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TABLE 6

Recommended Dosage and Schedule of Influenza Antiviral Medications for Treatment and Chemoprophylaxis in Children for the 2022–2023 Influenza Season: United States

TreatmentChemoprophylaxis
MedicationDosageDurationDosageDurationCommon Adverse Events
Oseltamivira,b 
 Adults 75 mg, twice daily 5 d 75 mg, once daily 7 d  
 Children ≥12 mo 
  ≤15 kg 30 mg, twice daily 5 d 30 mg, once daily 7 d Nausea 
  >15 kg–23 kg 45 mg, twice daily 5 d 45 mg, once daily 7 d Vomiting 
  >23 kg–40 kg 60 mg, twice daily 5 d 60 mg, once daily 7 d Headache 
  >40 kg 75 mg, twice daily 5 d 75 mg, once daily 7 d Skin reactions 
     Diarrhea (children aged <1 y) 
 Infants 9–11 moc 3.5 mg/kg per dose, twice daily 5 d 3.5 mg/kg per dose, once daily 7 d  
 Term infants 0–8 moc 3.0 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
 Preterm infantsd 
  <38 wk’ PMA 1.0 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
  38–40 wk’ PMA 1.5 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
  >40 wk’ PMA 3.0 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
Zanamivirb,e 
 Adults 10 mg (2 5-mg inhalations), twice daily 5 d 10 mg (2 5-mg inhalations), once daily 7 db Bronchospasm 
 Children ≥7 y: 10 mg (2 5-mg inhalations), twice daily 5 d ≥5 y: 10 mg (2 5-mg inhalations), once daily 7 db Skin reactions 
Peramivirf 
 Adults 1 600 mg dose via intravenous infusion, given over 15–30 min N/A Not recommended   
 Children     Diarrhea 
  6 mo–12 y 1 12 mg/kg dose (600 mg maximum) via intravenous infusion over 15–30 min N/A Not recommended  Skin reactions 
  13–17 y One 600 mg dose, via intravenous infusion over 15–30 min N/A Not recommended   
Baloxavirg 
 Individuals ≥5 y 
 <20 kg 2 mg/kg as single dose, orally N/A 2 mg/kg as single dose, orally N/A Nausea, vomiting, diarrhea 
  20 kg–<80 kg One 40-mg dose, orally N/A One 40-mg dose, orally N/A  
  ≥80 kg One 80-mg dose, orally N/A One 80-mg dose, orally N/A  
TreatmentChemoprophylaxis
MedicationDosageDurationDosageDurationCommon Adverse Events
Oseltamivira,b 
 Adults 75 mg, twice daily 5 d 75 mg, once daily 7 d  
 Children ≥12 mo 
  ≤15 kg 30 mg, twice daily 5 d 30 mg, once daily 7 d Nausea 
  >15 kg–23 kg 45 mg, twice daily 5 d 45 mg, once daily 7 d Vomiting 
  >23 kg–40 kg 60 mg, twice daily 5 d 60 mg, once daily 7 d Headache 
  >40 kg 75 mg, twice daily 5 d 75 mg, once daily 7 d Skin reactions 
     Diarrhea (children aged <1 y) 
 Infants 9–11 moc 3.5 mg/kg per dose, twice daily 5 d 3.5 mg/kg per dose, once daily 7 d  
 Term infants 0–8 moc 3.0 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
 Preterm infantsd 
  <38 wk’ PMA 1.0 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
  38–40 wk’ PMA 1.5 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
  >40 wk’ PMA 3.0 mg/kg per dose, twice daily 5 d 3–8 mo: 3.0 mg/kg per dose, once daily 7 d  
Zanamivirb,e 
 Adults 10 mg (2 5-mg inhalations), twice daily 5 d 10 mg (2 5-mg inhalations), once daily 7 db Bronchospasm 
 Children ≥7 y: 10 mg (2 5-mg inhalations), twice daily 5 d ≥5 y: 10 mg (2 5-mg inhalations), once daily 7 db Skin reactions 
Peramivirf 
 Adults 1 600 mg dose via intravenous infusion, given over 15–30 min N/A Not recommended   
 Children     Diarrhea 
  6 mo–12 y 1 12 mg/kg dose (600 mg maximum) via intravenous infusion over 15–30 min N/A Not recommended  Skin reactions 
  13–17 y One 600 mg dose, via intravenous infusion over 15–30 min N/A Not recommended   
Baloxavirg 
 Individuals ≥5 y 
 <20 kg 2 mg/kg as single dose, orally N/A 2 mg/kg as single dose, orally N/A Nausea, vomiting, diarrhea 
  20 kg–<80 kg One 40-mg dose, orally N/A One 40-mg dose, orally N/A  
  ≥80 kg One 80-mg dose, orally N/A One 80-mg dose, orally N/A  

Sources: 2018 Infectious Diseases Society of America Guidelines and https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. N/A, not applicable; PMA, postmentrual age.

a

Oseltamivir is administered orally without regard to meals, although administration with meals may improve gastrointestinal tolerability. Oseltamivir is available as Tamiflu in 30-mg, 45-mg, and 75-mg capsules, and as a powder for oral suspension that is reconstituted to provide a final concentration of 6 mg/mL. For the 6-mg/mL suspension, a 30-mg dose is given with 5 mL of oral suspension, a 45-mg dose is given with 7.5 mL oral suspension, a 60-mg dose is given with 10 mL oral suspension, and a 75-mg dose is given with 12.5 mL oral suspension. If the commercially manufactured oral suspension is not available, a suspension can be compounded by retail pharmacies (final concentration also 6 mg/mL) on the basis of instructions contained in the package label. In patients with renal insufficiency, the dose should be adjusted on the basis of creatinine clearance. For treatment of patients with creatinine clearance 10–30 mL per minute: 75 mg, once daily, for 5 days. For chemoprophylaxis of patients with creatinine clearance 10–30 mL per minute: 30 mg, once daily, for 10 days after exposure or 75 mg, once every other day, for 10 days after exposure (5 doses). See https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm and Infectious Diseases Society of America Guidelines.13  These recommendations differ from the package insert for oseltamivir: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021087s062lbl.pdf.

b

The Centers for Disease Control and Prevention recommends routine chemoprophylaxis with oseltamivir or zanamivir for 7 days after last known exposure; minimum of 14 days and continuing for 7 days after last known exposure if part of institutional outbreak (https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm). This differs from the package insert for zanamivir, which recommends prophylaxis for 10 days in community settings and 28 days in community outbreaks (https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021036s025lbl.pdf).

c

Approved by the US Food and Drug Administration for children as young as 2 weeks. Given preliminary pharmacokinetic data and limited safety data, oseltamivir can be used to treat influenza in both term and preterm infants from birth because benefits of therapy are likely to outweigh possible risks of treatment. Oseltamivir is not recommended for chemoprophylaxis for infants aged <3 months because of limited safety and efficacy data in this age group. Of note, the Centers for Disease Control and Prevention recommends a 3.0 mg/kg/dose, twice daily, for all infants aged <12 months; the Infectious Diseases Society of America guidelines11  include both AAP and Centers for Disease Control and Prevention recommendations.

d

Oseltamivir dosing for preterm infants. The weight-based dosing recommendation for preterm infants is lower than for term infants. Preterm infants may have lower clearance of oseltamivir because of immature renal function, and doses recommended for full-term infants may lead to very high drug concentrations in this age group. Limited data from the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group provides the basis for dosing preterm infants using their postmenstrual age (gestational age, plus chronologic age). For extremely preterm infants (aged <28 weeks), please consult a pediatric infectious disease physician.

e

Zanamivir is administered by inhalation using a proprietary “Diskhaler” device distributed together with the medication. Zanamivir is a dry powder, not an aerosol, and should not be administered using nebulizers, ventilators, or other devices typically used for administering medications in aerosolized solutions. Zanamivir is not recommended for people with chronic respiratory diseases, such as asthma or chronic obstructive pulmonary disease, which increase the risk of bronchospasm.

f

Peramivir requires dose adjustment in patients with renal insufficiency. For treatment of pediatric patients 6 months to 12 years of age: 2 mg/kg if creatinine clearance 10–29 mL per minute; 4 mg/kg if creatinine clearance is 20 to 49 mL per minute. For treatment of adolescents 13 and older, 100 mg if creatinine clearance 10–29 mL per minute; 200 mg if creatinine clearance is 20 to 49 mL per minute (https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/206426s004lbl.pdf).

g

Oral baloxavir marboxil is approved by the US Food and Drug Administration for treatment of acute uncomplicated influenza within 2 days of illness. Baloxavir marboxil is not recommended as monotherapy for treatment of influenza in individuals who are severely immunocompromised, pregnant, or breastfeeding.

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