Pharmacists Play Key Role in Helping Patients Choose Antipyretics

During the winter months, patients seek advice on the use of various OTC products marketed for the relief of mild to moderate symptoms associated with viruses, such as the common cold, COVID-19, influenza, and the respiratory syncytial virus, for which activity has increased especially among children.¹

Antipyretics are commonly used to reduce fevers and the associated discomfort.

Pharmacists are in a pivotal position to counsel patients regarding the safe use of OTC antipyretics and identify possible drug-drug interactions and contraindications in patients with medical conditions and/or those taking prescription medications. Pharmacists can also ascertain if self-treatment is appropriate and encourage patients to seek further medical evaluation when warranted.

In general, most fevers are non–life threatening and self-limited but can be associated with great discomfort and indicate an underlying process, such as an acute respiratory virus.² The occurrence of a fever is often a reason for concern for many patients, particularly parents and caregivers of children younger than 5 years. Pharmacists can assist by providing education on best measures to manage and treat fevers, including providing guidance on the proper use of nonprescription antipyretics.

A fever is defined as a body temperature greater than the normal core oral temperature of 100 °F (37.8 °C).^1,2 Normal body temperature can fluctuate and average between 97.5 °F (36.4 °C) and 98.9 °F (37.2 °C).^2-4 Fever is a very prevalent symptom and accounts for an estimated one-third of primary causes for emergency department and pediatrician visits among patients younger than 15 years.^2,3 Although most fevers can be easily managed with proper treatment, the presence of a fever may also indicate a serious underlying illness, such as an acute infection that necessitates immediate evaluation and treatment.²

A fever may be classified as idiopathic, but it can also result from an infectious or pathologic process, vigorous exercise, or a response to the use of certain pharmacological agents, also known as a drug fever.^2-7 Examples of drugs associated with drug fever include certain anti-infectives, such as macrolides, penicillin, and tetracyclines; antineoplastics, such as bleomycin, daunorubicin, and hydroxyurea; cardiovascular agents, such as methyldopa, nifedipine, and quinidine; and central nervous system agents, such as lithium, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants.

To manage a fever, clinicians typically tailor management to patient needs and monitor patients for fever recurrence.² Most fevers are caused by microbial infections including bacteria, fungal, viral, and yeast infections.^2,3,6 Fevers may also transpire after the administration of some immunizations.⁴ Patients with fevers may also experience other signs and symptoms that can cause discomfort, such as arthralgia, chills, flushed face, headache, malaise, myalgia, or sweating.

Common medication errors often associated with the use of OTC analgesics/antipyretics are overdosing, therapeutic duplications, and inappropriate dosing especially in children because of mathematical miscalculations in weight-based dosing.²

Treating Fever

Nonpharmacological measures and nonprescription anti-pyretics are often used to manage and treat fevers. The primary goal in the self treatment of fever is to relieve discomfort by reducing temperature. However, it is imperative to also identify and treat the underlying cause of the fever when feasible.^2,4,5 Nonprescription antipyretics include acetaminophen and nonsteroidal anti-inflammatory drugs, including aspirin, ibuprofen, and naproxen. Acetaminophen and ibuprofen are the most used antipyretics.^2,6,7

Ibuprofen is only approved in patients 6 months and older for fever reduction.²

Antipyretics are available in a variety of formulations for adults and children as combination or single-entity products as capsules, chewable tablets, enteric-coated tablets, extended- or sustained release forms, gel capsules, liquid gels, liquids, rapid-release gel capsules, suspensions, and tablets. Acetaminophen is also available in suppository form for children. Typically, alleviation of discomfort and fever reduction occur approximately 30 to 60 minutes after administration.²

On February 28, 2020, the FDA approved the first dual-action OTC fixed-dose combination formulation with 250 mg of acetaminophen and 125 mg of ibuprofen per caplet in a single dose for individuals 12 years and older.⁸ The combination product allows patients to take a lower maximum daily dose of each ingredient and provides up to 8 hours of therapeutic effects.⁸

Nonpharmacological measures tailored to patient needs include drinking fluids to prevent dehydration, maintaining a comfortable room temperature, and wearing lightweight clothing.^2,4

Counseling Patients and Caregivers

During counseling, pharmacists should ensure that patients and caregivers understand the appropriate dosing, administration, and possible adverse effects of selected products. Be sure to remind parents and caregivers to only give children those products formulated for them and to use appropriate measuring devices that accompany these products. Because antipyretics can also be found in allergy, cold, cough, and flu products, advise patients and caregivers to always read all medication labels prior to administration to avoid ther-apeutic duplications or possible medication overdose. If there are additional concerns, direct patients and caregivers to contact their primary health care providers immediately.

• Key counseling tips include the following^2,4-7
• Avoid alternating antipyretics because of the increased risk of potential dosing errors and adverse effects, especially among children.
• Avoid sponge baths using isopropyl or ethyl alcohol because that may result in alcohol poisoning from skin absorption, especially among children.
• Avoid the use of aspirin or aspirin-containing products for treating fever in children and teenagers who have or are recovering from chicken pox or influenza-like illness because of their increased risk of Reye syndrome.
• Do not rely on skin contact to detect fever. Always use an appropriate thermometer to ensure accuracy.
• Dosing of either acetaminophen or ibuprofen should be based upon a child’s weight instead of age.
• If a fever repeatedly rises above 104 °F (40 °C) in children of any age and/or if a fever persists for more than 24 hours in children younger than 2 years, seek medical care immediately.
• Immediately seek medical attention if fever continues or worsens after 3 days of self-treatment or if signs of infection are present.
• Only administer pediatric formulations to children, and always contact a primary health care provider if unsure about proper dosing.
• Seek further medical care for those with comorbid conditions, if rectal temperature is 104 °F (40.0°C) or greater, if those younger than 3 months have a rectal temperature exceeding 100.4 °F (38.0°C), or if patients have a history of febrile seizures.
• Always use a calibrated medication-measuring dosing device for liquid medications to ensure accurate dosing.
• Drink adequate amounts of fluids to maintain hydration and restore electrolytes, unless otherwise indicated by a primary health care provider, such as in patients on fluid-restricted diets.

References

1. Stein PJ. This year’s RSV surge: bigger, earlier, and affecting older patients than previous seasonal outbreaks. Clinical Advisor. December 12, 2022. Accessed December 14, 2022. https://www.clinicaladvisor.com/home/topics/infectious-diseases-information-center/rsv-surge-tripledemic/
2. Prince M, Glozier N, Sousa R, Dewey M. Measuring disability across physical, mental, and cognitive disorders. In: Regier DA, Narrow WE, Kuhl EA, Kupfer DJ, eds. The Conceptual Evolution of DSM-5. American Psychiatric Publishing Inc; 2011:189-227.
3. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010;(26):1-31.
4. Fever. John Hopkins Medicine. Accessed November 28, 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/fever.
5. Fever in children: overview. InformedHealth.org. Institute for Quality and Efficiency in Health Care. Updated June 6, 2019. Accessed November 28, 2022. https://www.ncbi.nlm.nih.gov/books/NBK279455/
6. Bush LM. Fever. Merck Manual Professional Version. Updated September 2022. Accessed November 28, 2022. http://www.merckmanuals.com/professional/infectious_diseases/biology_of_infectious_disease/fever.html
7. How to take your child’s temperature. HealthyChildren.org. Updated October 12, 2020. Accessed November 28, 2022. https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/How-to-Take-a-Childs-Temperature.aspx
8. FDA approves GSK’s Advil Dual Action with Acetaminophen for over-the-counter use in the United States. PR Newswire. News release. February 28, 2020. Accessed November 28, 2022. https://www.prnewswire.com/news-releases/fda-approves-gsks-advil-dual-action-with-acetaminophen-for-over-the-counter-use-in-the-united-states-301013675.html

About the Author

Yvette C. Terrie, BSPharm, RPh, is a consulting pharmacist and medical writer in Haymarket, Virginia.