New recommendations issued for palivizumab in RSV prophylaxis

To many of us in the northern hemisphere, January through March is "flu season." To pediatricians, it’s bronchiolitis season. We wish it weren’t; about one-third of all hospitalizations in children under 5 years are due to bronchiolitis, specifically to respiratory syncytial virus.

Life would be so much easier for all of us, let alone infants, if we could prevent RSV disease. And we can: Palivizumab (Synagis) has been passively preventing RSV since 1998. Its use has been restricted by its cost: If a season’s course of palivizumab cost $5 or even $50 instead of a yearly cost of upward of $5,000 (including the cost of administration), discussion of its use would be much different.

Dr. Lance Chilton

Some argue that other physicians don’t watch costs, so why should we? If we can prevent a nasty disease, why shouldn’t we, at any price? Where bronchiolitis is especially common, severe, and costly, such as Alaska’s Yukon-Kuskokwim Delta, it has been proposed that palivizumab be given to all newborns. But it won’t be paid for, even there.

Insurance companies and Medicaid payers have long used AAP standards to determine which infants can be given this expensive preventive measure. It is very likely that they will seize upon these new standards as well, and we will have to follow suit. I don’t have many parents of patients in my practice who will choose to pay out of pocket for palivizumab.

The new guidelines further restrict the use of palivizumab, continuing a process of restriction as more information has become available over the past 16 years. Hospitalization for bronchiolitis has become less common, even in premature infants. The technical report clearly lays out the committee’s reasoning and the new data underlying it. Many practitioners will be unhappy with the changes. Some of our patients will be hospitalized with RSV bronchiolitis when previous guidelines would have had them receiving palivizumab. Some of our patients will also die from having driven coupes instead of Panzer tanks. I’ll trust the careful analysis of the Committee on Infectious Diseases.

Lance Chilton, M.D., is a professor of pediatrics at the University of New Mexico in Albuquerque and a pediatrician at Young Children’s Health Center. He is on the speakers bureau for Merck.