Antiviral regimens for treatment and/or prophylaxis of seasonal influenza in adults

Antiviral agent	Treatment dose	Prophylaxis dose	Contraindications
Oseltamivir*	75 mg orally twice daily for 5 days^¶	75 mg orally once daily; usual duration 7 days*^Δ	N/A
Zanamivir^◊^§	10 mg (two 5 mg inhalations) twice daily for 5 days	10 mg (two 5 mg inhalations) once daily; usual duration 7 days	Zanamivir (inhaled) is contraindicated in patients with asthma or chronic obstructive pulmonary disease, and it should not be used for treatment of severe influenza (given limited data).
Peramivir*	600 mg intravenously as a single dose^¶^¥	N/A	Peramivir should be reserved for patients who cannot tolerate oral or inhaled agents.
Baloxavir^§^‡	40 kg to <80 kg: 40 mg orally as a single dose ≥80 kg: 80 mg orally as a single dose	Postexposure prophylaxis: same dose as for treatment, single dose^†	Baloxavir should not be used for treatment of severe influenza (given limited data), immunocompromised hosts (given concern for emergence of resistance), or pregnant patients (given limited data).

Refer to the UpToDate topic reviews on treatment and prevention of seasonal influenza for additional details about indications for use of an antiviral agent, choice of agent, dosing, and duration.

* Dose reduction of oseltamivir and peramivir is recommended for patients with renal impairment.

¶ For patients with ongoing symptoms of severe lower respiratory tract disease (particularly in the setting of immunosuppression), an extended duration of antiviral treatment (up to 10 days) may be reasonable, particularly in those who continue to have detectable viral RNA from a respiratory specimen after 5 days of antiviral treatment.

Δ Longer courses may be warranted in the setting of institutional outbreaks. Refer to UpToDate topic on prevention of seasonal influenza for further discussion.

◊ Zanamivir is administered via oral inhalation by using a plastic device included in the package; patients will benefit from instruction and demonstration of the correct use of the device.

§ During outbreaks caused by oseltamivir-resistant influenza virus, zanamivir or baloxavir may be used. It is important to assess the risk of oseltamivir-resistant influenza before selecting an antiviral drug; clinicians should review regional influenza surveillance data to determine which influenza types and subtypes are circulating, as well as resistance patterns. This information is available via the United States Centers for Disease Control and Prevention website.

¥ If peramivir is used for treatment of severe influenza, we favor administration for 5 days^[5].

‡ Coadministration of baloxavir with dairy products, calcium-fortified beverages, polyvalent cation-containing laxatives, antacids, or oral supplements (eg, calcium, iron, magnesium, selenium, zinc) should be avoided.

† Baloxavir is US Food and Drug Administration approved for postexposure prophylaxis but not for pre-exposure prophylaxis.

Adapted from:

Influenza Division, National Center, for Immunization, and Respiratory. Antiviral agents for the treatment and chemoprophylaxis of influenza -- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011; 60:1.
Centers for Disease Control and Prevention. Influenza antiviral medications: Summary for clinicians. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm (Accessed on December 9, 2019).
Xofluza (baloxavir marboxil) for oral use, prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/210854s001lbl.pdf (Accessed on October 17, 2019).
Uehara T, Hayden FG, Kawaguchi K, et al. Treatment-emergent influenza variant viruses with reduced baloxavir susceptibility: Impact on clinical and virologic outcomes in uncomplicated influenza. J Infect Dis 2020; 221:346.
de Jong MD, Ison MG, Monto AS, et al. Evaluation of intravenous peramivir for treatment of influenza in hospitalized patients. Clin Infect Dis 2014; 59:e172.

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Antiviral regimens for treatment and/or prophylaxis of seasonal influenza in adults