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Oseltamivir, Zanamivir and Amantadine in the Prevention of Influenza: a Systematic Review

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Oseltamivir, Zanamivir and Amantadine in the Prevention of Influenza: a Systematic Review Journal of Infection (2011) 62,14e25 www.elsevierhealth.com/journals/jinf Oseltamivir, zanamivir and amantadine in the prevention of influenza: A systematic review Rachel J. Jackson a,*, Katy L. Cooper a, Paul Tappenden a, Angie Rees b, Emma L. Simpson a, Robert C. Read c, Karl G. Nicholson d a Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK b School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK c Department of Infection & Immunity, School of Medicine, University of Sheffield, Beech Hill Rd, Sheffield, S10 2RX, UK d Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, LE2 7LX, UK Accepted 5 October 2010 Available online 13 October 2010 KEYWORDS Summary Objective: To systematically review evidence relating to the clinical efficacy of Influenza; oseltamivir, zanamivir and amantadine in the prevention of influenza. Prophylaxis; Methods: RCTs evaluating these interventions in seasonal prophylaxis and post-exposure pro- Prevention; phylaxis were identified using electronic bibliographic databases and handsearching of Amantadine; retrieved articles. Oseltamivir; Results: Oseltamivir was effective in preventing symptomatic laboratory-confirmed influenza Zanamivir; (SLCI) in seasonal prophylaxis in healthy adults and at-risk elderly subjects and in post-expo- Neuraminidase sure prophylaxis within households of mixed composition. Post-exposure prophylaxis using inhibitor; oseltamivir for paediatric contacts was observed to prevent SLCI. Zanamivir prevented M2 inhibitor; SLCI in seasonal prophylaxis in healthy adults, at-risk adults and adolescents and in post-expo- Systematic review sure prophylaxis within mixed households, with a trend for seasonal and post-exposure preven- tative effects in elderly subjects. Evidence for amantadine prophylaxis across subgroups was very limited. However, amantadine prevented SLCI in seasonal prophylaxis in healthy adults and in outbreak control amongst adolescent subjects. Interventions were reported to be well tolerated by subjects, with a relatively low proportion of subjects experiencing drug-related adverse events and drug-related withdrawals. Conclusions: Evidence was identified for the efficacy of oseltamivir and zanamivir in prevent- ing influenza in a range of population subgroups. The evidence base for amantadine was con- siderably more limited. Crown Copyright ª 2010 Published by Elsevier Ltd on behalf of The British Infection Association. All rights reserved. * Corresponding author. Tel.: þ44 114 222 0793; fax: þ44 114 272 4095. E-mail address: R.Jackson@Sheffield.ac.uk (R.J. Jackson). 0163-4453/$36 Crown Copyright ª 2010 Published by Elsevier Ltd on behalf of The British Infection Association. All rights reserved. doi:10.1016/j.jinf.2010.10.003 Prevention of influenza 15 Introduction Controlled Trials Register, BIOSIS, CINAHL, DARE, NHS EED and HTA databases, OHE HEED, NRR (National Research Influenza is a contagious, acute febrile respiratory infection Register), Science Citation Index, Current Controlled Trials, caused by the influenza virus. Influenza A and B are Clinical Trials.gov. The search strategies included subject responsible for nearly all influenza illness, with influenza headings and free text terms, combined using Boolean A accounting for approximately 80% of outbreaks.1 The logic, to identify all published and unpublished data level of influenza in a community is measured via a combi- relating to the clinical effectiveness of oseltamivir, nation of the consultation rate for influenza-like illness zanamivir and amantadine in the prevention of influenza. (ILI) and the laboratory-based identification of influenza Searches for the clinical effectiveness review were limited virus in samples from individuals with ILI.2 Seasonal influ- by publication type to controlled clinical trials, and enza generally occurs during the winter months in the systematic reviews. Searches were not restricted by the northern hemisphere.3 Worldwide pandemics occur infre- date of publication or by language. Published findings quently when a new influenza subtype of avian or porcine identified during this assessment are presented in this origin crosses the species barrier, is transmissible from publication. person-to-person, and differs antigenically from recently circulating human strains of influenza, so the population Study selection has little or no immunity to the new virus. In healthy adults, seasonal influenza is often self- Studies were considered eligible for inclusion if they limiting and does not require treatment. However, compli- related to the use of oseltamivir, zanamivir or amantadine cations such as pneumonia and exacerbations of asthma administered in line with current UK marketing author- 10 and chronic bronchitis can occur. Serious influenza- isations. Population groups considered were children, related complications are more common in individuals adults and the elderly (see Tables 1e3 for age composition who are aged 65 years or over, who live in long- of study populations), with each group being further sub- stay residential care facilities, or who have certain co- divided into healthy individuals or those at-risk of develop- morbidities, including chronic respiratory, cardiovascular, ing complications of influenza. Two prophylactic situations renal, hepatic or neurological disease, diabetes, or immu- were assessed: i) seasonal prophylaxis, and ii) post-expo- nosuppression.3 Complications may require antibiotic sure prophylaxis. Interventions were compared against treatment, hospitalisation, and are associated with each other and against no prophylaxis (whereby subjects increased mortality. Estimated numbers of deaths that received any of the following: placebo, no treatment or occur each year in the UK due to influenza have ranged expectant treatment following onset of symptomatic between 12,000 and 13,800 deaths, mainly among the influenza). The number of influenza cases prevented was elderly and individuals with co-morbidities.4,5,6 measured in terms of symptomatic, laboratory-confirmed The objective of this systematic review, commissioned influenza (SLCI) or, in the absence of this outcome, acute by the National Institute for Health and Clinical Excellence respiratory illness or influenza-like illness and/or confirmed (NICE) as an update to previous guidance7, was to evaluate influenza infection. Other outcomes of interest included the performance of the neuraminidase inhibitors oseltami- complications prevented, hospitalisations prevented, vir and zanamivir and the M2 inhibitor amantadine in influ- length of influenza illness, time to return to normal activi- enza prophylaxis. The scope of the NICE assessment ties, mortality, health-related quality of life, and adverse covered two prophylactic circumstances: i) post-exposure events. The following exclusion criteria were applied: prophylaxis and ii) seasonal prophylaxis. The populations intervention medications not used in accordance with their analysed included children, adults and older people, licensed indications, and studies only published in lan- with each group being further sub-divided into healthy guages other than English. Studies based on experimen- individuals or those at-risk of developing complications of tally-induced influenza are not described in this report influenza. The review findings, together with a related due to limited generalisability to clinical practice. Based health economic decision model, were used to inform the on the above inclusion/exclusion criteria, study selection current NICE guidance on the use of antiviral drugs in sea- was undertaken by one reviewer (RJ), with involvement sonal and post-exposure influenza prophylaxis.8,9 of a second reviewer (KC/ES) when necessary to provide consensus on inclusion or exclusion of studies. Methods Data abstraction Identification of evidence Data was extracted by one reviewer (RJ) using a form A review protocol outlining the planned approaches to the developed for this purpose. All data abstraction was review was developed and adhered to throughout the checked and confirmed by a second reviewer (KC). conduct of the review. The search strategy consisted of the following approaches: searching of electronic databases Quality assessment (searched August 2007 and updated in August 2009); contact with topic experts; and handsearching of bibliographies of The quality of included randomised controlled studies was retrieved papers. Searches were performed in electronic assessed using quality criteria based on those developed databases including Medline, Medline in Process, EMBASE, by the NHS Centre for Reviews and Dissemination.11 Quality Cochrane Database of Systematic Reviews, Cochrane assessment was confirmed by a second reviewer (KC). 16 R.J. Jackson et al. Table 1 Characteristics of included oseltamivir prophylaxis trials. Trial and reference Population characteristics Interventions Preventative Prophylaxis details (no. of patients strategy duration in each arm) WV15825; Peters At-risk elderly subjects living Intervention arm: Seasonal 6 weeks et al., 200161 De in a residential home (Mean Oseltamivir 75 mg Bock et al., 200082 age Z 81e82 yrs across once daily n Z 276 treatment arms age 81 yr) Placebo arm: n Z 272 (98% with concomitant disease in each group), Intervention arm: 80.4% vaccinated Placebo arm: 80.1% vaccinated WV15673; Hayden Healthy unvaccinated adults Intervention arm: Seasonal 6 weeks
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