Antiviral treatment options
|Tamiflu (Oseltamivir)||Effective to treat influenza A or B|
|Documented hypersensitivity||Caution in renal impairment, chronic cardiac or respiratory disease, and breastfeeding||None reported|
|Relenza (Zanamivir)||Effective against both influenza A and B||5-mg inhalation bid for 5 days||Documented hypersensitivity, obstructive airway disease||Monitor respiratory status; caution in breastfeeding||None reported|
|Flumadine (Rimantadine)||Indicated for both prophylaxis and acute treatments||Documented hypersensitivity||Acetaminophen and aspirin reduce levels when taken concurrently; cimetidine increases plasma levels when taken concomitantly|
|Symmetrel (Amantadine)||Indicated for both prophylaxis and acute treatments||<65 years: 200 mg/day PO qd or divided bid >65 years: 100 mg PO qd||Documented hypersensitivity||Resistant virus strains may develop and be transmitted|
|Drugs with anticholinergic or CNS stimulant activity increase toxicity|
Recommendation for singers
- 1.Prophylaxis: As with other diseases, prevention is the most effective strategy for professional voice users. This can take the form of either chemoprevention or vaccination:
- a.Short-term chemoprevention is indicated under the following conditions
- i.A 14-day course of prophylaxis should be considered for the 2-week interval following the immunization of performers when there is influenza activity in the community or performance troupe at the time of immunization.
- ii.A 10-day course of prophylaxis should be considered for all individuals in the performance troupe with known contact with an index case of influenza.
- b.An extended course of prophylaxis (to cover the entire period of significant influenza activity in the community) should be considered in selected settings:
Chemoprophylaxis can be accomplished with amantadine, rimantadine, zanamivir, or oseltamivir. Amantadine (200 mg/day orally in two divided doses, or 100 mg/day in those susceptible to CNS side effects) and rimantadine (200 mg/day in two divided doses) are effective only against influenza A. Oseltamivir (75 mg/day) and zanamivir (10 mg inhaled daily) are effective against influenza A and B. All the above medications will reduce the attack rate among unvaccinated individuals if begun shortly after exposure. Comparative trials among the agents have not been done.
- i.Protection of singers for whom the vaccine is contraindicated (eg, singers with a history of anaphylactic reaction to eggs)
- ii.Protection of immunized high-risk singers if vaccine strain poorly matches circulating influenza strains
- c.Vaccination is indicated in performers expecting to work in a city where there is an influenza outbreak.
- Inactivated influenza vaccine can be concurrently administered if the singer is expected to reside in the influenza affected for more than 2 weeks. Live attenuated vaccination cannot, however, be coadministered with a chemoprophylaxis regimen since limited viral replication is necessary for this vaccination modality to be effective.
- 2.Acute treatment:
- a.In most healthy people, influenza is cured in 7–10 days. The worst symptoms usually last 3–4 days. Affected singers without imminent important performances may prefer to rest, with only light voice use. Analgesics and a cough mixture may be used. Home treatment to ease symptoms and prevent complications is usually all that is needed.
- b.For the singer with performance requirements, antiviral medications, when started within 48 hours of the onset of symptoms, can be taken to:
- i.Reduce the severity and duration of symptoms caused by infection with influenza A or B virus.
- ii.Shorten the length of the illness.
- iii.Control outbreaks of the flu in the performance troupe.
- iv.Reduce complications from the flu.Amantadine or rimantadine, in the same doses as used for prophylaxis, appreciably decrease the duration of symptoms and signs. Rimantadine is preferred in patients with renal failure.
- c.Theoretically, corticosteroids as potent anti-inflammatory agents could be thought to effectively reduce nasal symptoms, but results of clinical studies of either intranasal or oral steroids have shown no clinical benefit.26,27,28
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- Common infections and inflammations and other conditions.in: Sataloff R.T. The Professional Voice—The Science and Art of Clinical Care. 2nd ed. Singular Publishing Group, San Diego, CA1997: 429-436
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- Common viral respiratory infections.in: Fauci A.S. Brawnwald E. Isselbacher K.J. Harrison's Principles of Internal Medicine. 14th ed. McGraw-Hill, New York1998: 1100-1105
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- “FLU: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It.”.Macmillan, London1999
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- Randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections.J Int Med Res. 2004; 32: 132-140
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- Amantadine and rimantadine for preventing and treating influenza A in adults.Cochrane Database Syst Rev. 2004; (CD001169)
- A controlled trial of amantadine and rimantadine in the prophylaxis of influenza A infection.N Engl J Med. 1982; 307: 580-584
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- Safety and prophylactic efficacy of low-dose rimantadine in adults during an influenza A epidemic.Antimicrob Agents Chemother. 1990; 34: 1633-1636
- Neuraminidase inhibitors: zanamivir and oseltamivir.Ann Pharmacother. 2001; 35: 57-70
- Influenza.Expert Opin Pharmacother. 2000; 1: 367-375
- Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza.N Engl J Med. 1999; 341: 1336-1343
- Long-term use of oseltamivir for the prophylaxis of influenza in a vaccinated frail older population.J Am Geriatr Soc. 2001; 49: 1025-1031
- Management of influenza in households: a prospective, randomized comparison of oseltamivir treatment with or without postexposure prophylaxis.J Infect Dis. 2004; 189: 440-449
- Prevention of influenza virus infections by current inactivated influenza virus vaccines.in: Brown L.E. Hampson A.W. Webster R.B. Options for the Control of Influenza III. Elsevier Science B.V., Amsterdam1996: 97-106
- Development and characterization of cold-adapted viruses for use as live virus vaccines.Vaccine. 1985; 3: 355-369
- Evaluation of trivalent, live, cold-adapted (CAIV-T) and inactivated (TIV) influenza vaccines in prevention of virus infection and illness following challenge of adults with wild-type influenza A (H1N1), A (H3N2), and B viruses.Vaccine. 2000; 18: 899-906
- Clinical trials with live cold-reassortant influenza virus vaccines.in: Kendal A.P. Patriarca P.A. Options for the Control of Influenza. UCLA Symposia on Molecular and Cellular Biology. Vol. 36. Alan R. Liss, New York1986: 223-241
- Use of live attenuated cold-adapted influenza A reassortant virus vaccines in infants, children, young adults, and elderly adults.Infect Dis Clin Pract. 1993; 2: 174-181
- A randomized controlled trial of cold-adapted and inactivated vaccines for the prevention of influenza A disease.J Infect Dis. 1994; 169: 68-76
- Product Information: FluMist, Influenza Virus Vaccine Live, Intranasal.Medimmune Vaccines, Inc./Wyeth Vaccines, Gaithersburg, MD/Philadelphia, PA06/2003 (reviewed 08/2003)
- Oral prednisone therapy in experimental rhinovirus infections.J Allergy Clin Immunol. 1996; 97: 1009-1014
- The common cold: effects of intranasal fluticasone propionate treatment.J Allergy Clin Immunol. 1998; 101: 726-731
- A randomized controlled trial of glucocorticoid prophylaxis against experimental rhinovirus infection.J Infect Dis. 1990; 162: 1173-1177