What are the recommendations for using zinc lozenges or antiviral medications, such as oseltamivir (Oseltamivir) or zanamivir, in patients with end-stage renal disease (ESRD)?

Antiviral Medications for ESRD Patients with Influenza

For patients with end-stage renal disease (ESRD), antiviral medications—specifically oseltamivir or zanamivir—are the recommended treatment for influenza, while zinc lozenges have no established role in this population. 1

Zanamivir: Preferred Option for ESRD

Zanamivir requires no dose adjustment in ESRD patients and is the simplest choice for influenza treatment or prophylaxis. 1

• Zanamivir is administered as an inhaled powder at 10 mg (two inhalations) twice daily for treatment, regardless of renal function 1
• For prophylaxis, the dose is 10 mg (two inhalations) once daily 1
• Only 4-17% of inhaled zanamivir is systemically absorbed, with the remainder deposited in the oropharynx and excreted in feces 1
• While patients with severe renal failure show increased systemic exposure when given intravenous zanamivir, healthy volunteers tolerated much higher systemic levels than those achieved with inhaled dosing 1
• The manufacturer recommends no dose adjustment for a 5-day treatment course in patients with any degree of renal impairment, including ESRD 1

Important Caveat for Zanamivir

• Zanamivir is contraindicated in patients with underlying chronic respiratory disease (asthma, COPD) due to risk of bronchospasm 1
• Patients must be able to use the inhalation device correctly 1

Oseltamivir: Requires Significant Dose Reduction in ESRD

Oseltamivir carboxylate (the active metabolite) accumulates dramatically in ESRD, necessitating substantial dose reductions. 1, 2

For ESRD Patients on Hemodialysis

Treatment regimen: 2, 3

• 30 mg immediately, then 30 mg after every hemodialysis cycle (not to exceed 5 days total treatment duration) 2
• The first dose following influenza diagnosis need not wait until after the next HD session—a single 30 mg dose can be given during the 12 hours before the next HD session to raise concentrations quickly 3

Prophylaxis regimen: 2, 3

• 30 mg immediately, then 30 mg after alternate hemodialysis cycles 2
• This provides adequate trough concentrations for prophylaxis without excessive accumulation 3

For ESRD Patients on Continuous Ambulatory Peritoneal Dialysis (CAPD)

Treatment regimen: 2, 4

• A single 30 mg dose administered immediately 2
• Alternative: 30 mg once weekly after a dialysate exchange for extended treatment 4

Prophylaxis regimen: 2, 4

• 30 mg immediately, then 30 mg once weekly 2
• This dosing provides sufficient oseltamivir carboxylate exposure (AUC 32,400-33,400 ng·h/mL) comparable to standard dosing in patients with normal renal function 4

For ESRD Patients NOT on Dialysis

Oseltamivir is NOT recommended for ESRD patients who are not receiving dialysis 2

• Without dialytic clearance, oseltamivir carboxylate accumulates to potentially toxic levels 1

For Patients with Severe Renal Impairment (CrCl 10-30 mL/min, not yet on dialysis)

• Treatment: 30 mg once daily for 5 days 1, 2
• Prophylaxis: 30 mg every other day 1, 2

Pharmacokinetic Rationale

• Oseltamivir carboxylate is cleared primarily by glomerular filtration and tubular secretion 1
• In ESRD patients on hemodialysis, oseltamivir carboxylate clearance is 7.43 L/min during HD sessions but only 0.19 L/min between sessions 3
• A 30 mg dose after each HD session produces trough concentrations above the median achieved with standard 75 mg twice-daily dosing in patients with normal renal function 3
• In automated peritoneal dialysis, metabolite clearance by continuous cycler-assisted peritoneal dialysis (0.32 L/h) is 1.9-fold faster than CAPD (0.17 L/h) 5

Clinical Considerations

Timing is critical: Oseltamivir must be initiated within 48 hours of symptom onset in healthy individuals for maximum benefit 1

• However, for immunocompromised patients (including those with ESRD who may be transplant candidates), treatment should be initiated regardless of symptom duration if viral replication is documented 1

Resistance monitoring: Patients with viral replication beyond 7-10 days despite therapy should be evaluated for antiviral resistance 1

Drug interactions: For ESRD patients on antiretroviral therapy (common in HIV-associated nephropathy), oseltamivir has minimal drug interactions compared to other antivirals 1

Zinc Lozenges: No Role in ESRD

There is no evidence supporting the use of zinc lozenges for influenza treatment or prophylaxis in any population, including ESRD patients. The provided guidelines focus exclusively on neuraminidase inhibitors (oseltamivir, zanamivir) as the evidence-based antiviral options for influenza 1.