When the flu hits, it can feel relentless: rising fever, cough, stuffy nose and sore throat. For many people, relief can come in the form of Tamiflu, a prescription antiviral drug used to treat and even prevent the disease.
But some people may not realize that Tamiflu is not the only option.
Other flu treatments are available in the United States. These alternatives sometimes fly under the radar, in part because some are targeted at specific populations. But Xofluza, a single-dose pill, is approved for people age 5 and older — and can be a powerful alternative for some people who might otherwise be prescribed Tamiflu.
Antiviral medications tend to work best when taken within two days of the onset of symptoms, so easy access to treatment options is key to treating the flu most effectively.
To treat the flu this season, there are four antiviral drugs recommended by the US Centers for Disease Control and Prevention: Tamiflu or oseltamivir, Xofluza or baloxavir, Relenza or zanamivir, and Rapivab or peramivir.
Tamiflu is used to treat the flu in people 2 weeks of age and older and to reduce the chance of getting the flu in people 1 year of age and older. The medicine comes in liquid or capsule form and usually needs to be taken twice a day for five days when used to treat the flu. When used for post-exposure prophylaxis, it is usually taken once a day for 10 days. Available as a generic drug or under the trade name Tamiflu, it can cost about $50 or less without insurance. The most common side effects include nausea and vomiting.
As another option, Xofluza is given as a single-dose tablet and is approved for ages 5 and older. It can be used to treat or prevent the flu and can cost nearly $200 without insurance, but eligible patients can use coupons to lower costs. The most common side effects include diarrhea and vomiting.
“The most common complaint I hear about is vomiting from Tamiflu,” Dr. Ari Brown, a Texas pediatrician and author of the Baby 411 book series, said in an email. She cited a 2023 study that showed about 18 percent of people experience vomiting with Tamiflu, compared to 5 percent with Xofluza.
The study also found that about 5 percent of people got diarrhea with Xofluza, compared to none not taking Tamiflu. “We’ve also had a few pediatric patients experience moodiness with Tamiflu, which is reported in the literature,” she said.
The “biggest difference” between Tamiflu and Xofluza is that Xofluza can stop viral shedding in one day, while Tamiflu can take about three days, Brown said.
That means the rest of the household may have less exposure to the flu and fewer people may be affected by it, but “both antivirals will help reduce the duration of the mess by a few days,” Brown said. For example, with treatment, some people may experience five days of flu symptoms instead of seven.
Rapivab is one of the other prescription drugs approved to treat the flu. The drug is approved for ages 6 months and older, given once as an intravenous infusion by a healthcare provider. It can cost up to about $1,000 without insurance, and the most common adverse reaction in adults tends to be diarrhea.
Finally, Relenza is the other recommended flu medicine. It is inhaled as a powder and is usually given using an inhaler device twice a day for five days. The prescription drug is approved to treat the flu in ages 7 and older and for preventative use in ages 5 and older. It can cost up to about $90 without insurance. Side effects include allergic reactions, dizziness or nasal irritation, and it is not recommended for people with breathing problems such as asthma.
“Xofluza is growing in popularity”
Among the recommended flu treatments, Tamiflu tends to be the recommended flu medication for most patients. But Xofluza is becoming more widely used, Brown said.
However, it may not always be available in pharmacies, recommended by providers, or covered by insurance.
“I guess it depends on the region,” Brown said of access to treatment.
“When one part of the country has flu cases going up, there’s more demand. We haven’t seen that problem in Austin,” she said. For example, this flu season, she received a single prescription for Xofluza that she had to send to another pharmacy because the first pharmacy was out of stock.
But overall, “Xofluza is growing in popularity over Tamiflu,” Brown said.
“One dose. Fewer side effects. More insurance covers the cost now, and the manufacturer’s coupon makes it less expensive than in previous years,” she said, adding that she prefers it for her patients. “But all of the above factors—cost, ability to swallow a pill, availability—can affect that decision.”
Another factor that may affect decisions: There is growing concern about the flu virus developing resistance to Xofluza.
“This is more in the doctor’s mind — and I think that’s one of the reasons it hasn’t been used more often — the flu virus can develop resistance to baloxavir, to Xofluza, during treatment,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University Medical Center.
“That sometimes happens about 10 percent of the time, so it’s not uncommon. And that’s why I think long-term Tamiflu continues to be favored — that and the side effect of diarrhea,” he said. “So Tamiflu tends to be prescribed more frequently, despite the fact that you have to take it for five days.”
Resistance to Xofluza appears to be occurring even more frequently in younger children, said Dr. Tim Uyeki, medical director of the influenza division at CDC’s National Center for Immunization and Respiratory Diseases, during a call earlier this month from CDC’s Clinician Outreach and Outreach (COCA).
“This emergence of baloxavir resistance is associated with longer duration of symptoms,” Uyeki said during the call. “Fortunately, the transmission of a baloxavir-resistant virus from one person to another has been very, very limited. It has been reported, but it appears to be very uncommon, and there is no circulation of baloxavir-resistant viruses or oseltamivir-resistant viruses in the general population.”
National influenza experts discussed at the COCA call that Tamiflu or oseltamivir are preferred for treating hospitalized patients and people with progressive disease.
Xofluza is not recommended during pregnancy, during breastfeeding, ambulatory patients with complicated or progressive disease, people with severe immunosuppression or hospitalized patients, due to the lack of information regarding its use for these groups.
However, there are situations where Xofluza may be preferred.
“For a patient with known or suspected influenza B, baloxavir has much greater efficacy against influenza B compared to oseltamivir,” Uyeki said during the call, adding that the drug is “generally well tolerated.”
“A single dose of baloxavir is not associated with many side effects and with fewer side effects compared to oseltamivir,” he said. “For patients, I think every patient would prefer a single oral dose of baloxavir to five days of twice-daily oseltamivir treatment.”
At the end of the call, Uyeki added that researchers should continue to study the potential benefits of treating flu patients with a combination of antiviral drugs, especially those with severe disease.
“I think we need more data for the treatment of influenza in hospitalized patients with influenza, so severe influenza,” he said. “And for that we need more data for a combination antiviral treatment, for example oseltamivir-plus-baloxavir.”
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