Antiviral Medications for ESRD Patients with Influenza

Introduction to Antiviral Treatment

The Centers for Disease Control and Prevention recommends antiviral medications, specifically oseltamivir or zanamivir, as the treatment for influenza in patients with end-stage renal disease (ESRD), while zinc lozenges have no established role in this population 1, 2

Zanamivir requires no dose adjustment in ESRD patients and is the simplest choice for influenza treatment or prophylaxis, according to the Centers for Disease Control and Prevention 1, 2, 3
Zanamivir is administered as an inhaled powder at 10 mg (two inhalations) twice daily for treatment, regardless of renal function, as recommended by the Centers for Disease Control and Prevention 1, 2
For prophylaxis, the dose is 10 mg (two inhalations) once daily, as recommended by the Centers for Disease Control and Prevention 1, 2
Only 4-17% of inhaled zanamivir is systemically absorbed, with the remainder deposited in the oropharynx and excreted in feces, according to the Centers for Disease Control and Prevention 4
The manufacturer recommends no dose adjustment for a 5-day treatment course in patients with any degree of renal impairment, including ESRD, as stated by the Centers for Disease Control and Prevention 1, 2, 3

Oseltamivir carboxylate (the active metabolite) accumulates dramatically in ESRD, necessitating substantial dose reductions, according to the Centers for Disease Control and Prevention 1, 2
For ESRD patients with severe renal impairment (CrCl 10-30 mL/min, not yet on dialysis), the treatment dose is 30 mg once daily for 5 days, as recommended by the Centers for Disease Control and Prevention 1, 2
For ESRD patients with severe renal impairment (CrCl 10-30 mL/min, not yet on dialysis), the prophylaxis dose is 30 mg every other day, as recommended by the Centers for Disease Control and Prevention 1, 2

Oseltamivir carboxylate is cleared primarily by glomerular filtration and tubular secretion, according to the Centers for Disease Control and Prevention 4

The American Society of Transplantation recommends that oseltamivir must be initiated within 48 hours of symptom onset in healthy individuals for maximum benefit, but for immunocompromised patients (including those with ESRD who may be transplant candidates), treatment should be initiated regardless of symptom duration if viral replication is documented 6
The American Society of Transplantation suggests that patients with viral replication beyond 7-10 days despite therapy should be evaluated for antiviral resistance 6
The Infectious Diseases Society of America states that oseltamivir has minimal drug interactions compared to other antivirals for ESRD patients on antiretroviral therapy (common in HIV-associated nephropathy) 7, 8