Chapter 35 The problem most frequently noted with APAP involves difficulty in determining proper dosing in children. The FDA continues to issue safety alerts on various preparations to state that the dosing is confusing. All cough and cold medications that contain acetaminophen and are marketed for children younger than 2 years have been withdrawn from the market. Current guidelines recommend avoiding use of these products PO in children younger than 2 years because of the risk of toxicity associated with improper dosing. For information for patients, go to www.knowyourdose.org. A new formulation of IV acetaminophen for pediatric use went on the market in 2011. The use of acetaminophen in the management of fever is discussed in this chapter. For additional information on the use of APAP in the treatment of pain, see Chapter 43 It is essential for the clinician to identify and treat the cause of fever and not just the symptoms. Fever is a symptom with many causes, the most common of which is infection. The danger in treating a fever involves the risk that symptoms of a worsening infection may be masked. A fever may be an important indication of antibiotic resistance. Fever of unknown origin is defined as an unexplained case of fever exceeding 38.3°C on several occasions for at least 3 weeks in patients without neutropenia or immunosuppression. Causes of fever and hyperthermia are listed in Table 35-1. TABLE 35-1 Causes of Fever and Hyperthermia • Simon LS et al: Pain in osteoarthritis, rheumatoid arthritis and juvenile chronic arthritis, ed 2, Glenview, IL, 2002, American Pain Society. • Acetaminophen is an OTC medication; many patients self-administer this product for both pain relief and fever reduction. • APAP use appears relatively straightforward in adults. Maximum adult total daily dose is 3 g/day for self-treating users and 4 g/day for those under the care of a health care provider. However, in all individuals, particularly in children, its use becomes more complicated and presents many opportunities for overdosage. Different dosages are used for different age and weight groups, and many formulations with different strengths are available. APAP is a frequent constituent of other OTC combination products. These formulations change frequently. See Table 35-2 for a list of formulations and strengths. Note the broad array of products with different strengths. TABLE 35-2 Strengths of Various Formulations of Acetaminophen
Acetaminophen
Drug Class
Generic Name
Trade Name
Antipyretic/analgesic
acetaminophen
Tylenol, generic
Therapeutic Overview
Pathophysiology
Disease Process
Common Causes of Fever
Less Common Causes of Fever
Causes of Hyperthermia
Infections: bacteria, virus, rickettsia, fungus, parasites
Cardiovascular disease: myocardial infarction, thrombophlebitis, pulmonary embolism
Heatstroke
Autoimmune disease
GI disease: inflammatory bowel disease, alcoholic hepatitis, granulomatous hepatitis
Malignant hyperthermia of anesthesia
CNS disease, including head trauma and mass lesions
Medication: drug fever
Malignant neuroleptic syndrome
Malignant disease, especially renal cell, liver, leukemia, and lymphoma
Other: sarcoidosis, tissue injury, hematoma, and factitious causes
Treatment Principles
Standardized Guidelines
Cardinal Points of Treatment
Formulation
Strength
Drops, infant
80 mg/0.8 ml
Elixir, liquid, child suspension/syrup
160 mg/5 ml
Caplets, Geltabs, extra strength
500 mg
Tablets
325 mg
Tablets, extra strength
500 mg
Adult liquid, extra strength
500 mg/15 ml
Extended-release Geltabs
650 mg
Suppositories
80, 120, 125, 300, 325, 650 mg
Intravenous solution
10 mg/mL solution
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