Peramivir

Paul G. Auwaerter, M.D., Kathryn Dzintars, Pharm.D., BCPS
Pediatric Dosing Author: Alice Jenh Hsu, PharmD, BCPS, AQ-ID

INDICATIONS

FDA

  • FDA-approved for uncomplicated influenza in patients ≥ 6 months with symptoms present for less than 2 days.

NON-FDA APPROVED USES

  • Treatment of influenza for hospitalized adult and pediatric patients for whom therapy with an IV anti-influenza drug is needed.
    • Hospitalized influenza when oral/enteric oseltamivir cannot be tolerated or reliably absorbed (off-label).
      • Clinical benefit of peramivir has not been established in hospitalized patients.

FORMS

brand name

preparation

manufacturer

route

form

dosage

cost*

Peramivir

IV peramivir

BioCryst Pharmaceuticals, Inc.

IV

vial

200 mg per 20 mL (10 mg per mL)

$19.00 per mL

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP).

USUAL ADULT DOSING

  • Uncomplicated influenza: 600 mg IV as a single dose infused over 15-30 minutes, in patients within 48 h of symptom onset.
  • Hospitalized/severe influenza: oral or enteric oseltamivir is preferred. Because enteric oseltamivir is generally reliably absorbed even in critically ill patients, peramivir is mainly considered when enteric administration or absorption is problematic.
    • Parenteral peramivir is not routinely recommended because clinical benefit has not been established. It may be considered when enteric oseltamivir cannot be tolerated or reliably absorbed.
    • If used, daily dosing for ≥5 days has been studied, but the optimal dose and duration are unknown. Consider longer treatment for prolonged severe illness or ongoing viral replication.
  • Must be diluted before IV administration.
  • CDC[1] continues to include single-dose IV peramivir as an option for uncomplicated outpatient influenza but does not routinely recommend it for hospitalized patients because clinical-benefit data are insufficient.
    • WHO 2024 conditionally recommends against peramivir for both nonsevere and severe influenza.[10]
  • Check the CDC Influenza Antiviral Medications page, especially if neuraminidase-resistant strains are circulating.

ADULT RENAL DOSING

RENAL DOSING

Uncomplicated/FDA renal dosing influenza:

  • CrCl ≥ 50 mL/min: no dose adjustments needed.
  • CrCl 30-49 mL/min = 200 mg single dose
  • CrCl 10-29 mL/min = 100 mg single dose

Hospitalized patients: derived from the 2009 FDA EUA.[11]

  • CrCl ≥ 50 mL/min: 600 mg IV q 24h
  • CrCl 31-49 mL/min = 150 mg IV q 24h
  • CrCl 10-30 mL/min = 100 mg IV q 24h
  • CrCl <10 mL/minute (not on RRT): 100 mg IV on day 1, then 15 mg IV q24h.

DOSING IN HEMODIALYSIS

100 mg IV on day 1, then 100 mg IV 2 hours after each HD session on dialysis days only.

DOSING IN PERITONEAL DIALYSIS

No data.

DOSING IN CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)

Estimate total clearance from CRRT plus residual renal function and use the corresponding EUA renal-dose band.[11] Data are very limited, and the assumptions used in the original FDA model may overestimate CRRT clearance; individualized pharmacy/CRRT consultation is advised--see pediatric renal dosing below.

PEDIATRIC DOSING

USUAL PEDIATRIC DOSING

  • Uncomplicated influenza (FDA-approved dosing):
    • 6 mos - 12 years old: 12 mg/kg/dose (max 600 mg/dose) IV once
    • 13 years and older: see Adult dosing
  • Hospitalized patients with influenza (NOT FDA-approved dosing):
Pediatric Dosing Recommendations

Age

Dose

Birth to 30 days old

6 mg/kg/dose IV q24h

31 to 90 days old

8 mg/kg/dose IV q24h

91 to 180 days old

10 mg/kg/dose IV q24h

181 days to 5 years old

12 mg/kg/dose IV q24h (max 600 mg/dose)

6 to 17 years old

10 mg/kg/dose IV q24h (max 600 mg/dose)

PEDIATRIC RENAL DOSING

  • Uncomplicated influenza (FDA-approved dosing):
    • For children 6 months to <2 years with CrCl <50 mL/min, insufficient data are available to recommend a dose adjustment.
    • 2-12 years old:
      • CrCl ≥50 mL/min: 12 mg/kg/dose IV once (max 600 mg/dose)
      • CrCl 30-49 mL/min: 4 mg/kg/dose IV once
      • CrCl 10-29 mL/min: 2 mg/kg/dose IV once
    • 13 years and older: see adult dosing
  • Hospitalized influenza (off-label; 2009 FDA EUA/model-derived dosing): These multidose pediatric renal-adjustment regimens derive from the FDA’s 2009 H1N1 Emergency Use Authorization. Pediatric dosing was based on modeling and simulation of adult pharmacokinetic data, body weight, and renal maturation; no pediatric patients had received peramivir in clinical trials at that time.[11]
Pediatric Renal Dosing Recommendations

CrCl or Estimated Clearance (CL CRRT + Residual Renal CL)

Age

50-80 mL/min/1.73m2

31-49 mL/min/1.73m2

10-30 mL/min/1.73m2

< 10 mL/min/1.73m2 and

NOT on HD or CRRT

< 10 mL/min/1.73m2 on HD

Birth to 30 days

6 mg/kg/dose IV q24h

1.5 mg/kg/dose IV q24h

1 mg/kg/dose IV q24h

1 mg/kg on Day 1, then 0.15 mg/kg/dose IV q24h

1 mg/kg on Day 1, then 1 mg/kg given 2 hrs after each HD session on dialysis days only

31 to 90 days

8 mg/kg/dose IV q24h

2 mg/kg/dose IV q24h

1.3 mg/kg/dose IV q24h

1.3 mg/kg on Day 1, then 0.2 mg/kg/dose IV q24h

1.3 mg/kg on Day 1, then 1.3 mg/kg given 2 hrs after each HD session on dialysis days only

91 to 180 days

10 mg/kg/dose IV q24h

2.5 mg/kg/dose IV q24h

1.6 mg/kg/dose IV q24h

1.6 mg/kg on Day 1, then 0.25 mg/kg/dose IV q24h

1.6 mg/kg on Day 1, then 1.6 mg/kg given 2 hrs after each HD session on dialysis days only

181 days to 5 years old

12 mg/kg/dose IV q24h

3 mg/kg/dose IV q24h

1.9 mg/kg/dose IV q24h

1.9 mg/kg on Day 1, then 0.3 mg/kg/dose IV q24h

1.9 mg/kg on Day 1, then 1.9 mg/kg given 2 hrs after each HD session on dialysis days only

6 to 17 years old

10 mg/kg/dose IV q24h

2.5 mg/kg/dose IV q24h

1.6 mg/kg/dose IV q24h

1.6 mg/kg on Day 1, then 0.25 mg/kg/dose IV q24h

1.6 mg/kg on Day 1, then 1.6 mg/kg given 2 hrs after each HD session on dialysis days only

  • Calculating Estimated Clearance (CL CRRT + Residual Renal CL) for pediatric patients on CRRT:
    • For slow continuous ultrafiltration (SCUF) or continuous arterio-venous hemofiltration (CAVH) or continuous veno-venous hemofiltration (CVVH):
      • CL CRRT = Qf (ultrafiltration rate (mL/min))
    • For continuous arterio-venous hemodialysis (CAVHD) or continuous veno-venous hemodialysis (CVVHD):
      • CL CRRT = Qd (dialysate flow rate (mL/min))
    • For continuous arterio-venous hemodiafiltration (CAVHDF) and continuous veno-venous hemodiafiltration (CVVHDF):
      • CL CRRT = Qf + Qd
    • If the patient has any residual renal function while on CRRT, an estimate of the patient’s renal clearance should be added to CLCRRT in order to estimate total clearance

ADVERSE DRUG REACTIONS

GENERAL

  • Generally well tolerated. In controlled studies of uncomplicated influenza, the most common adverse reaction was diarrhea.

COMMON

  • GI:
    • Nausea/vomiting
      • Children: vomiting 3% with peramivir versus 9% with oseltamivir in the pediatric trial.
    • Diarrhea (8% vs. 7% for placebo)

OCCASIONAL

  • Neuropsychiatric:
    • Postmarketing reports of delirium, hallucinations, and abnormal behavior have occurred in patients with influenza receiving neuraminidase inhibitors, including peramivir. The frequency and causality are uncertain because influenza itself may produce these manifestations.
  • Neutropenia (8% vs placebo 6%)
  • Glucose >160 mg/dL (5% vs 3% placebo)
  • CPK elevation (4% vs 2% placebo)
  • ALT elevation (3% vs 2% placebo).

RARE

  • Serious skin reactions: Stevens-Johnson syndrome and erythema multiforme have been reported.
  • Anaphylaxis

DRUG INTERACTIONS

  • Drug–drug interaction potential is low.
  • No clinically meaningful interactions have been demonstrated with oseltamivir, oral contraceptives, rimantadine, or probenecid.
  • LAIV: Because antivirals may inhibit replication of live attenuated influenza vaccine, avoid LAIV within 2 weeks before or 48 hours after peramivir, according to the FDA labeling.

RESISTANCE

  • Reduced susceptibility can emerge with neuraminidase substitutions and is virus- and subtype-dependent.
  • Some neuraminidase substitutions confer cross-resistance among peramivir, oseltamivir, and/or zanamivir.

PHARMACOLOGY

MECHANISM

Inhibits neuraminidase of influenza A and B, preventing release of influenza virions from plasma membranes of infected cells.

PHARMACOKINETIC PARAMETERS

Metabolism and Excretion

  • Not significantly metabolized in humans.
  • Peramivir is not a substrate for CYP enzymes, does not affect glucuronidation, and is not a substrate or inhibitor of P-glycoprotein-mediated transport.
  • The major route of elimination is renal.
    • Negligible accumulation observed after multiple daily doses for up to 10 days total.

Protein Binding

Less than 30% protein binding.

Cmax and AUC

Following a single 600mg IV administration, Cmax 46.8 µg/mL, AUC 102,700 ng·h/mL (102.7 µg·h/mL).

T1/2

20 h after a single 600mg IV dose in healthy volunteers.

Distribution

Central volume of distribution: 12.56 L.

DOSING FOR DECREASED HEPATIC FUNCTION

Not studied in hepatic impairment. Clinically important PK changes are not expected because elimination is predominantly renal.

PREGNANCY RISK

Human data are limited and insufficient to determine a drug-associated risk. Influenza itself increases maternal and fetal risk. Oral oseltamivir is the preferred antiviral during pregnancy; consider peramivir when an IV agent is needed and the anticipated benefit outweighs the uncertainty.

BREAST FEEDING COMPATIBILITY

No human data are available regarding peramivir in breast milk, effects on the breastfed infant, or milk production. Peramivir is present in rat milk. Consider the benefits of breastfeeding and the mother’s clinical need for therapy

COMMENTS

  • Peramivir is the only IV neuraminidase inhibitor approved in the U.S.
    • A single IV dose modestly shortens symptoms in uncomplicated influenza treated within 48 hours.
      • The pivotal placebo-controlled study found a median 21-hour reduction in time to symptom alleviation. Comparative trials generally suggest similar clinical outcomes to oseltamivir, including in some high-risk patients, but the evidence base is considerably smaller.
      • Clinical benefit has not been established in serious influenza requiring hospitalization, and oral/enteric oseltamivir remains preferred in hospitalized patients.
        • Study 301 randomized 398 hospitalized patients to peramivir 600 mg daily ×5 days plus standard care versus placebo plus standard care and showed no improvement in time to clinical resolution
  • Acquisition and administration costs are generally substantially greater than for generic oral oseltamivir.

Basis for recommendation

  1. CDC, Influenza Antiviral Medications: Summary for Clinicians; https://www.cdc.gov/flu/hcp/antivirals/summary-clinicians.html (last revised 3/10/2026; accessed 8/31/2026)

    Comment: A handy and updated page that is helpful for getting the most up-to-date recommendations, especially if resistant influenza strains are known to circulate.

References

  1. Gao Y, Zhao Y, Liu M, et al. Antiviral Medications for Treatment of Nonsevere Influenza: A Systematic Review and Network Meta-Analysis. JAMA Intern Med. 2025;185(3):293-301.  [PMID:39804622]

    Comment: Network meta-analysis of 73 RCTs (34,332 participants). Peramivir probably has little or no effect on mortality, with evidence for other patient-important outcomes limited or uncertain. This analysis informed the 2024 WHO guideline.

  2. Gao Y, Guyatt G, Uyeki TM, et al. Antivirals for treatment of severe influenza: a systematic review and network meta-analysis of randomised controlled trials. Lancet. 2024;404(10454):753-763.  [PMID:39181595]

    Comment: Modern WHO-commissioned synthesis. Peramivir may shorten hospitalization, but certainty is low; effects on mortality and ICU admission remain very uncertain.

  3. Chen HD, Wang X, Yu SL, et al. Clinical Effectiveness of Intravenous Peramivir Compared With Oseltamivir in Patients With Severe Influenza A With Primary Viral Pneumonia: A Randomized Controlled Study. Open Forum Infect Dis. 2021;8(1):ofaa562.  [PMID:33447633]

    Comment: Very small RCT (n≈40) of severe influenza A pneumonia. Most clinical and virologic outcomes were similar. In this study, fever resolved faster with peramivir. Too small to establish superiority or equivalence, but one of the very few modern severe influenza RCTs.

  4. Hsieh YH, Dugas AF, LoVecchio F, et al. Intravenous peramivir vs oral oseltamivir in high-risk emergency department patients with influenza: Results from a pilot randomized controlled study. Influenza Other Respir Viruses. 2021;15(1):121-131.  [PMID:33006445]

    Comment: 179 high-risk ED patients were randomized to single-dose peramivir vs oseltamivir. Serial FLU-PRO outcomes were comparable and noninferior. Complications were similar.

  5. Nakamura S, Miyazaki T, Izumikawa K, et al. Efficacy and Safety of Intravenous Peramivir Compared With Oseltamivir in High-Risk Patients Infected With Influenza A and B Viruses: A Multicenter Randomized Controlled Study. Open Forum Infect Dis. 2017;4(3):ofx129.  [PMID:28761899]

    Comment: This RCT of 92 high-risk adults, inpatient and outpatient, found that peramivir 600 mg once vs oseltamivir 75 mg BID ×5 d produced similar time to clinical stability, viral titers, and symptoms. Useful evidence for high-risk patients, but a relatively small trial.

  6. Bentley ML, Hollistera AS, Hansenb AC, et al. Peramivir pharmacokinetics in a patient receiving continuous veno-venous hemodiafiltration during the 2009 H1N1 influenza A pandemic. Int J Clin Pharmacol Ther. 2014;52(12):1105-11.  [PMID:25345428]

    Comment: Peramivir is readily cleared by CVVHDF, having a calculated saturation coefficient close to 1.

  7. de Jong MD, Ison MG, Monto AS, et al. Evaluation of intravenous peramivir for treatment of influenza in hospitalized patients. Clin Infect Dis. 2014;59(12):e172-85.  [PMID:25115871]

    Comment: Randomized, controlled trial evaluating the use of peramivir 600mg IV daily for 5 days compared to placebo, both with standard of care. Time to clinical resolution with peramivir was 42.5 hours as compared to 49.5 hours with placebo (p = 0.97). Larger treatment effects were seen in those presenting with symptoms < 48 hours or those admitted to an ICU. Peramivir use was also associated with greater reductions in viral shedding, but again this difference was not statistically significant. This trial ceased at interim analysis due to futility and highlights challenges in clinical trial design. Peramivir was generally well tolerated.

  8. Kohno S, Yen MY, Cheong HJ, et al. Phase III randomized, double-blind study comparing single-dose intravenous peramivir with oral oseltamivir in patients with seasonal influenza virus infection. Antimicrob Agents Chemother. 2011;55(11):5267-76.  [PMID:21825298]

    Comment: Non-inferiority trial (n=1,091) found the median durations of influenza symptoms were 78.0, 81.0, and 81.8 h in the groups treated with 300 mg of peramivir, 600 mg of peramivir, and oseltamivir, respectively.

  9. WHO. Clinical practice guidelines for influenza [12 Sept 2024; accessed 8/31/26]. https://www.who.int/publications/i/item/9789240097759

    Comment: WHO takes a different stance compared to the CDC, with a conditional recommendation not to use peramivir for either nonsevere or severe influenza. However, it acknowledges a potential role when oral or enteric antivirals cannot be used.


  10. FDA. Questions and Answers for Health Care Providers: Renal Dosing and Administration Recommendations for Peramivir IV. https://www.fda.gov/files/drugs/published/Questions-and-Answers-for-Health...[2009 ;accessed 8/31/26]

    Comment: Hospitalized/severe influenza (off-label): The following multidose renal-adjustment regimens derive primarily from FDA’s 2009 H1N1 Emergency Use Authorization and pharmacokinetic modeling rather than clinical efficacy studies. Current FDA labeling addresses only single-dose treatment of uncomplicated influenza.



  11. RAPIVAB- peramivir solution. htttps://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7fdedaec-9e53-4a37-a4e4-a301c8a251b8 [revised 6/2024; accessed 8/31/26].

    Comment: Current U.S. prescribing information. Includes Study 305, a randomized, active-controlled pediatric study supporting the indication down to 6 months of age; efficacy outcomes were secondary, and the study was not powered to detect efficacy differences.

Last updated: September 6, 2026