin reactions & neuropsychiatric events

ozeltamivir (Tamiflu)

requires renal dose adjustments

zanamivir (Relenza)

-avoid in those with dairy allergies

-avoid in those with underlying airway disease

peramivir (Rapivab)

-ideal for those who cannot take oral or inhaled therapies

-requires renal dose adjustments

2 mg/kg qd

What is the dose of baloxavir (Xofluza) for <20 kg?

40 mg po qd

What is the dose of baloxivir (Xofluza) for 20-80 kg?

80 my po qd

What is the dose of baloxivir (Xofluza) for > 80 kg?

AEs of Xofluza

-D

-V

polyvalent cations (electrolytes)

What are the DDIs with Xofluza?

uncomplicated flu infections

Xofluza is indicated in what type of flu infection?

> 5

How old do you have to be to get Xofluza?

October through march

What is the "RSV season"?

RSV

-most common cause of lower respiratory tract infections in elderly and infants

-no available antiviral therapies for tx

risk factors for severe RSV

• ≥ 75 years of age

• immunosuppressed patients

• history of cardiac or pulmonary diseases

• preterm birth

• < 6 months during RSV season

s/s of RSV

nasal congestion, rhinorrhea, cough, fever, sore throat, headache

s/s of severe RSV

tachypnea, dyspnea, wheezing, hypoxia, cyanosis

Beyfortus (Nirsevimab)

-<8 months: born to an unvaccinated pregnant parent during or entering their first RSV season

- 8-19 months: at increased risk of severe RSV disease and entering their second RSV season including:

- Chronic lung disease requiring medical support

(e.g. corticosteroids, diuretics, or oxygen therapy)

- Cystic fibrosis with severe lung disease manifestations

- Severely immunocompromised

- Can still be administered if < 5 doses of Synagis was administered during RSV season

Beyfortus (nirsevimab) MOA

monoclonal antibody that acts on the F protein on the surface ofRSV to inhibit fusion of the virus to the cell membrane

50 mg IM once

What is the dosing of Beyfortus (nirsevimab) for pts < 5 kg?

100 mg IM once

What is the dosing of Beyfortus (nirsevimab) for pts > or = 5 kg?

warning of beyfortus (nirsevimab)

caution in those with a bleeding disorder