There have been some remarkable advances in medicine over the past two decades. HIV infection is no longer a death sentence. Hepatitis C is now readily curable. There is now a vaccine to prevent cervical cancer one of only two cancer vaccines in existence. Targeted approaches to cancer, as well as the use of genetic information for personalizing therapies for individual patients have the potential to completely change the way that cancer and maybe other diseases are treated.
But, science is unpredictable. There are still diseases that simply won t yield, despite the huge amount of research that is thrown at them.
Influenza is one of them.
Vaccinations in general, and flu vaccines in particular, have been in the news virtually every day during this flu season. This is because this year s vaccine is astonishingly ineffective. Its rate of protection 23 percent is at or near an historic low.
As we have discussed before, this is no one s fault. The flu simply beat the vaccine this year. (Keep in mind that even though 23 percent protection is very low, it is illogical to forgo the shot, since there is essentially no downside to it.)
The next line of defense is a group of antiviral drugs called neuraminidase (The N in H1N1, for example) inhibitors, which inhibit this enzyme that is required to release newly formed viruses from infected cells. The problem is that they just don t work very well.
ACSH s Dr. Josh Bloom, a former researcher in the antiviral area, says, It is far from clear what the right answer is when it comes to taking these drugs. There is no medical consensus here. Doctors are questioning whether the benefit of the drugs is sufficient to offset the side effects, mostly gastrointestinal.
A study just published in Lancet reinforced data found in previous studies that oseltamivir (Tamiflu), if given within 48 hours of the onset of symptoms, decreases the time of the infection by about one day. The drug also decreased the likelihood of lower respiratory infections that required antibiotic treatment by about half, and cut the rate of all cause hospital admissions by about two-thirds.
ACSH advisor Dr. David Shlaes, the former head of infectious disease research at Wyeth is in the procamp. He says, I m a big fan of tamiflu and other antivirals for acute viral infections. The problem is that for acute infections, its hard to show that the antivirals work to shorten disease even though, scientifically, they should.
Why the discrepancy?
Shlaes explains, Clinical trials are not real life - patients tend to be less sick and are more likely to recover faster spontaneously. This is the result of the various inclusion/exclusion criteria used to enroll patients in trials meant to provide evidence to support regulatory approval.
Perhaps more important, For some acute viral infections, by the time you make the diagnosis, the infection itself may be winding down, but the inflammatory process unleashed by the virus may continue.
In other words, Dr. Bloom explains, in real life, it is difficult to know that you have the flu during the window of time that taking the drugs will do any good. And if you actually have the flu, you will know it. Influenza will make you so sick that you won t even be able to imagine that you will live through it. (And you may not even want to.) If you add nausea and vomiting to this (the incidence of these side effects is about eight percent), you are then talking about cruel and unusual punishment.
The authors of the Lancet paper acknowledge this. Lead author, Dr. Arnold S. Monto, of the Department of Epidemiology at the University of Michigan School of Public Health concludes, Our meta-analysis provides compelling evidence that oseltamivir therapy reduces by one day the typical length of illness in adults infected with influenza and also prevents complications and reduces the number of people needing hospital treatment. Whether the magnitude of these benefits outweigh the harms of nausea and vomiting needs careful consideration.
So, what is the right answer?
Dr. Bloom says, There really isn t one. When the risks and benefits of a drug are similar, the decision of whether to take it becomes far more difficult. Sometimes in medicine, as in life, there are simply no good choices. Ask any New York sports fan.
