Treatment and prevention of influenza in geriatric patients

ABSTRACT

Introduction

Older adults are the most vulnerable population to the effects of influenza. These patients have age-related characteristics that make response to both infection and therapeutics different than younger patients.

Areas covered

Influenza vaccination and antiviral therapy are the foundational approaches to preventing and treating influenza in geriatric patients. Older adults should receive one of the three enhanced vaccines before influenza season beings. There are five antivirals used in influenza. Geriatric patients have been under-enrolled in antiviral studies but have been included in small numbers. Oseltamivir has the most abundant evidence, including in the hospital and long-term care (LTC) facilities, and the strongest evidence for reducing mortality and complications. Peramivir offers the shortest time for symptom alleviation, while baloxavir is best tolerated.

Expert opinion

Oseltamivir has the most versatility in preventing and treating influenza in geriatric patients. Parenteral peramivir and zanamivir are second-line alternatives for complicated influenza when oseltamivir cannot be used. Single-dose peramivir and baloxavir are attractive alternatives to oseltamivir in uncomplicated influenza but will not increase in utilization until more evidence is available regarding mortality and complications, particularly in hospitalized and LTC patients. More studies, including comparative trials, are required to elucidate the role in therapy for each therapeutic in the geriatric population.

KEYWORDS:

• Antivirals
• geriatric
• influenza
• older adult
• prevention
• treatment
• vaccine

Article highlights

• Older adults (age ≥ 65 years) are at high risk for influenza-related mortality and complications.

• Unless contraindicated, older adults should receive an enhanced vaccine to protect against influenza and related complications. Immunization should occur within 1 month to 2 weeks before the start of influenza season to allow immunity development before the season starts and minimize immunity waning before the season ends.

• Age-related physiologic changes have the potential to affect antiviral pharmacokinetics and subsequent safe and effective use.

• Oseltamivir has the most evidence supporting its safe and effective use in treating and preventing influenza in older adults, including those with complicated infections or who reside in long-term care facilities.

• Oseltamivir, peramivir, and intravenous zanamivir require dose adjustments in patients with decreased kidney function beginning at creatinine clearance thresholds common in older adults. Baloxavir has not been studied in patients with a creatinine clearance less than 50 mL/minute.

• Peramivir may produce faster symptom alleviation versus other antivirals in older adults.

• Baloxavir is the best tolerated antiviral and provides a therapeutic option in those unable to tolerate the neuraminidase inhibitors.

Declaration of interest

MN Bulloch reports involvement in Genentech’s Xofluza speaker’s bureau 2019–2022 (outside the scope of the current review). The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.