Hi Beth... I must say you read through the lines here!
I can't recommend that for everyone, but a logical consideration of this whole issue, including primary care access, urgent care costs, the new availability of OTC rapid antigen tests for influenza A/B/Covid for $14, the hassles with insurance companies and pharmacies, some people being high risk with infection... it all adds up to your logical question. If a patient asked me this I would hash it out with them, and be open to considering this.
I really appreciate how you "examine" ideas, trusting your reader's intelligence to parse the data with you! But lending some actual experience while writing about things from a practicing doctor's perspective is much more relevant than just topical articles from non-clinicians.
Question - since Xofluza is one day treatment, and Tamiflu 5, what are the implications of that?
Thanks Grant! I've increasingly written these types of articles at a bit higher level, since most of the interactions I have with patients are increasingly well-informed and self-educated. Dr. Google and AI are not all bad, but need to be filtered through clinical experience in my opinion. Savvy people want numbers, too, not just stories.
Regarding the 1 versus 5 days - it makes more sense to just take one pill, especially if more effective and compliance thereby ensured... but patient expectations have to be managed. Psychologically it's hard to take one pill on one day and then not feel better for a few days regardless... but if taking pills for 5 days and gradual improvement being noted (thanks to innate immune system and maybe some help from the antiviral) then treatment experience makes more sense and feels more satisfactory perhaps.
I thought much the same on reading this. Ryan’s combination of thorough analysis and practicing primary care doc perspective is tremendous. It’s also mind-boggling how many variables a physician needs to take into account to make good judgments in caring for patients. Yet another tip of the 🎩 to Ryan for this article.
Hi Susan and I appreciate your appreciation:) we primary care docs have very broad knowledge at the expense of the more narrow depth a subspecialist can attain as you know. But it takes all kinds of players on the field to play the game. If this were soccer I think we would be midfielders. Not much glory but we see the whole field!
Thank you for this pertinent information Dr. McCormick. As a physiologist, I recommend vaccines to all in my family. I was so grateful when they finally allowed adults to receive flu shots. When I was a teacher I caught one or another flu virus every year single year, sometimes twice. Ever since flu shots have become available I haven't missed a year and haven't had flu. I also keep COVID shots current. My children got every vaccine available so they avoided all childhood diseases for which vaccines were available.
When I was a child (1933 to 1945) I caught every damned childhood disease that came around. I wish we could develop vaccines against cancer and I'm sure those will come in the future. Cancer killed 3 of my 4 children - the other child died from mental health complications.
Now with mRNA vaccines, I'm very hopeful that we'll conquer more diseases.
Thanks for sharing this Fay. First I extend respect and sympathy and love for losing 4 children. That's unimaginable. Secondly, I agree with your flu shot experience, as I don't recall having more than one influenza illness in the past twenty years. I get yearly shots, too. Probably had influenza but mild.
The mRNA platform is amazing in terms of promise. I hope they can find ways to increase the durability of immunity thus gained, and find more connections between cancer prevention and immunization. Sending you well wishes :)
Here's an N of 1 story: my 8 year old granddaughter had influenza A last week--was seen within 8 hours of symptom onset and started on tamiflu and her recovery was amazingly fast. Fever gone in a day, no respiratory symptoms other than mild congestion. The rest of the family took prophylaxis and all are well. I have never seen a more rapid recovery.
Personally, the flu has knocked me down for weeks in the past and I give it the respect it deserves.
My health department is sub typing some influenza A samples to screen for bird flu.
Jan - this has often been my experience too... and Im so glad your grand daughter bounced back so quickly without getting the whole house sick! Not to sound like a quack, but I will agree that many of these RCTs miss symptom improvement/alleviation as they tend to measure "resolution." A persistent nasal congestion is way more tolerable than persistent malaise and fever, though both would extend the "symptomatic" phase measured in these trials and therefore be counted as equivalencies. I recall one of the Paxlovid studies showing "paxlovid doesn't reduce symptom duration" suffering from this methodology, too.
Hard to discount what you see in actual practice, good to temper that with the studies but keep watching real life!
Please advise if H5N1 detected in your area, as it will then be time to panic a bit, especially if MAGA CDC and other reporting now sucks.
My mom is 91 and had real bad cold and was so fatigued she stayed in bed. Did a video appointment and Dr prescribed Tamiflu. On the second day of taking it my mom became very confused and started having hallucinations (seeing rabbits in her Christmas tree) We took her to the er thinking it might be an infection, they ruled out any infection or sepsis and told us to stop the tamiflu. My mom also has vascular dementia. She also drinks 3-4 glasses of wine a day. Could that have interfereed with Tamiflu and caused the symptoms I just don’t know what to do if she gets flu again, if she should take Tamiflu? At first I blamed the Tamiflu, but I think it might have been a reaction with the alcohol?
Hi Lynn, that must have been really upsetting for everyone involved. It sounds like the combination of factors you described all contributed to the change in mental status. Specifically regarding tamiflu this is rare but not unheard of. Here is what I found:
“Delirium is a recognized neuropsychiatric adverse event (NPAE) associated with oseltamivir use, though its exact frequency varies across studies. Clinical trial data often report low rates of NPAEs, including delirium, with no significant difference between oseltamivir and placebo groups (e.g., 0.5% vs. 0.6%) in phase III studies. However, real-world data and case reports suggest a higher risk, particularly in vulnerable populations.
For elderly individuals, limited specific data exist. Case reports document instances of delirium in geriatric patients receiving oseltamivir, but these are rare. A disproportionality analysis also noted psychiatric disorders, including delirium, among older patients treated with neuraminidase inhibitors like oseltamivir. Post-marketing surveillance highlights the need for caution, as abrupt onset of delirium has been reported, often resolving quickly after discontinuation.”
Thanks Ryan! We've started a very small stockpile of Tamiflu since it's so cheap. I used to think .75 day reduction in symptom duration was nonsense and not clinically meaningful, but now as a parent, 0.75 day reduction seems very relevant!
Hi Zhong, thanks for stopping by... especially since you are not in your own flu season down under! I'll admit we have the same stash though some expired. Ive done that since the H1N1 "swine flu" 2009 pandemic... which is hard to remember now except that I think I was really happy to get my shot.
And as a parent, getting a child back to school one day earlier is truly significant. Our daughter recently had a flu like illness, though tested negative so we did not treat, but went back to school with a mask after a couple days off. Though kids ridicule masks here, her friends were actually happy her mouth was covered by default with a bad cough.
Ryan, I am still amazed at how you are constantly reading and staying updated on things from the research and how that applies to your everyday practice. Your patients are fortunate to have you.
"Let’s hope this avian influenza stuff does not become a human pandemic. Let’s hope we have excellent public health leadership if it does. Let’s hope for a deep appreciation for science and a healthy respect for scientists among our elected leaders."
The above quote from you is a red flag. I fear the current administration in charge of things is not preparing for this. We all remember what happened with Covid-19 when they were in charge of things. Thank God for Dr. Fauci and Dr. Birx and all the people working along with them.
100% agree Arthur. Thank you for reading and for your kind words. That quote was sarcastic for sure. Our public health and political leadership is in wreckage, intentionally, by a centralized leadership that wants power and control over truth and expertise. It will come back to haunt all of us. I tone down what I say here, but as you know any public health worker or clinician without an incredibly strong right wing political ideology is horrified by the actual facts of what has happened these past two weeks.
I saw a good example of this watching 8th grade girls basketball last night! Lots of grit, courage, and indeed bravery, and when that's deployed in a team effort, its a unique human superpower.
Winning in this realm is reducing suffering and improving health.
Such an impressive deep dive, Doc. I didn’t know there was a second flu drug. It does seem like shaving a day or less of the flu may not be worth the side effects. And the chase to find the X one likely misses the critical window for starting it, as you’ve pointed out.
Here’s a chuckle (or maybe not, considering current epidemiological events): the only flu shot I ever got was about a month before I got COVID (I’m not drawing a correlation there, it was just the timing). I got it in my upper left arm, where I have a giant tattoo of a raven reading a book while standing on a stack of books. I joked at the time that it was my bird flu shot 🙃. (I’ll see myself out now 🤦🏼♀️).
Thank you for your info-packed article. Please remind people that wearing a properly fitted N95 or equivalent mask in public indoor spaces is more effective in preventing respiratory infections than are the flu and covid vaccines.
Is claiming bird flu has spread to fifty mammal species and is airborne. This newsletter has no provenance listed and is requesting people to share their data. Do you know anything about this newsletter or its claims of airborne spread of bird flu?
Hi Melissa, scary stuff and I think the airborne versus droplet dichotomy is not helpful, but rather represent two points along a continuum. I’ll keep an eye on this. Does that person provide any sources for review? Here’s one:
I’m past 65, should I ask my PCP for an Rx in advance? It’s unlikely I could get an appointment within 2 days.
Hi Beth... I must say you read through the lines here!
I can't recommend that for everyone, but a logical consideration of this whole issue, including primary care access, urgent care costs, the new availability of OTC rapid antigen tests for influenza A/B/Covid for $14, the hassles with insurance companies and pharmacies, some people being high risk with infection... it all adds up to your logical question. If a patient asked me this I would hash it out with them, and be open to considering this.
Thanks. I’ll talk to her about it.
I really appreciate how you "examine" ideas, trusting your reader's intelligence to parse the data with you! But lending some actual experience while writing about things from a practicing doctor's perspective is much more relevant than just topical articles from non-clinicians.
Question - since Xofluza is one day treatment, and Tamiflu 5, what are the implications of that?
:)
Thanks Grant! I've increasingly written these types of articles at a bit higher level, since most of the interactions I have with patients are increasingly well-informed and self-educated. Dr. Google and AI are not all bad, but need to be filtered through clinical experience in my opinion. Savvy people want numbers, too, not just stories.
Regarding the 1 versus 5 days - it makes more sense to just take one pill, especially if more effective and compliance thereby ensured... but patient expectations have to be managed. Psychologically it's hard to take one pill on one day and then not feel better for a few days regardless... but if taking pills for 5 days and gradual improvement being noted (thanks to innate immune system and maybe some help from the antiviral) then treatment experience makes more sense and feels more satisfactory perhaps.
I thought much the same on reading this. Ryan’s combination of thorough analysis and practicing primary care doc perspective is tremendous. It’s also mind-boggling how many variables a physician needs to take into account to make good judgments in caring for patients. Yet another tip of the 🎩 to Ryan for this article.
Hi Susan and I appreciate your appreciation:) we primary care docs have very broad knowledge at the expense of the more narrow depth a subspecialist can attain as you know. But it takes all kinds of players on the field to play the game. If this were soccer I think we would be midfielders. Not much glory but we see the whole field!
Thank you for this pertinent information Dr. McCormick. As a physiologist, I recommend vaccines to all in my family. I was so grateful when they finally allowed adults to receive flu shots. When I was a teacher I caught one or another flu virus every year single year, sometimes twice. Ever since flu shots have become available I haven't missed a year and haven't had flu. I also keep COVID shots current. My children got every vaccine available so they avoided all childhood diseases for which vaccines were available.
When I was a child (1933 to 1945) I caught every damned childhood disease that came around. I wish we could develop vaccines against cancer and I'm sure those will come in the future. Cancer killed 3 of my 4 children - the other child died from mental health complications.
Now with mRNA vaccines, I'm very hopeful that we'll conquer more diseases.
Thanks for sharing this Fay. First I extend respect and sympathy and love for losing 4 children. That's unimaginable. Secondly, I agree with your flu shot experience, as I don't recall having more than one influenza illness in the past twenty years. I get yearly shots, too. Probably had influenza but mild.
The mRNA platform is amazing in terms of promise. I hope they can find ways to increase the durability of immunity thus gained, and find more connections between cancer prevention and immunization. Sending you well wishes :)
Here's an N of 1 story: my 8 year old granddaughter had influenza A last week--was seen within 8 hours of symptom onset and started on tamiflu and her recovery was amazingly fast. Fever gone in a day, no respiratory symptoms other than mild congestion. The rest of the family took prophylaxis and all are well. I have never seen a more rapid recovery.
Personally, the flu has knocked me down for weeks in the past and I give it the respect it deserves.
My health department is sub typing some influenza A samples to screen for bird flu.
Jan - this has often been my experience too... and Im so glad your grand daughter bounced back so quickly without getting the whole house sick! Not to sound like a quack, but I will agree that many of these RCTs miss symptom improvement/alleviation as they tend to measure "resolution." A persistent nasal congestion is way more tolerable than persistent malaise and fever, though both would extend the "symptomatic" phase measured in these trials and therefore be counted as equivalencies. I recall one of the Paxlovid studies showing "paxlovid doesn't reduce symptom duration" suffering from this methodology, too.
Hard to discount what you see in actual practice, good to temper that with the studies but keep watching real life!
Please advise if H5N1 detected in your area, as it will then be time to panic a bit, especially if MAGA CDC and other reporting now sucks.
My mom is 91 and had real bad cold and was so fatigued she stayed in bed. Did a video appointment and Dr prescribed Tamiflu. On the second day of taking it my mom became very confused and started having hallucinations (seeing rabbits in her Christmas tree) We took her to the er thinking it might be an infection, they ruled out any infection or sepsis and told us to stop the tamiflu. My mom also has vascular dementia. She also drinks 3-4 glasses of wine a day. Could that have interfereed with Tamiflu and caused the symptoms I just don’t know what to do if she gets flu again, if she should take Tamiflu? At first I blamed the Tamiflu, but I think it might have been a reaction with the alcohol?
Hi Lynn, that must have been really upsetting for everyone involved. It sounds like the combination of factors you described all contributed to the change in mental status. Specifically regarding tamiflu this is rare but not unheard of. Here is what I found:
“Delirium is a recognized neuropsychiatric adverse event (NPAE) associated with oseltamivir use, though its exact frequency varies across studies. Clinical trial data often report low rates of NPAEs, including delirium, with no significant difference between oseltamivir and placebo groups (e.g., 0.5% vs. 0.6%) in phase III studies. However, real-world data and case reports suggest a higher risk, particularly in vulnerable populations.
For elderly individuals, limited specific data exist. Case reports document instances of delirium in geriatric patients receiving oseltamivir, but these are rare. A disproportionality analysis also noted psychiatric disorders, including delirium, among older patients treated with neuraminidase inhibitors like oseltamivir. Post-marketing surveillance highlights the need for caution, as abrupt onset of delirium has been reported, often resolving quickly after discontinuation.”
Thanks Ryan! We've started a very small stockpile of Tamiflu since it's so cheap. I used to think .75 day reduction in symptom duration was nonsense and not clinically meaningful, but now as a parent, 0.75 day reduction seems very relevant!
Hi Zhong, thanks for stopping by... especially since you are not in your own flu season down under! I'll admit we have the same stash though some expired. Ive done that since the H1N1 "swine flu" 2009 pandemic... which is hard to remember now except that I think I was really happy to get my shot.
And as a parent, getting a child back to school one day earlier is truly significant. Our daughter recently had a flu like illness, though tested negative so we did not treat, but went back to school with a mask after a couple days off. Though kids ridicule masks here, her friends were actually happy her mouth was covered by default with a bad cough.
Ryan, I am still amazed at how you are constantly reading and staying updated on things from the research and how that applies to your everyday practice. Your patients are fortunate to have you.
"Let’s hope this avian influenza stuff does not become a human pandemic. Let’s hope we have excellent public health leadership if it does. Let’s hope for a deep appreciation for science and a healthy respect for scientists among our elected leaders."
The above quote from you is a red flag. I fear the current administration in charge of things is not preparing for this. We all remember what happened with Covid-19 when they were in charge of things. Thank God for Dr. Fauci and Dr. Birx and all the people working along with them.
100% agree Arthur. Thank you for reading and for your kind words. That quote was sarcastic for sure. Our public health and political leadership is in wreckage, intentionally, by a centralized leadership that wants power and control over truth and expertise. It will come back to haunt all of us. I tone down what I say here, but as you know any public health worker or clinician without an incredibly strong right wing political ideology is horrified by the actual facts of what has happened these past two weeks.
Ryan, never, never back down or they will win.
I saw a good example of this watching 8th grade girls basketball last night! Lots of grit, courage, and indeed bravery, and when that's deployed in a team effort, its a unique human superpower.
Winning in this realm is reducing suffering and improving health.
Thank you. Bookmarked for sharing.
Such an impressive deep dive, Doc. I didn’t know there was a second flu drug. It does seem like shaving a day or less of the flu may not be worth the side effects. And the chase to find the X one likely misses the critical window for starting it, as you’ve pointed out.
Here’s a chuckle (or maybe not, considering current epidemiological events): the only flu shot I ever got was about a month before I got COVID (I’m not drawing a correlation there, it was just the timing). I got it in my upper left arm, where I have a giant tattoo of a raven reading a book while standing on a stack of books. I joked at the time that it was my bird flu shot 🙃. (I’ll see myself out now 🤦🏼♀️).
Thank you for your info-packed article. Please remind people that wearing a properly fitted N95 or equivalent mask in public indoor spaces is more effective in preventing respiratory infections than are the flu and covid vaccines.
Good reminder, plus a reminder to have the courage to do so in tight situations especially when feeling socially awkward.
Dear Dr. McCormick, Another Substack newsletter,
https://substack.com/@sarscov2covid19/note/c-90696577?r=yq0zh&utm_medium=ios&utm_source=notes-share-action,
Is claiming bird flu has spread to fifty mammal species and is airborne. This newsletter has no provenance listed and is requesting people to share their data. Do you know anything about this newsletter or its claims of airborne spread of bird flu?
Thank you, Melissa
Hi Melissa, scary stuff and I think the airborne versus droplet dichotomy is not helpful, but rather represent two points along a continuum. I’ll keep an eye on this. Does that person provide any sources for review? Here’s one:
https://www.cidrap.umn.edu/avian-influenza-bird-flu/ferret-study-suggests-connection-between-h5n1-shedding-air-and