Facts About Fever: A Guide to OTC Antipyretics

The presence of fever is often a cause for concern among patients and caregivers. Pharmacists can be an excellent resource for those seeking guidance regarding the use of nonprescription antipyretics.

Fever is a very common symptom that is often recognized as one of the primary causes for pediatrician and emergency department visits for children younger than 15 years.¹ Although the majority of fevers can be managed easily with proper treatment, fever may also indicate a serious underlying illness, such as an acute infection, that requires immediate evaluation and treatment.^1,2

Fever is defined as a body temperature higher than the normal core temperature of 100°F (37.8°C).^1,2 Normal body temperature can fluctuate, ranging from 97.5°F (36.4°C) to 98.9°F (37.2°C).^1-3 Fever may be idiopathic in nature, or it can result from various factors such as an infectious or pathologic process, vigorous exercise, or a response to the use of certain pharmacologic agents (also known as a drug fever).^1-6 Fever may also occur after the administration of common childhood immunizations.³ The majority of fevers are caused by microbial infections, including bacterial, viral, fungal, and yeast infections.^2,5

Patients with fever may also experience other signs and symptoms that can cause discomfort, such as headache, flushed face, a general feeling of malaise, chills, sweating, and arthralgia or myalgia.^1-3

Detecting Fever

During counseling, patients and caregivers should be advised to avoid feeling the forehead to check for fever and instead to use a reliable thermometer and follow the manufacturer’s recommended procedures to obtain an accurate reading. Digital thermometers, the most widely used measuring devices, are available with a variety of features enabling temperature measurement via oral, tympanic, axillary, rectal, or temporal routes.^1,7 During a course of illness, temperature should be measured with the same thermometer at the same site because readings from different thermometers or sites can vary (Table 1^1,8).

Use of a rectal thermometer is the preferred method for temperature measurement in patients 6 months and younger.^1-3 Tympanic thermometers are not recommended for this age group because of the shape and size of an infant’s ear.¹ While measuring temperature rectally is preferred for patients aged 6 months to 5 years, oral, tympanic, or temporal temperature measurement may be used in this patient age group if proper technique is used.¹ In patients older than 5 years, oral, tympanic, or temporal temperature measurement can be used.¹

Treating Fever

The primary goal in the treatment of fever is to relieve discomfort; this occurs when body temperature decreases to normal. It is also important, however, to identify and treat the underlying cause of fever.^1,3,4 Nonprescription antipyretics and nonpharmacologic measures are often used in the treatment and management of fever. Available nonprescription antipyretics include acetaminophen (N-acetylp- aminophenol) and nonsteroidal antiinflammatory drugs, including aspirin, ibuprofen, and naproxen. Acetaminophen and ibuprofen are the 2 most extensively used antipyretics.^1,5 Ibuprofen is only approved for fever reduction in patients older than 6 months.¹ Antipyretics are available in a variety of formulations for the adult and pediatric patient population, including singleentity or combination products in tablet, capsule, gel capsule, liquigel, enteric-coated, extendedor sustained-release, liquid, suspension, rapid-release gel capsule, and chewable tablet forms (Online Table 2). Typically, temperature decrease and alleviation of discomfort occur about 30 to 60 minutes after administration of antipyretics.¹

TABLE 2: EXAMPLES OF NONPRESCRIPTION ANTIPYRETICS

Active Ingredient

Brand Name

Acetaminophen

• Children's Tylenol Meltaways Chewable Tablets
• Children's Tylenol Oral Suspension
• Infants’ Tylenol Oral Suspension
• Little Remedies Fever + Pain Reliever
• PediaCare Fever Reducer
• Tylenol (Regular and Extra Strength)

Aspirin

• Bayer Aspirin
• Ecotrin 325 mg Regular Strength

Ibuprofen

• Advil Film-Coated Tablets
• Advil Liqui-Gels
• Advil Tablets
• Children's Advil Suspension
• Children's Motrin
• Infants’ Advil Concentrated Drops
• Junior Strength Advil Chewables
• Motrin IB
• Motrin Infants’ Drops

Naproxen sodium

• Aleve

Miscellaneous product

• Be Koool Fever Soft Gel Sheets

Homeopathic/alternative remedies

• Kids Relief Pain & Fever

Nonpharmacologic measures (eg, adequate fluid intake to prevent dehydration, wearing lightweight clothing, maintaining a comfortable room temperature) should also be incorporated in treatment.^1,3

Role of the Pharmacist

During counseling, pharmacists should ensure that patients and caregivers understand how to use antipyretics products properly, including dosing, administration, and possible adverse effects (Online Table 3).^1,3,6,8,9 Pharmacists should also screen for potential drug interactions and contraindications. Because antipyretics can also be found in many allergy, cough, cold, and flu products, patients should be advised to always read all medication labels before administering antipyretics to avoid therapeutic duplications or possible medication overdose. Moreover, caregivers who are unsure about correct dosing, especially for infants and children, should always contact their primary health care provider to avoid potential dosing errors. Patients and caregivers should be advised to always contact their primary health care provider immediately regarding fever in the following circumstances^1,3,8,10:

• A child younger than 3 months has a rectal temperature of 100.4°F (38°C) or higher.
• A child aged 3 to 12 months has a temperature of 102.2°F (39°C) or higher.
• A child 2 years or younger has a fever lasting longer than 24 to 48 hours.
• Fever rises above 104°F in a child of any age.
• The patient has a fever accompanied by rash.
• The patient refuses to drink any fluids and shows signs of dehydration such as dry mouth and decreased urinary output.
• The patient is extremely irritable, sleepy, or weak.
• The patient shows signs of infection, such as severe sore throat or severe ear pain.
• The patient is vomiting or has a stiff neck.
• The patient has a history of seizures, especially febrile seizures.
• The patient has a headache or diarrhea, or is in extreme discomfort.
• The patient has immune system problems or other chronic medical conditions.

TABLE 3: KEY COUNSELING TIPS REGARDING FEVER

• Never use isopropyl or ethyl alcohol for body sponging because it may result in alcohol poisoning from skin absorption, especially among pediatric patients.

• Due to the increased risk for Reye's syndrome, avoid the use of aspirin or aspirin- containing products for treating fever in children younger than age 15 years.

• Unless otherwise indicated by a primary health care provider, drink an adequate amount of fluids to maintain hydration.

• Seek immediate medical attention if fever continues or worsens after 3 days of self-treatment or if signs of infection are present.

• Avoid alternating antipyretics because of the increased risk for potential dosing errors and adverse effects, especially in children.

• Use single-entity products to avoid therapeutic duplications.

• Base dosing of ibuprofen and acetaminophen on the child’s weight instead of age.

• To ensure accurate dosing and avoid dosing errors, always use a calibrated medication measuring/dosing device for liquid medications.

• Seek immediate medical attention if temperature measures 104°F or higher repeatedly for a child of any age or if fever persists for longer than 24 hours in a child younger than 2 years.

• Only administer pediatric product formulations to children, and contact the primary health care provider if unsure about proper dosing.

Adapted from references 1, 3, 6, 8, and 9.

Excellent patient education resources regarding fever and temperature taking in the pediatric population can be found on the American Academy of Pediatrics healthychild.org website:

• How to Take a Child’s Temperature— www.healthychildren.org/English/health-issues/conditions/fever/pages/How-to-Take-a-Childs-Temperature.aspx
• When to Call the Pediatrician: Fever—www.healthychildren.org/English/health-issues/conditions/fever/Pages/When-to-Call-the-Pediatrician.aspx

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

1. Feret B. Fever. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.

2. Definition of fever. The Free Medical Dictionary website. http://medical-dictionary.thefreedictionary.com/fever. Accessed January 2, 2015.

3. Fever. John Hopkins Health Library website. www.hopkinsmedicine.org/healthlibrary/conditions/non-traumatic_emergencies/fever_85,P00831/. Accessed January 2, 2015.

4. Too hot to handle? Facts about fevers. NIH News in Health website. http://newsinhealth.nih.gov/2009/March/feature2.htm. Accessed January 2, 2015.

5. Fever. The Merck Manual Professional Edition website. www.merckmanuals.com/professional/infectious_diseases/biology_of_infectious_disease/fever.html. Accessed January 2, 2015.

6. Sullivan JE, Farrar HC, et al. Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587.

7. How to take your child’s temperature. Children’s Advil website. http://childrens.advil.com/how-to-take-your-childs-temperature. Accessed January 2, 2015.

8. Fever. Medline Plus website. www.nlm.nih.gov/medlineplus/ency/article/003090.htm. Accessed January 2, 2015.

9. Fever without fear. American Academy of Pediatrics’ Healthy Children.org website. www.healthychildren.org/English/health-issues/conditions/fever/Pages/Fever-Without-Fear.aspx. Accessed January 2, 2015.

10. Fever: When to call the doctor. American Academy of Pediatrics’ Healthy Children.org website. www.healthychildren.org/English/health-issues/conditions/fever/Pages/When-to-Call-the-Pediatrician.aspx. Accessed January 2, 2015.