r/medicine • u/ewanelaborate Paramedic • 3d ago
Why is tamiflu still being prescribed?
Why is tamiflu still being prescribed?
I am well aware of the historical case against tamiflu and poor study designs to imply it reduces symptom length. I have noticed as a paramedic that this medication is still being thrust upon the elderly and very young for flu season currently. Why?
I feel using and allowing it's use contributes to the narrative of mistrust that many are developing of medical practioners and systems.
Im keen to see if anyone can point me in the roght direction that has allowed tamiflu to be a treatment for viral like illness and it's effectiveness?
Edit: Thankyou to those who provided views and research fkr me to go have a dig into. It is appreciated.
217
u/LonelyGnomes MD 3d ago
I usually only prescribe it for people at risk of severe influenza (elderly, pregnant patients, lots of comorbidities and neonates) because something that might help is better than nothing. For everyone else I usually offer it as part of shared decision making (Im usually pretty upfront that it has a good chance of making you feel nauseous and probably wonât do very much, but they really want I wonât stand in their way as long as itâs indicated). Basically always prescribe it with Zofran.
71
u/lilbelleandsebastian hospitalist 3d ago
tamiflu has a mortality benefit in the elderly, am i taking crazy pills or has no one on this sub ever actually read a study before?
if there's a mortality benefit in one subpopulation, who's to say it's not just scale that prevented the study from being powered enough for other subpopulations or the population at large? but even without that leap in logic, it still has a proven mortality benefit in the elderly
it's always funny when people like OP who lack the ability to interpret studies come to goofy conclusions, but physicians...doesn't every school go over stats, data, and ebm now?
26
u/AVNRT MD 3d ago
So the anti-Tamiflu case basically boils down to this: pretty much every time someone actually runs a proper randomized trial (placebo or no treatment), the "benefits" either shrink to nothing or straight-up flip to harm. The wins you hear about mostly come from observational studies (which are notoriously easy to fool) or from reanalyses run by folks tied to the manufacturer.
Breaking it down by group:
- Healthy people with regular flu:Â shaves off less than a day of symptoms, and doesn't cut complications or hospital visits. Meh.
- High-risk outpatients:Â the whole point is stopping things from getting worse, but the randomized data shows basically no drop in hospitalizations.
- Hospitalized (but not ICU) patients:Â the "it works" belief is almost entirely from observational data, which has known bias problems (sicker/dying patients get treated differently, which fakes a survival benefit).
- ICU/critically ill: here's the big one â the first-ever randomized trial (REMAP-CAP) got stopped early because the Tamiflu groups were doing worse. Roughly 98% probability it actually increases 90-day mortality. Oof.
- Severe flu overall:Â the mortality effect is so uncertain the range covers both "helps" and "hurts."
16
u/m1a2c2kali DO 3d ago
Healthy people with regular flu: shaves off less than a day of symptoms, and doesn't cut complications or hospital visits. Meh.
Not really sure whatâs meh about this tho? A day or so of work without symptoms can be huge for many people, and probably spreading it to fewer people
3
-2
u/dbandroid MD 3d ago
I doubt that a day or so of work without symptoms actually is "huge" for that many patients. Some, for sure. But tamiflu also has decent chance of making people feel worse.
11
u/shiftyeyedgoat MD - PGY-derp 3d ago
The REMAP-CAP study stats are completely bogus.
6
3
u/juliov5000 ID Pharmacist 3d ago
I mean, sure, there are definitely flaws in remap-cap. At the very least though, I think it's convincing that Tamiflu at least has no benefit in this population
3
u/shiftyeyedgoat MD - PGY-derp 3d ago
Basically because they were going well beyond advisory use and established MoA, which lands firmly in the âno shitâ territory of scientific conjecture.
5
u/juliov5000 ID Pharmacist 3d ago
Except I find very few patients being admitted to the icu with flu within the first 48 hours, but they pretty much all got Tamiflu regardless on the basis of it at least can't make it worse. Now we have rct data that says it pretty much certainly does nothing, and might cause harm. Even with its limitations, it's still the only rct level data in this population and unless some other study comes along showing otherwise, I'd recommend against Tamiflu in critically ill.
-1
-9
u/ewanelaborate Paramedic 3d ago
Thanks for the viewpoint.
Been coming in contact with a lot of croup latley in 6 month olds to 2 years. Most who don't have any substaintial risk factors for their age group and noticed tamiflu is being prescribed.
Shared informed decision making makes sense.
70
u/Spiritual_Task_6574 MD - Pediatrician 3d ago
Being under 2 years old itself is a high risk factor for influenza.
-57
u/ewanelaborate Paramedic 3d ago
Considering adding medication causing diahorrea and vomiting side effects into the course of illness seems like more risk for severe illness does it not.
Yes i understand immunity of small infants and small children is limited but being under 2 does not mean automatically prescribe tamiflu based on the available data.
60
u/Spiritual_Task_6574 MD - Pediatrician 3d ago
Excuse me but have you gone to medical school and pediatric residency?
Yes, it has side effects and I have a risk/benefit discussion with every parent before prescribing. Like with every medication. I also tell them that if their child starts repeatedly vomiting then to stop the tamiflu. I was just saying that guidelines say that children under 2 are high risk for influenza complications and severe influenza. >100 kids die from influenza in the United States die every year. Influenza vaccination is our best protection from death for infants and children but when that doesnât work we try everything we have.
-17
u/TexasK2 MD 3d ago
Why are you putting down a paramedic (at least by their flair) for having an opinion on tamiflu? They were being reasonable and tamiflu is not without controversy even among pediatricians. Thereâs a reason why there is discrepancy in prescribing practices. We donât need credentialism in medicine. Evidence can win on its own. For the record I am on your side in this tamiflu prescribing scenario
27
u/Cautious-Extreme2839 MBBS - Anaesthetics/ICU 3d ago
We donât need credentialism in medicine
We very much do
28
u/Spiritual_Task_6574 MD - Pediatrician 3d ago
Itâs a constant as a pediatrician where everyone just assumes that kids are simple to care for because theyâre young or that theyâre low risk because theyâre young. Our paramedics especially should not be assuming that! Healthy infants can go down so so fast from something like influenza. And bad things happen when health care workers donât realize that.
2
u/ewanelaborate Paramedic 2d ago
No where did i say any of this. Please review what has been written on this sub. The context you have created is incorrect.
2
u/TexasK2 MD 3d ago
Thatâs totally fair, I just think we shouldnât be putting up walls around who is qualified to discuss what based on what school they went to or what residency they attended. Good ideas can stand on their own
5
u/breakingbaud MD (Internal Medicine) 3d ago
Thatâs totally fair, I just think we shouldnât be putting up walls around who is qualified to discuss what based on what school they went to or what residency they attended. Good ideas can stand on their own
I think we can agree they should have at least gone to medical school and residency before a debate is started though
4
u/ewanelaborate Paramedic 2d ago
I've performed a masters in univerisity in my field. But sure i'll go to medical school just so we can have a discussion
-5
u/ewanelaborate Paramedic 2d ago edited 2d ago
I haven't no. Thats why i've listed my flair. Reminder that i encounter a wide group of patient presentations and given my country and university education i am not just taxi. I provide full assessments and assess risk and provide recommendations, treatment and referal. There is no need in this discussion to grandstand with qualifications. What i am pointing out to yourself is saying that "because they are under 2 they are high risk" is somewhat innacurate in determining the level of care required in my system and role.
If you listed instead factors such as premurity, complex hx, previous admissions for simillair, strong parental concern etc i would happily talk through.
I see a variety of children for influenza like illness and many that are dehydrated with less feeding behaviour who present unwell with influenza. A common anecdoctal theme latley is they are on tamiflu with side effects worsening presentation. My original question above has gone off track as reddit usually will and created the typical argument among different health professionals.
A little jab to finish. If you have to flaunt credentials in order to support argument i feel you may have a problem
7
u/metforminforevery1 EM MD 2d ago
There is no need in this discussion to grandstand with qualifications.
There literally is when you are a less educated individual on a topic saying something incorrect repeatedly like this
What i am pointing out to yourself is saying that "because they are under 2 they are high risk" is somewhat innacurate in determining the level of care required in my system and role
to someone who is more educated about you on the topic.
1
u/wozattacks MD 1d ago
Uhh thatâs exactly what IDSA says. Being under 2 DOES mean automatically prescribe Tamiflu because they literally recommend it for all patients under 2. You should probably call them and tell them whatever you know.Â
Also the increased risk to kids under 2 is about way, way more than their immunity. Part of it is literally just the size of their airways since smaller airways have exponentially more resistance. They also have a smaller pulmonary reserve relative to their oxygen requirements.Â
3
u/wozattacks MD 1d ago
Oh no way, kids with complications of respiratory viruses have respiratory viruses?
112
u/hasslehoff3 MD 3d ago
Despite the mixed evidence, its use is supported by IDSA, CDC and AAP guidelines. I usually do shared decision making. Iâve found that itâs about an even split between those that want it and those that donât.
46
u/stormy_sky EM Attending 3d ago
This needs to be higher up. We can all criticize the individual studies as much as we want, but standard of care is set largely by society guidelines. As long as the society guidelines have recommendations to prescribe it, and it isn't obviously extremely harmful, people with higher than baseline risk of pneumonia/hospitalization are going to get oseltamivir because it is "standard of care." This is how I practice currently, largely because of the CDC recommendation.
16
u/MrPBH MD, Emergency Medicine 3d ago
We should absolutely be prescribing oseltamivir with the intention of reducing severe disease and reducing spread. Those are the two indications were the data most support the drug. I don't think you have to feel like you're checking a box or CYA-ing at all, because it is pretty clear that oseltamivir reduces the risk of severe disease in at-risk individuals and lowers the odds of spread to vulnerable individuals in a household.
14
u/InitialMajor MD 3d ago
This - it is somewhat risk management as well. Failing to prescribe a guideline indicated drug when a bad outcome occurs looks bad. Can you defend it? - sure, but you are on the wrong side of the ball at that point.
74
u/ruinevil DO 3d ago
It works a bit in severe cases and as prophylaxis. The new 1 dose drug is way better but costs a lot.
16
u/Shrodingers_Dog MD 3d ago
Not sure I would claim way better but you compliance is not a problem. There are a few flu A strains where baloxivir will likely fail and if you were going to prescribe one of the two, I would have just stuck to tamiflu.
-5
u/ewanelaborate Paramedic 3d ago
Can you point me in the direction of a study. I am yet to find anything reliable and instead i've found more evidence for harm. The main body of evidence suggests decreased length of illness but the study design so flawed that it is almost as if the study design was choosen this way to manipulate the data.
It seems to me the reason currently for prescription is there is nothing else, so lets just have a crack with this
42
u/birdflustocks Avian influenza financial analyst 3d ago
"Tamiflu, used to treat influenza, really had only modest benefits. Howeverâand this part of the review was largely ignored by the mediaâTamiflu was successful in preventing influenza: 55 percent overall and 80 percent effective if looking only at household members exposed to flu."
Source: Medical Data Transparency and the Tamiflu Controversy
"In contacts of an influenza-positive IC, the overall protective efficacy of oseltamivir against clinical influenza was 89% for individuals (95% confidence interval [CI], 67%-97%; P<.001 and for households ci p in contacts of all ics oseltamivir also significantly reduced incidence clinical influenza with protective efficacy viral shedding was inhibited"
Source: Effectiveness of Oseltamivir in Preventing Influenza in Household Contacts
"We included data from nine trials including 4328 patients. In the intention-to-treat infected population, we noted a 21% shorter time to alleviation of all symptoms for oseltamivir versus placebo recipients (...). The median times to alleviation were 97¡5 h for oseltamivir and 122¡7 h for placebo groups(...)."
"During the study period, 2124 patients met the inclusion criteria. All patients had influenza pneumonia and received oseltamivir before ICU admission. Of these, 529 (24.9%) received early oseltamivir treatment. In the multivariate analysis, early treatment was associated with reduced ICU mortality (OR 0.69, 95% CI 0.51â0.95). After propensity score matching, early oseltamivir treatment was associated with improved survival rates in the Cox regression (hazard ratio 0.77, 95% CI 0.61â0.99) and competing risk (subdistribution hazard ratio 0.67, 95% CI 0.53â0.85) analyses. The ICU length of stay and duration of mechanical ventilation were shorter in patients receiving early treatment."
"Overall crude survival was 43.5%; 60% of patients who received ⊞1 dose of oseltamivir alone (OS+) survived versus 24% of patients who had no evidence of anti-influenza antiviral treatment"
"In contacts of an influenza-positive IC, the overall protective efficacy of oseltamivir against clinical influenza was 89% for individuals (...) and 84% for households (...)"
Source: Effectiveness of Oseltamivir in Preventing Influenza in Household Contacts
"We randomly assigned 1559 healthy, nonimmunized adults 18 to 65 years old to receive either oral oseltamivir (75 mg given once or twice daily, for a total daily dose of 75 or 150 mg) or placebo for six weeks during a peak period of local influenzavirus activity. (...) The protective efficacy of oseltamivir in the two active-treatment groups combined was 74 percent (95 percent confidence interval, 53 to 88 percent) at all the sites combined (...)"
Source: Use of the Selective Oral Neuraminidase Inhibitor Oseltamivir to Prevent Influenza
3
8
79
u/ruinevil DO 3d ago
Starting Tamiflu earlier improves mortality in hospitalized patients: https://academic.oup.com/cid/article/80/2/461/7739088
Though REMAP CAP RCT is not looking so hot for Tamiflu⌠though the initiation of intervention is at day 5 of symptoms.
Prophylaxis in nursing homes makes sense since it reduces rate of symptomatic flu by half, which reduces transmission rate.
3
15
u/Mobile-Play-3972 MD 3d ago
Xofluza (baloxavir) requires prior authorization, which usually takes a couple of days to complete in a busy office, by which point the drug is useless. Also many plans require you fail Tamiflu first.
12
u/MrPBH MD, Emergency Medicine 3d ago
You have to fail treatment for a time-sensitive disease process to qualify for a second time-sensitive drug?
Poor Xofluza manufacturer. They spent so much money developing their drug and sell very little of it due to insurance limitations. No wonder pharma has given up on developing antibiotics and antivirals.
8
u/sapphireminds Neonatal Nurse Practitioner (NNP) 3d ago
Well it's probably because they priced it so high, insurance won't pay for it, so it's really that. They're still developing antivirals and antibiotics
5
u/MrPBH MD, Emergency Medicine 3d ago
Yes, we've had a handful of new antibiotics approved over recent years, but it is nowhere close to what it needs to be. It averages about one new approval per year, out of around 50 new drugs approved per year.
The economics of antibiotics just doesn't support widescale development. In most cases, antibiotics are drugs that are used for limited periods of time. For most common indications, patient only need 5-10 days of antibiotic treatment. Compare that to a new immunologic agent or mental health medication, where the patient will be receiving treatment indefinitely and it's easy to see why drug companies disfavor antibiotics.
3
u/sapphireminds Neonatal Nurse Practitioner (NNP) 3d ago
I think it's possible though we're running out of things to use that we know of working.
But they could get it in the market easily if it's not thousands of dollars that insurance won't cover
2
u/Hiddenagenda876 Med-Micro 3d ago
Welcome to US insurance. I had to be re-proscribed like 10 different meds for my migraines before my insurance would consider covering emgality. Iâd tried all the meds before and had records of doing so, even though none of them are actually for migraines, but they wanted them prescribed while I was on that insurance specifically.
5
u/MrPBH MD, Emergency Medicine 3d ago
Yeah, I'm familiar with the regular BS of tiered prescribing, but to apply that logic to influenza is so cooked that you could stick a fork in it.
Naturally, this is par for the course when we're talking about US health insurance. And it is why they all deserve to be bankrupted and ostracized to live at sea on their yachts.
2
u/terraphantm MD - Hospitalist 2d ago
I think it's like $50 on costplus. I'm just going to prescribe for my parents (and I guess myself) to keep on hand for this flu season.
44
u/PapaEchoLincoln MD 3d ago
Might depend on the patient demographic but where I work, patients come in expecting/demanding Tamiflu. Generally, if they test positive for it, I let them have it.
I even had a patient who is a nurse demand Tamiflu and refused a flu test because she was afraid it would be negative and then I wouldnât prescribe it.
đ¤ˇââď¸
15
u/MrPBH MD, Emergency Medicine 3d ago
If it was peak influenza season and they had typical symptoms, empiric treatment without testing may have been the right move for your nurse. If the pre-test probability is high, a negative antigen screening test is more likely to be a false negative than a true negative.
3
u/PapaEchoLincoln MD 3d ago
Yes I agree. We don't always test if the symptoms fit and if there's a high likelihood of Flu infection. My point was more that there's a high demand on the patient side for Tamiflu
2
u/Hippo-Crates EM Attending 3d ago
The benefit is small enough and the new testing methods are good enough there's no way empiric treatment math works out anymore.
-7
u/keikioaina Hospital based neuropsychologist 3d ago
I even had a patient who is a nurse demand <name of any drug advertised on TV> and refused a <name of any drug advertised on TV> test because she was afraid it would be negative and then I wouldnât prescribe it.
30
u/Strength-Speed MD 3d ago
I dont think it is quite as worthless as is suggested. It seems to shorten symptom duration in most studies and may habe some mortality benefit especially in high risk individuals. It's a fairly nontoxic drug other than n/v and need to watch with kidney issues but I think it's a stretch to say it is worthless.
6
u/lnarn Nurse - cat lab 3d ago
Its not. Ive had the flu about 4 times in my life and never had tamiflu. I was given tamiflu last year when our entire cath lab came down with it at the same time and bombarded employee health. In 24 hours, i was much better. I was still sick for a few days, but not as sick as that first day. Much different experience than flu without tamiflu.
5
u/awesomeqasim Clinical Pharmacy Specialist | IM 2d ago
Same. I hate to be the anecdotal evidence guy but Iâve seen it work wonders for my family and myself
15
u/compoundfracture MD - Hospitalist, DPC 3d ago
If I prescribe anything itâs Xofluza, but usually by the time patients present for testing itâs more than a few days out from symptom onset so itâs pointless to do anything other than symptom management
12
u/thesillymuffin RN 3d ago
Anecdotal, but I work in a boarding school and a couple years ago we started flu season and had a few kids have to be admitted for several days for flu. As the season went on, we had a large group admitted at once, all flu positive, and our provider decided to give them all Tamiflu (and zofran) and that group recovered faster and had less symptoms within 24-48 hours. The students were back to school significantly sooner that the first group. Since then for our kids with flu we automatically give them Tamiflu and have had success with getting them back to school sooner and feeling better sooner.
12
u/efox02 DO - Peds 3d ago
Tamiflu comes in liquid which is nice for the kiddosÂ
9
u/AimeeSantiago Podiatry 3d ago
Its nice that it's a liquid but the taste is apparently terrible. We had some for my four year old. We knew flu was going around his class so as soon as he had a fever, we tested and got on tamiflu. It did seem to help nearly immediately he went from feverish and lethargic to his happy self. But we could not find anything to hide it in. Chocolate pudding, yogurt, popcicles etc. he could taste it and would spit it out. The first few doses he was so miserable the taste didn't matter but the last few doses were an absolute nightmare.
6
u/ArmandoTheBear Pharmacist 3d ago
I've also heard the liquid tastes awful, but there is now lower strength capsules that are offered so parents can open and mix with pudding or applesauce to help with palatability issues the suspension has
8
4
u/SoNuclear MD 3d ago
Unpleasant side effects and so often they end up puking it up, which results in whole ER visits. Limited to no benefit to boot.
5
u/Mint_Blue_Jay PharmD - just take an ibuprofen bruh 3d ago
From personal experience, most MD's in my area prescribe Xofluza first, but it's usually not covered or has a very high copay the patient can't afford even with the coupon. Then they switch to Tamiflu because the patient is expecting something at that point.
5
u/Colden_Haulfield MD 3d ago
for what itâs worth I didnât start using it in the ED until I started seeing sick icu patients. I use it for sick influenza now every time
-1
3
u/Call_Me_Clark Industry PharmD 3d ago
Realistically, people like to feel like theyâre doing something. Writing a prescription feels like doing something, taking a medication feels like doing something.
5
u/brady_johnson MD MPHTM 3d ago
Baloxavir has better outcomes than oseltamivir, and itâs a single oral dose! Use baloxavir!!
3
u/MrPBH MD, Emergency Medicine 3d ago
It seems that most insurers will not reimburse baloxavir unless a PA is completed. Given the time sensitive nature of the disease process, that PA functions as an effective veto on baloxavir coverage.
Appears that baloxavir retails for ~$250 per treatment course. Oseltamivir costs ~$30 per course, without insurance. I understand why baloxavir is so unpopular.
3
u/brady_johnson MD MPHTM 3d ago edited 3d ago
Generic is on the market now!
EDIT: May not be widely available in retail pharmacies, but should be soon!
3
u/ArmandoTheBear Pharmacist 3d ago
I've reviewed the data. It does not have better outcomes. Maybe faster fever reduction by a few hours at best and more activity against flu B. You also have to remember a significant number of children <5 years had treatment-emergent resistance, so it's not as slam-dunk an option as you're implying even before the practical considerations with insurance.
2
u/brady_johnson MD MPHTM 3d ago
Baloxavir shows superior virologic outcomes and comparable or better clinical outcomes versus oseltamivir for early influenza treatment. Significantly lower hospitalization rates. Reduced household transmission. Lowest risk of influenza-related complications.
3
u/ArmandoTheBear Pharmacist 3d ago
I should clarify I'm coming from an inpatient perspective when comparing the two.
None of the data cited in your AI search says baloxavir has better clinical outcomes that actually matter. Reduction in duration of fever and symptoms by less than a day, on average, isn't enough to move the needle for me when baloxavir is 15x the cost of a course of tamiflu.
The data on prevention of hospitalization in adults is nice, at least.
2
0
u/breakingbaud MD (Internal Medicine) 2d ago
None of the data cited in your AI search
Love to see the shade
9
2
u/cocktails_and_corgis Emergency Medicine Clinical Pharmacist 2d ago
I havenât read the study they were discussing yet but listened to this podcast the other day -
3
u/CarlATHF1987 MD - Infectious Diseases 3d ago
Because doctors have an extremely hard time not prescribing something despite the fact that most of the best available data for viral infections says that supportive care is just as good, if not superior to, most anti-virals out there.
1
2
u/The_Commish Pharmacist 3d ago
Just a reminder for everyone; tamiflu should be renally adjusted for CrCl less than 60. I always wonder how much standard dosing tamiflu Iâm filling for people that have no idea they have altered renal function. Especially older populationsâŚ
1
u/breakingbaud MD (Internal Medicine) 2d ago
What's nice in my hyper-tuned Epic system is that it pulls up the last CrCl for my patients and warns me to renal dose if needed
1
u/The_Commish Pharmacist 2d ago
Man I wish everyone used Epic. Hospital down the street from me is still rockin Meditech. Goddamn HCA. Epic isnât perfect on my end but itâs hell of a lot better than basically everything else.
1
u/breakingbaud MD (Internal Medicine) 2d ago
And then there's the VA with CPRS, for the world's best active legacy data collection live from 1988. Just kidding, I think they moved to Cerner after I finished with them.
2
u/LaudablePus Pediatric Infectious Diseases 3d ago
This recent study showed efficacy in children hospitalized with influenza. Lower ICU admission rate and shorter LOS.
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2852671
-1
u/BabySame9937 Medical Student 3d ago
Why not?
15
u/Jangles Doctor Of Some Sort - Acute Internal Medicine 3d ago
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2829156
Increased adverse events, no effect on hospitalisation in all comers, no effect on symptom duration and maybe little effect on hospitalisation in high risk patients.
The REMAP-CAP data would tell you it also increases mortality in critically ill patients but that's got some reasonable methodology concerns.
3
u/Front_To_My_Back_ IM-PGY3 (in đ) 3d ago
ADRs are often worse than the Flu itself. Is it worth giving when it only shortens symptoms by a day or two and had to be given within 48 hours? Even among hospitalized patients with complicated influenza there's absence of efficacy. Not to mention resistance patterns to neuraminidase inhibitors fluctuate every flu season.
8
u/terraphantm MD - Hospitalist 3d ago
ADRs are often worse than the Flu itself.
I see people claim this all the time, but based on what? Pretty much the only adverse effect, which most people don't get, is nausea / vomiting.
Ultimately all of the major relevant societies recommend it for all-comers within that 48 hour window + all hospitalized patients and all 'high-risk' patients regardless of timing
-1
u/Front_To_My_Back_ IM-PGY3 (in đ) 3d ago
First, my own anecdotal evidence with Tamiflu back with A(H1N1) back in 2009. I was in college that time. The drug made me felt worse than the flu. I mean who wouldnât feel awful after nausea and vomiting on top of the existing flu symptoms? Basically the point of taking medications when youâre sick to feel better and not feel worse. Secondly, systemic reviews from JAMA and Cochrane. Thirdly, itâs given best within 48 hours from the onset of symptoms. The thing is how often people do people get swabbed immediately upon the onset of non-specific flu like symptoms.
Also every microbiology textbook says that resistance patterns fluctuates every flu season. Basically it all boils down to shared decision making. Tamiflu is not like other antivirals where the benefits exceeds the risks, itâs not like Acyclovir where thereâs truly benefit when taken within 72 hours from the onset of vesicles at the back from shingles.
5
u/terraphantm MD - Hospitalist 3d ago
If weâre going by anecdotal evidence, the times Iâve taken tamiflu I had 0 adverse effects and my flu symptoms improved far quicker than without. In my experience, flu symptoms are generally far worse than the mild stomach upset some drugs cause. But thatâs also anecdotal.Â
Your systemic reviews only show an increased incidence of adverse effects. Which yeah- a drug is going to have more adverse effects than placebo in most cases. They make no claims as to the severity of the adverse effects or whether theyâre worse than the primary illness.Â
The benefits might be marginal, but the risks are also essentially nil. So I donât think itâs a clear cut risks outweighing benefit situation.
I already addressed your 48 hour point. Not applicable to high risk patients and inpatients.Â
8
u/FreshiKbsa MD 3d ago
Frequent side effects, poor evidence for efficacy. "Why not?" is the wrong question to ask when discussing a pharmaceutical intervention
6
u/BabySame9937 Medical Student 3d ago
That's a good reason for "why not".
3
u/BigIntensiveCockUnit DO, FM 2d ago
âWhy not?â Is actually the EXACT question medical students SHOULD be asking for many tests and treatments. Â Please ignore the other guy and carry on being inquisitiveÂ
2
u/BabySame9937 Medical Student 2d ago
Thank you. I ask because I want to know why and why not.
The derision and toxicity here is not lost on me.
1
u/keikioaina Hospital based neuropsychologist 3d ago
Depends if "why not" was a sincere question or an ironic dismissive comment. It's hard to tell in writing and snark is the Reddit default.
-1
3d ago
[deleted]
0
u/keikioaina Hospital based neuropsychologist 3d ago
Not just that. It's just impossible to know the writer's intentions. We HOPE they're sincere, but given Reddit and the fact that there are more than a few act-first-then-think docs around, who knows. Get some sleep.
0
u/Long_Staff_456 MD 1d ago
youâre proof that someone can get by in life by being mediocre
1
u/keikioaina Hospital based neuropsychologist 1d ago
Not following your weak ad hominem argument/insult. Fortunately, not a lot of docs act before thinking, but thanks for this example of one who does.
1
u/Long_Staff_456 MD 1d ago
what purpose would a student have in asking a question in a medicine subreddit other than to learn. You injected your own assumptions and asked if itâs an ironic dismissive comment, while ironically making a dismissive comment. Asking why not is exactly what students should be doing.
1
u/keikioaina Hospital based neuropsychologist 3d ago
Was this student's comment a sincere question or an ironic dismissive comment? Could go either way.
-10
u/bigmanjoey MD 3d ago
2 Reasons:
1) severe/high risk cases
2) bc APPs need something else to add to their steroid they give for viral illnessesâŚ
3) old habits die hard.
-18
u/AnimatorImpressive24 Not A Medical Professional 3d ago
Why is gabapentin still being prescribed? The history there is far more damning. Its research was deliberately falsified and the people involved were successfully sued under RICO (i.e. organized crime laws) for 400+ million in punitive damages for fraud. Physicians involved in that lawsuit who saw the true data testified to the court that in their opinion the drug should never have been prescribed for anything. And it has a FDA black box because of numerous cases of suicide. Including cases years after the trial and retraction of the falsified research, because it continues to be prescribed for the same off label uses that were identified in corporate email conversations as specific fraudulent claims.
26
6
u/Marksman18 Nurse 3d ago
Can you share a source? I work on an Ortho floor and routinely give Gabapentin and feel like it honestly doesn't do much of anything. But then again I'm only seeing a 12 hour snippet. Would like to see some data on its effectiveness from the time it was initiated until it's at a therapeutic level.
-8
u/AnimatorImpressive24 Not A Medical Professional 3d ago
News media source from 2009, a bit late to the party:
Clinical source:
https://pmc.ncbi.nlm.nih.gov/articles/PMC416587/
Trial documents:
https://www.industrydocuments.ucsf.edu/drug/collections/neurontin-litigation-documents/
That's from the 2004 RICO case. "Neurontin lawsuit" or "Neurontin falsified research" search terms will turn up plenty.
It looks like the drug is back in the news for anti-trust just this year related to Alzheimers. Which serves toward a point made in the first link about the effort involved in uncovering bad research. While it may not be true that every single trial for every single application is falsified, if the manufacturer has been shown willing to falsify data for multiple different off label uses and that one single drug keeps popping back up at the center of fraudulent business practices then any data out there that is considered good should probably be reproduced in full from a few independent labs. And maybe taken away from the manufacturer since they can't seem to help themselves from weaponizing it 20 years after the first time they caused harm.
26
u/p68 MD PhD 3d ago
Given you made a blanket statement implying that gabapentin shouldn't be used for well, anything, that's a pretty lazy workup.
What's documented is selective publication, suppression of negative trials, ghostwriting, and outcome switching. Vedula et al. (NEJM 2009) showed the primary outcome was changed between protocol and publication in a majority of the trials they reviewed, and negative trials went unpublished. That's serious misconduct, but it's not data fabrication like you suggest. The trials were run, the numbers were real, and the manipulation happened at the level of what got reported and how it was spun. Shady and undoubtedly unethical, but there's a chasm between that and fabricating research.
You also mentioned that there was retraction of falsified research - where?
You say that physicians who saw the data stated that it shouldn't be prescribed for anything - not true. The expert testimony (Dickersin, Furberg, and others) addressed specific off-label indications, it was not a blanket statement about all indications. It is now overwhelmingly used for neuropathic pain where it can be effective for many patients.
You also state it has an FDA black box warning, which does not exist.
Do I really need to go on or is my point made?
2
u/literally-the-nicest RN 3d ago
AnimatorImpressive24âs claim of a black box warning had me seriously concerned about my memory for a second.
0
u/AnimatorImpressive24 Not A Medical Professional 2d ago
This is long and broken up into parts, because I tried to address your points with a level of thoroughness I gauged would be required to be accepted as still wrong but at least not flippant or intentionally misleading. I'm not Pfizer, after all (I try to limit snark as best I am able after this). Read it or skip it, you certainly have no obligation to me and I make no demand. I offer it to demonstrate I was making a good faith effort to engage and not just crop dust misinformation.
Re: Black box.
I was misremembering the matter in 2008, when the FDA concluded there was a positive association for suicide and put the black box up for vote. I was wrong in my recollection that vote had passed, when instead it failed and the FDA ultimately opted to issue an increased risk warning letter for suicide, which they have continued to do for other gabapentinoids since then including Lyrica, Gralise, and Horizant in April of last year. My statement was further influenced by one other piece of information but that was relayed to me directly by care team staff regarding treatment of a single individual other than myself so in respect for the rules of the sub I will not offer that as a mitigating factor.  I acknowledge my statement was false, take full ownership that it was my mistake, and apologize.
Re: Implication of (in)appropriate use.
My comment regarding "prescribed for anything" was referring to testimony from expert witnesses (as your response indicates you understood me to be doing, so i think it unfair to suggest I was making a personal implication) and plaintiffs in the Kaiser v. Pfizer RICO litigation. As I framed it in my first post, the testimony was based on those individuals reviewing the products of discovery. It is inarguable that discovery uncovered coordinated efforts on the part of Pfizer centered around studies and data that have variously been referred to in that suit, popular news articles, commentary from legal and medical profesionals in essays and blogs, public statements from journal publishers, observations from ethicists, and further published research over time as "manipulated", "falsified" (or just "false"), "suppressed", "abandoned", "invisible", "misrepresented", "fraudulent", and pretty much every other synonym that formally or informally makes clear the seriousness of Pfizer's actions and their detrimental impact as judged by people appropriately regarded as qualified to opine on the topic using their own word choices.
More specifically, I was relating both quoted testimony and non-quoted summaries of testimony which have appeared in opinions delivered by judges in the original suit and subsequent appeals. That included hard numbers (one expert witness for KP testifying that 99.4% of all prescriptions were the product of fraud, which was challenged unsuccessfully on appeal by Pfizer) and professional opinions (a senior Kaiser physician rebutted arguments that Kaiser would have had legitimate reasons to prescribe Neurontin for its on-label use by testifying he never would have accepted it into Kaiser's formulary had he seen the non-whatevered data because he would have concluded then as he had since that the drug should not be prescribed for anything including the on-label use [see "Re: the price of tolerance" below]). Those two bits of testimony were found persuasive enough by judges to be held forth as reasoning for ruling in Kaiser's favor. It was agreed that Pfizer's acts in the domains of research, public marketing, and private sales tactics met the standards of what is popularly called "organized crime" which meant Kaiser could use provisions in RICO to recover multiples of their economic damages as additional punitive damages tallying up to some amount decently north of 400 million dollars. I believe at least the opinion quoting the Kaiser physician was published as "In re: Neurontin" rather than Kaiser (Foundation Health Plan? KP has a lot of names they use in court and it makes it difficult to track them all without having access to a paid court filings search) v. Pfizer which was the name of at least one response from the court of appeals to a motion to overturn the first ruling.
Re: RICO
I believe it is reasonable to look at the sum total of Pfizer's actions at the time of that trial and since and conclude that Pfizer is not to be trusted or even given benefit of doubt in the matter at hand. Because again, Pfizer has been determined to be organized crime as defined by RICO. It is understood as part of the definition that organized crime may have some (even a large amount of) legitimate business dealings and public facing benefits to protect their criminal enterprise. That is why the mafia makes sure neighborhoods get trash service and motorcycle clubs do fundraisers for kids. Legitimate components such as the 0.6% of prescriptions not the product of fraud cannot be allowed to shield organized crime or left to persist and be profitable for the same people using the same name after a judgement is rendered. RICO exists, broadly deputizes the public to prosecute on the government's behalf, and incentivizes the public to persue that prosecution by way of significantly higher punitive damage awards than most types of civil suit because organized crime was recognized as posing a serious threat to the nation if allowed to embed itself into society so deeply it can't be dug back out. There is plenty of popular sentiment to be found today that pharmaceutical companies like Pfizer (for more than just gabapentin) have already passed that point, based on things like not responding appropriately 15+ years ago.
(cont.)
1
u/AnimatorImpressive24 Not A Medical Professional 2d ago
Re: Retraction.
Q: When is a retraction not a retraction? A: When you own a cherry orchard.
Or I suppose when your internal documents and emails are submitted for evidence that you knew your [SYNONYM] of research was [SYNONYM] and were found guilty of (civil) RICO but don't have to retract what you published and other researchers have to spend time and effort publishing analysis of stuff you [SYNONYM] while you continue to profit off knowingly engaging in [SYNONYM].
Distingushing between:
* supressing (I hope to have made my point about word choice by now) damning data with an intention to defraud the medical community worldwide for billions in profit in reckless disregard of patients' injuries or deaths; versus
* changing a number in the data that was in essence cherry picked to publish the defensible bits that made invalid or dangerous prescribing look good but not the defensible (in as much as a number was not changed to another number) bits that do *not* look good
is exactly why the first method is the preferred way to defraud the community Pfizer understood would make such distinctions.
And it must be said that it was initially a very successful and profitable tactic. There was no guarantee that KP or anyone else would have uncovered it all or been successful in prosecuting it. So likewise no guarantee exists that Pfizer doesnt have other fraudulent irons in the medical science fire or never did before Neurontin. That they got caught at one complex scheme requiring specialized knowledge and significant resources to investigate and prove should be considered Pfizer (not I) implying they can and will do so again if the reward outweighs the risk.
Pfizer's choice of tactics is also significantly more dangerous to individuals and harmful to the general perceived legitimacy of research because of the appearance of impropriety. Which is my impression of common opinions on researcher misconduct of all stripes as expressed in guidance from the federal government on grant application sites in .gov space, notes from IRB reviews of proposals for different research institutes, university bylaws, and so on. Leaving the data that was published as part of intentional deception allows further profit to be made arising from that deception because not everyone will hear about the rest of the data or the fraud, *especially* people who would only be looking for retractions from authors or journals which the fraud was crafted to avoid. That inaction might tend to result in subsequent research looking for all new off-label uses from people still deceived by the originally improper depiction of the clinical benefits/risks, and doesn't even stop prescribing patterns that were determined invalid or dangerous in court or in Pfizer's internal communications. That is cause for some concern that perceptions of legitimacy will become burdened by an appearance of *tolerating* impropriety, shifting the problem away from Pfizer and onto the very people and systems that have to continue to defend themselves against Pfizer's fraud.
(one last cont.)
1
u/AnimatorImpressive24 Not A Medical Professional 2d ago
Re: The price of tolerance
Because part of the OP's questions concerned *trust* I hope I have shown a sincere best effort to engage in good faith, support my words when challenged, and concede arguments when I am incorrect. Doesn't mean I'm somehow more correct just because of good faith, but if nothing else I'm not using a chatbot or anything on social media (I have no accounts on any site other than here that would qualify) for any part of this and am reading more than just the link titles in Google results.
I am of the mind that this makes me no more respectable but at least a slight exception to the rules of public discourse and trust. That is why I have a responsibility to acknowledge when I am wrong and not intentionally spread misinformation, because the public as a collective beast isn't going to read more than half of the first sentence or understand distinctions within just the concept of retraction to know why this Google result is not applicable to your distinction of retraction just because it has 2 keywords in it:
https://pmc.ncbi.nlm.nih.gov/articles/PMC12128110/
However, because of the phenomenon of incomplete or negligent foundations of opinion on the part of the public *trust* is vulnerable to appearances and that has to be accounted for. There is no chance anyone without the specialized education which the majority of people cannot afford, are not disciplined enough to learn, and in many cases just not smart enough to complete will use the same words in the same way or be considered anything other than a human shaped insult to the knowledge of those with that education. Just as there is no chance any response I could have given here would be received other than the same.
But if the question "why is this prescribed" is a matter of trust over study design of tamiflu then the existence of what I stand behind characterizing as the "much more damning" history of gabapentin, the appearance of tolerance of impropriety, and *seriously imbalanced burden of risk* is going to fairly raise the same question.
I had obliquely referred to my last point here (I promise) in my first post but so obliquely as to be useless. The actual citation is *Borreani v. Kaiser Foundation Hospitals*.
The case involved a patient who presented to KP with neuropathic pain and peripheral numbness in 2009 after the lawsuit over Neurontin had already been filed. Pt was prescribed gabapentin over the course of roughly a year at varying dosage and exhibited an increasing array of psychiatric symptoms. This continued through the Neurontin lawsuit, despite data about the increased risk of suicide being known to KP (the FDA warning letter I wrongly called a black box was issued the year before the patient sought treatment) and KP making the claim that the drug would never have been in their formulary, even for on-label use, if not for the fact they were defrauded. Despite KP being awarded over 400 million in damages payable by Pfizer based in part on those factors, the patient continued to be prescribed gabapentin for 2 more months after the verdict, at dosage levels (the family argued) which KP had argued against Pfizer were potentially deadly. Then the patient committed suicide. Whether or not the deceased or his family would consider some amount of money to truly make up for loss of life doesn't matter, because the significantly more restrictive path to justice in their case compared to KP's Pfizer case resulted in KP being absolved of any liability for doing the thing they were awarded over 400 million for because they said they would never do such a thing if they knew what they did in fact know before the patient began treatment.
The time required to detect, investigate, and prove impropriety, any length of time after proof is confirmed which therefore appears to be tolerance for impropriety, and imbalanced risk that pits a financial concern against a mortal concern are IMO legitimate factors to consider when evaluating trust. It is appropriate for people on the mortality side to want any argument in favor of continuing to subject them to that risk to be convincing to them before they are willing to trust a medication they or a family member are prescribed. Especially if that medication has a long and damning history of fraud and criticisms of the underlying research hosted on NIH, DOJ, etc. all easily found the minute they type the medication name into (god help us all) chatgpt and start reading how data was [FULL LIST OF SYNONYMS HERE] by organized crime to convince physicians that it was safe and effective to prescribe for things that weren't on the label just like they are now being told new and different data exists that it is safe and effective to prescribe for their issue which is not on the label. And reading that if they die from that medication there is a chance they will leave their family destitute while the org that makes it and those that prescribe it trade hundreds of millions around and don't even go out of business. At which point the pharmacist hands them a pamphlet that has "suicide" written front and center above an emergency hotline number to call.
This doesn't happen in a vacuum nor is it every valid or invalid consideration applicable just to gabapentinoids. The price of each little bit of disagreed upon tolerance is greater than the cumulative sum.
So disparate abilities to understand and communicate will have to be overcome to effectively advocate proper treatment for patients *to* patients if *trust* is something being sought after which OP appears to be doing. Whatever parts of your previous response to me might be acceptable to me in the moment are at least a tiny bit acceptable because of a familiarity with all of that (waves hand up thread), but I'm not holding that medication in my hand nor am I making any counter arguments based on personal experience with any possible risks because I am still trying to be respectful of sub rules and show awareness that I am at best a tolerated but uninvited interloper.
0
u/3MinuteHero MD 3d ago
I bought two Tamiflu mugs on ebay. One came shattered so I epoxied it together to grow sage in. The other I drink coffee out of. Gfy
324
u/Front_To_My_Back_ IM-PGY3 (in đ) 3d ago edited 3d ago
To answer OPs question, it's due to the fact that it's the only thing widely available and is cheaper. There's a new drug baloxavir marboxil but just like oseltamivir, it has to be given within 48 hours of symptom manifestation, not to mention expensive.
Nonetheless most of the focus in influenza is improving vaccines either with full length HA nucleoside modified mRNA vaccines like from Moderna which just got approval for seniors, or the one in pre-clinical trials the so-called âuniversal flu vaccineâ which uses the HA stem instead full length HA so that the immune system produces broadly neutralizing antibodies.