Mental HealthBest Clinical Management For H5N1 Infection Debated
The best ways of managing patients with H5N1 infection (avian influenza)
are debated by experts in this week"s open access journal PLoS Medicine.
Higher than recommended doses of the antiviral drug oseltamivir (Tamiflu)
should be used to fight H5N1 influenza, argues Nicholas White (Mahidol
University, Bangkok, Thailand). In contrast to the current WHO guidelines
recommending that oseltamivir be given at a dose of 75 mg twice daily for
five days, Dr. White argues that higher doses should be given for H5N1
infection to avoid any possibility of under-dosing those patients with
unusual
pharmacokinetics and more resistant organisms. This will come at the
expense of increased toxicity, he says, but is necessary given the
mortality
burden of H5N1 infection and the fact that H5N1 replicates more rapidly
than seasonal influenza viruses, reaches much greater viral burdens than
do
other human influenza viruses, and resistance develops swiftly.
Robert Webster and Elena Govorkova from St. Jude Children"s Research
Hospital in Memphis, USA, writing in response to Nicholas White"s article,
disagree. They argue that we must instead consider a multidrug approach to
managing patients with H5N1, an approach that is supported by animal data
and "can guard against the emergence of resistant strains." Tim Uyeki
from the Centers for Disease Control and Prevention in Atlanta, USA,
emphasizes theneed for more data to help inform clinical management of
patients with H5N1 infections. In the absence of these data, he argues, we
need
a multipronged strategy: pharmacological strategies including combination
antiviral treatment, anti-inflammatory agents, and immunotherapy, and
non-pharmacological strategies such as the standardization of optimal
ventilator and fluid management, especially for acute respiratory distress
syndrome, and management of other complications.
In a 2007 article in PLoS Medicine (PLoS Med 4(5): e119), Holger J.
SchÃønemann and colleagues described a new process used by the World Health
Organization for rapidly developing clinical management guidelines in
emergency situations. These situations include outbreaks of emerging
infectious
diseases. The authors discussed how they developed such a "rapid advice"
guideline for the pharmacological management of avian influenza A (H5N1)
virus infection. The guideline recommends giving the antiviral drug
oseltamivir at a dose of 75 mg twice daily for five days.
Funding: NJW is a Wellcome Trust Principal Fellow. RGW and EAG are funded
by the National Institute of Allergy and Infectious Diseases, National
Institutes of Health, Department of Health and Human Services, under
Contract No. HHSN266200700005C; and by the American Lebanese Syrian
Associated
Charities (ALSAC). The funders had no role in the decision to publish or
preparation of the manuscript. TMU received no specific funding.
Competing Interests: NJW is the co-chairman of the World Health
Organization antimalarial treatment guidelines committee. RGW reports
receiving
research funding from Hoffmann-La Roche and BioCryst Pharmaceuticals and
receiving consulting fees from GlaxoSmithKline. EAG reports receiving
research funding from Hoffmann-La Roche and BioCryst Pharmaceuticals.
Citation:
"What Is the Optimal Therapy for Patients with H5N1 Influenza?"
White NJ, Webster RG, Govorkova EA, Uyeki TM (2009)
PLoS Med 6(6): e1000091.
PLoS Medicine