Ribavirin for RSV: Not Effective Acutely or Harmful Long-term
Ribavirin for RSV: Not Effective Acutely or Harmful Long-term
ABSTRACT & COMMENTARY
Synopsis: Children treated for respiratory-synctial lower respiratory tract infection did not have more severe respiratory symptoms or worse pulmonary function measurements than placebo-treated controls.
Source: Long CE, et al. Long-term follow-up of children hospitalized with respiratory synctial virus lower respiratory tract infection and randomly treated with ribavirin or placebo. Pediatr Infect Dis J 1997;16:1023-1028.
Fifty-four children participating in randomized trials of ribavirin therapy were enrolled in a prospective follow-up study. Subjects were examined annually and had age-appropriate pulmonary function tests and interim histories. Recurrent lower respiratory tract illness was reported at least once for 70% of the ribavirin group and 73% of the placebo group. In the first five years after respiratory synctial virus (RSV), 54% of the ribavirin group and 50% of the placebo group reported wheezing. There were no significant differences between the groups in annual rates, timing, or severity of recurrent lower respiratory tract illness. No significant differences in pulmonary function were detected by tests of oxygen saturation, peak expiratory flow, and spirometry.
Children in the ribavirin treatment group did not have exacerbated respiratory symptoms compared with those in the control group, and their pulmonary function measurements were equal to those in the placebo-treated group.
n COMMENT BY THOMAS DOLAN, MD
Bronchiolitis caused by RSV remains a leading cause of infants’ admission to hospitals each winter. It is particularly serious in patients who were born prematurely, who have congenital heart disease, broncho-pulmonary dysplasia, or other chronic lung disease. Over the years, many new approaches to the prevention or management of RSV have been attempted. To date, it is fair to say we have had limited success. Early trials with a vaccine led to increased severity of disease when patients came into contact with the live virus. Clinical trials using cortico-steroids, theophylline, Vitamin A, and immunoglobulins have all shown no improvement.
In the early 1980s, ribavirin was introduced. This was greeted with a great enthusiasm as it was the first antiviral agent targeted against the offending agent. Early reports were enthusiastic, and the 1994 American Academy of Pediatrics Red Book recommended its use for high-risk infants. There has always been concern about using the drug for several reasons. The drug is expensive, possibly teratogenic, and, for most of the day, the patient was in a mist tent that obscured visibility to attendings. It was also believed that mortality figures could be improved with better nursing care and use of intensive care units and respirators when indicated. Recent studies have shown that ribavirin therapy has no beneficial effects and may even increase hospitalization stay. The current study is interesting in that it also points out no real advantages for use of the drug. Somewhat reassuring for the many infants who have been treated were long-term follow-up studies that showed no deleterious effects, for pulmonary function tests of treated infants were equal to those of placebo-treated patients. The 1997 American Academy of Pediatrics Red Book now tepidly recommends ribavirin "at the physician’s discretion."1
Analyses of large groups of patients with RSV bronchiolitis show that a subset respond to inhaled albuterol, and some studies suggest that inhaled racemic epinephrine may be deleterious. It is important to use a scoring system (respiratory rate, work of breathing, pulse oximetry, or O2 requirement) to determine if a sympathomimetic agent is effective.
Recent studies seem to confirm that RSV immunoglobulin given to the high-risk infants for the four or five months of the RSV season decreases the severity of disease and the hospitalization rate. The therapy is expensive and time consuming, and one must pay close attention to volume overloading when administering the agent.
Finally, prevention is the best therapy, and once the RSV season starts in your hospital, extreme care as to handwashing and isolation techniques must be practiced. (Dr. Dolan is Professor of Pediatrics, Pulmonary Medicine, Yale University School of Medicine.)
Reference
1. Peters G, ed. Report of the committee of infectious diseases. In: American Academy of Pediatrics Red Book 1997. Elk Grove, IL: American Academy of Pediatrics; 1997.
Ribaviran therapy for RSV bronchiolitis:
a. is currently indicated in infants considered to be at high risk.
b. is associated with more reactive airway disease in later life.
c. results in longer hospitalization stays for treated children.
d. reduces the need for RSV immunoglobin therapy.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.