OTC Case Studies: Fever

CASE 1: MERCURY THERMOMETER

Q: CJ is a 73-year-old woman seeking information about how and where she can recalibrate her mercury-in-glass thermometer. She will be babysitting her grandchildren for a week and wants to ensure that she has all the necessary supplies in case of an emergency or any of her grandchildren became ill.

A: Urge CJ to dispose of the mercury-in-glass thermometer according to local environmental standards. Because of the environmental concerns about mercury and the damage it can cause to the human immune and nervous systems, mercury thermometers are no longer recommended. The Environmental Protection Agency has launched an effort to reduce the distribution, manufacturing, and sale of mercury thermometers. Because of concerns about difficult-to-read displays and glass breakage, mercury-in-glass thermometers, compared with electronic thermometers, have fallen out of favor.^1,2 Instead, recommend that CJ purchase an oral electronic probe thermometer. General instructions for use include to wait 20 to 30 minutes after drinking or eating, place the tip of the thermometer under tongue, and close the mouth completely until the thermometer beeps about 5 to 30 seconds later. A reading will appear on the digital screen.³

CASE 2: FEVER

Q: TH, a 39-year-old woman, is seeking advice on what medication to give her 7-month-old baby. The baby has been irritable, and TH reported that axillary temperatures have ranged from 100.6°F to 102.1°F over the past 5 days. TH has been giving her oral acetaminophen liquid (160 mg/5 mL) at 10 to 15 mg/kg every 4 to 6 hours. TH is becoming concerned about the fever, and she wants to know what else the pharmacist recommends for fever management. Her friend recommended ibuprofen for better fever control.

A: Refer TH to a pediatrician for medical evaluation. Acetaminophen and ibuprofen are effective and safe to use for fever, but if no improvement is seen after 3 days, the patient should be referred for medical evaluation to investigate the fever’s origin, such as infection or toxins.⁴ If TH’s baby had not been using the acetaminophen for >3 days, it would be appropriate for the pharmacist to recommend ibuprofen 5 to 10 mg/kg per dose every 6 to 8 hours. Some parents alternate the use of acetaminophen and ibuprofen for fever management. Given the risk of miscalculations and overdosing, pharmacists should educate parents about appropriate dosing intervals (every 4-6 hours for acetaminophen and every 6-8 hours for ibuprofen) if they are planning to alternate agents.⁵

CASE 3: PEDIATRIC DOSINGQ: CB is a 44-year-old father of 2 children. He calls the pharmacy to inquire about dosing for ibuprofen. His younger child, TB, is 2 years old and has been having fevers. CB has children’s ibuprofen liquid (100 mg/5 mL) at home from when his older child fell ill a few months ago. CB reports that TB weighs 28 lb. He asks whether giving the child a tablespoon of the ibuprofen liquid would be appropriate.

A: CB should be reminded that the weight-based dosing for ibuprofen and most other pediatric medications is per kilograms of a child’s body weight, not per pounds. If TB weighs 28 lb, the child’s weight in kilograms is about 13 kg. The recommended dosing for ibuprofen in children >6 months is 5 to 10 mg/kg every 6 to 8 hours, with a maximum of 4 doses per day. The dosing range for TB is 65 to 130 mg every 6 to 8 hours, meaning that 100 mg would be an appropriate dose. If the concentration of ibuprofen is 100 mg/5 mL, the patient should be given 5 mL (1 tsp [5 mL], not tbsp [15 mL]) of children’s ibuprofen liquid.⁵ Urge CB to use the dose-delivery devices of cup, spoon, or syringe provided in the ibuprofen package. Because of concerns about dosing inaccuracy, the FDA released a guidance document to manufacturing, marketing, and distributing companies regarding appropriate devices that should be dispensed with OTC liquid medications. The devices should have applicable and clear units, and health care providers should demonstrate to consumers the appropriate use of the dose-delivery devices. Consumers should use only the delivery devices with the medication for which it was provided.⁶

CASE 4: TYMPANIC THERMOMETER

Q: KP, a 33-year-old woman, is seeking a new thermometer for her 10-month-old baby. She thinks that the baby will not be able to hold an oral thermometer in place without getting fussy. KP is looking for a tympanic thermometer and asks whether the pharmacist could demonstrate how to use it.

A: Instruct KP to place a disposable lens cover over the ear probe and turn on the thermometer. Once it is ready for use, she needs to straighten the baby’s ear canal. Given that KP’s baby is still younger than 1 year, she will need to pull the baby’s ear backward to straighten the ear canal and then place the probe into the canal, aiming toward the baby’s eye. Next, she should press the button to measure the temperature (<5 seconds) and then record the temperature and discard the cover. Once KP’s baby is older than 1 year, she will need to pull the baby’s ear backward and up to straighten the ear canal. An inappropriate technique can lead to variations in temperature readings. Other nonoral options for temperature measurement include axillary, color-change, nontouch, rectal, and temporal artery. Regarding the accuracy of core temperature reading, rectal temperature measurement is considered the gold standard. Typically, an axillary temperature >99.3°F, an oral temperature >99.7°F, a rectal temperature >100.4°F, a temporal artery measurement >100.1°F, and a tympanic temperature >100.0°F are considered a fever.^3,7

Ammie J. Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care specialist at RWJBarnabas Health, part of the Barnabas Health Medical Group.

Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

Caitlyn Bloom, PharmD, BCACP, AE-C, is a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care clinical pharmacist at RWJBarnabas Health, part of the Barnabas Health Medical Group, in Eatontown, New Jersey.

REFERENCES

• Mercury thermometers. US Environmental Protection Agency website. epa.gov/mercury/mercury-thermometers. Accessed November 11, 2019.
• Laws and resolutions. Health Care Without Harm website. noharm-uscanada.org/issues/us-canada/laws-and-resolutions. Accessed November 11, 2019.
• Thermometer comparison. C.S. Mott Children’s Hospital Michigan Medicine website. mottchildren.org/health-library/tw9223. Updated September 23, 2018. Accessed November 20, 2019.
• American Academy of Pediatrics. When to call the pediatrician: fever. HealthyChildren.org website. healthychildren.org/English/health-issues/conditions/fever/pages/When-to-Call-the-Pediatrician.aspx. Updated November 21, 2015. Accessed November 11, 2019.
• Li SF, Lacher B, Crain EF. Acetaminophen and ibuprofen dosing by parents. Pediatr Emerg Care. 2000;16(6):394-397. doi: 10.1097/00006565-200012000-00003.
• Dosage delivery devices for orally ingested OTC liquid drug products. FDA website. www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM188992.pdf. Updated October 17, 2019. Accessed November 11, 2019.
• El-Radhi AS, Barry W. Thermometry in paediatric practice. Arch Dis Child. 2006;91(4):351-356. doi: 10.1136/adc.2005.088831.