Opinion
Video
Current Standards of Care in RSV Treatment for Children
The panel highlights the current standards of care and strategies for treating children with RSV.
Adam C. Welch, PharmD, MBA, FAPhA: Let’s now talk about some of the treatment and standards of care that we use for RSV. So [Debra Boyer, MD, MHPE], what are some of the current guidelines and recommendations for the prevention and management of RSV infections, particularly in children?
Debra Boyer, MD, MHPE: I’ll start with management because I think that’s probably the simplest one. And I think ultimately management is generally supportive care, right? It’s thinking about hydration, suctioning, supplemental oxygen if the child needs it. In terms of other therapies such as β agonists, nebulize, epinephrine—those in the past were thought to be—studied—and thought to be maybe effective, but ultimately…didn’t really seem to change outcomes. So they’re generally not recommended. Similarly, we don’t usually give steroids or antibiotics in simple RSV infection. I think as you move on—and you asked about…prevention—I think hand hygiene, and we can talk about that forever, but hand hygiene as it’s transmissive of respiratory secretions…that would be the best way to prevent that. And then we can talk a little bit about immunization strategies. But I think those are another way to think about prevention and those that…fall into infant immunization, maternal immunization. And even now, the new adult immunization as well. I think in terms of prevention, the other thing to talk about is prophylaxis. And I think right now we’re talking about the specific recommendations that really relate to the current monoclonal antibody that we have, palivizumab, and that’s really mostly for the treatment of chronic lung disease. So that would be…a baby born less than 32 weeks of age [who] requires supplemental oxygen after 28 days of gestation. Kids with hemodynamic significant congenital heart disease. And those are the ones who are clear-cut and [in whom] it’s clearly recommended. Other categories, it becomes a little bit more [of a considered recommendation], and this is where I think you get into sometimes challenges in getting it paid for, right? Because it’s not strong—it’s more of a considered recommendation. So those are the infants, born less than 29 weeks of age, without chronic lung disease, kids with anatomic pulmonary abnormalities or neuromuscular diseases, immunocompromised children, children with cystic fibrosis, all of those categories—the recommendations are to consider it. So again, it’s not formally recommended.
Adam C. Welch, PharmD, MBA, FAPhA: These guidelines can be complicated by a lot of shared clinical decision-making and really evaluating it on a case-by-case basis, which makes payment policy a little bit more challenging when you’re thinking about providing the right coverage for the right people so that they can remain healthy. Do you see any other unmet needs as far as the current guidelines for RSV infection?
Debra Boyer, MD, MHPE: For me, a lot of the unmet needs would be those populations we still don’t truly understand, where…the recommendations are to consider the prophylactic treatment but not definitively. I think if we could better understand the cost benefit, the risk benefit of giving these children prophylactic medications, [that] would be important. And then learning more about long-term outcomes as well. I think we have talked in the past about whether RSV leads to the development of asthma. And I think understanding that would also be helpful. I think also understanding how social determinants of health impact everything that we have talked about and will talk about is important because different populations of children have different risk depending on their social determinants of health. And I think being aware of that can also guide our thoughts on what would be the appropriate interventions and best prophylactic strategies.
Kimberly C. Chen, DO, MSHLM: What I found to be quite interesting is that…the indication for infants and children seems to be much more strict compared to the Medicare…individuals. Meanwhile RSV is known to affect infants and children [more than] adults.
Adam C. Welch, PharmD, MBA, FAPhA: That’s really interesting when you’re thinking about RSV. We mentioned earlier that everyone can get infected with RSV, and we do have vaccines now that are recommended in older adults, but the infection in infants is really something that’s of concern. And there are really a couple of ways to sort of target those infants. You can target it through moms, through the pregnancy, and build that antibody, or you can target the infants themselves.
Adam C. Welch, PharmD, MBA, FAPhA: When we’re thinking about these treatment options, these preventative antibodies in infants, Dr Borja, how do we identify who should receive this therapy?
Debra Boyer, MD, MHPE: Again, I think this is going to continually evolve. I think looking at the studies that have been done so far on the new monoclonal [antibodies], the ones with the shorter half-life, it seems to be effective in both full-term and preterm infants. So, I think it’s going to be that cost-benefit analysis of trying to understand… how many kids you have to treat to have an effect that is beneficial. And that’s certainly beyond my knowledge base right now. But I think it will be different with each therapy and similar for maternal vaccination. I think it’s going to be a cost-benefit analysis.
Adam C. Welch, PharmD, MBA, FAPhA: Dr Chen, really similar question: Policy wise and structurally from a payer’s perspective, how do you determine…who’s the right patient to receive this antibody prevention?
Kimberly C. Chen, DO, MSHLM:Definitely, we depend a lot on the recommendations from ACIP [Advisory Committee on Immunization Practices] and physicians. We take input from the evidence-based medicine. We all have the medical policy committees and just start doing all these recommendations and then make our own general medical policy.
Adam C. Welch, PharmD, MBA, FAPhA: So, it sounds like it’s really dependent on some of the information that ACIP is evaluating and some of the recommendations that are coming out very shortly and that will help guide some of the decisions on really who needs these preventive therapies and how we’re going to use them. So, thank you.
Transcript edited for clarity.
