L4 Fever_SA.pdf

Fever Understanding the Basics and Exploring OTC Treatment Options 12/16/23 1 Outlines • Introduction • Clinical Presentation of Fever • Treatments options for Fever • OTC Medications for fever Management • Non-Medication Approaches for fever Management • Fever Management in special population...

Fever Understanding the Basics and Exploring OTC Treatment Options 12/16/23 1 Outlines • Introduction • Clinical Presentation of Fever • Treatments options for Fever • OTC Medications for fever Management • Non-Medication Approaches for fever Management • Fever Management in special populations 12/16/23 2 Fever Fever is caused by a regulated rise in body temperature, maintained by the hypothalamus, in response to a pyrogen. Fever is defined by a body temperature higher than the normal core (oral) temperature of 100º F (37.8º C). Generally, fever is self-limited and nonthreatening in presentation; however, fever can cause a great deal of discomfort and occasionally may indicate a serious underlying pathologic condition (e.g., acute infectious process). 12/16/23 3 Fever, Hyperthermia and Hyperpyrexia • Fever increases the body’s thermoregulatory set point. • Hyperthermia is a malfunctioning of the normal thermoregulatory process at the hypothalamic level caused by excessive heat exposure or production. • Hyperpyrexia is defined by a body temperature greater than 106 ℉ (41.1 ℃; oral) that typically is associated with mental and physical signs and symptoms. Hyperpyrexia may develop with either fever or hyperthermia. 12/16/23 4 Pathophysiology of Fever Immune cell Exogenous pyrogen (macrophage, lymphocytes) Activated immune cell Endogenous pyrogen (Interleukins , interferons, and tumor necrosis factor) Circulation Anterior hypothalamus (Chemical mediator – prostaglandins) Increased “set point” 12/16/23 Fever 5 Clinical Presentation of Fever Clinical manifestations of fever are nonspecific and do not occur in all patients. Therefore, specific cause of a fever may be difficult to determine. The most important indicator of fever is an elevated body temperature. Fever is symptomatic of a larger underlying process, whether an infection, an abnormality of metabolism, or a drug-induced syndrome. 12/16/23 6 Clinical Presentation of Fever – continue • Signs and symptoms that associated with fever: • Headache • Diaphoresis • Generalized malaise • Chills • Tachycardia • Arthralgia • Myalgia • Irritability • Anorexia. 12/16/23 7 Medications That Induce Hyperthermia Anti-infectives Aminoglycosides, Amphotericin B, Cephalosporins, Clindamycin, Chloramphenicol, Imipenem Isoniazid, Linezolid, Macrolides, Mebendazole, Vancomycin, Aminoglycosides, Nitrofurantoin, Paraaminosalicylic acid, Penicillins, Rifampin, Streptomycin, Sulfonamides, Tetracyclines Antineoplastics Bleomycin, Chlorambucil, Cytarabine, Daunorubicin, Hydroxyurea, LAsparaginase, 6-Mercaptopurine, Procarbazine, Streptozocin Cardiovascular Epinephrine, Hydralazine, Methyldopa, Nifedipine, Procainamide, Quinidine, Streptokinase 12/16/23 8 Medications that induce hyperthermia (continue) CNS Agents Amphetamines, Barbiturates, Benztropine, Carbamazepine, Haloperidol, Lithium, Nomifensine, Phenytoin, Phenothiazines, serotoninnorepinephrine reuptake inhibitors Selective serotonin reuptake Inhibitors, Tricyclic antidepressants, Sumatriptan, Thioridazine, Trifluoperazine, Topiramate, Zonisamide, Monoamine oxidase inhibitors Other Agents Allopurinol, Atropine, Azathioprine, Cimetidine, Corticosteroids, Folate, Inhaled anesthetics, Interferon, Iodides, Metoclopramide, Propylthiouracil, Prostaglandin E2, Salicylates, Tolmetin 12/16/23 9 Physical assessment techniques Feeling a part of the body may identify an increase in skin temperature but does not accurately detect a rise in core temperature A thermometer must be used to measure the core temperature for accurate fever detection. Core temperature can be estimated using various types of thermometers at the rectal, oral, axillary, tympanic, or temporal sites 12/16/23 10 Physical assessment techniques (continue) • Body temperature should be measured with the same thermometer at the same site throughout the course of an illness, since readings from different thermometers or body sites may vary: • Individual body temperature may differ by 1.8°F- 2.5°F (1.0°C-1.4°C) • Diurnal rhythms cause body temperature to vary during the day, with higher temperatures 12/16/23 11 Physical assessment techniques (continue) • Estimate temperature equivalency between sites using the following simplified conversion: • Add 1°F to an oral temperature for a rectal, tympanic, or temporal equivalent • Subtract 1°F from an oral temperature for an axillary equivalent 12/16/23 12 Detection of Fever Site Norma Range Fever Rectal 97.9 ℉–100.4 ℉ >100.4℉ (38.0 ℃) (36.6 ℃–38.0 ℃) Oral 95.9 ℉ –99.5 ℉ >99.5 ℉ (37.5 ℃) (35.5 ℃–37.5 ℃ ) Axillary 94.5 ℉ –99 ℉ >99 ℉ (37.2℃) (34.7 ℃–37.2℃) Tympanic 96.3℉–100.4℉ >100.4℉ (38.0℃) (35.7℃–38.0 ºC) Temporal 12/16/23 97.9℉ –100.1 ℉ 0–2 months of age: >100.7 ℉ (38.1℃) (36.6℃–37.8 ℃) 3–47 months of age: >100.3℉ (37.9℃) >4 years of age: >100.1℉ (37.8℃) 13 Recommended temperature measurements site(s) by age Younger than 3 months of age: rectal method of temperature measurement is preferred if caregiver can safely use this route 3 months - 3 years of age: rectal, oral, or temporal method of temperature measurement may be used Tympanic method of temperature measurement may be used starting at 6 months of age Older than 3 years of age: oral, tympanic, or temporal method of temperature measurement is appropriate 12/16/23 14 Complications of Fever • Dehydration • Change in mental status. • Seizures • Febrile seizure is defined as a seizure accompanied by fever in infants or children who do not have an intracranial infection, a metabolic disturbance, or an otherwise defined cause. 12/16/23 15 Treatment of Fever 12/16/23 16 Treatment Goals 12/16/23 17 Treatment Algorithm Patient with suspected fever 12/16/23 Ask patient / caregiver how the body temperature was measure Was body temperature measured correctly? NO Yes Offer to take patient temperature. Explain proper methods of temperature measurement. If fever precent go to next box Obtain symptom information information, medical history, allergy information Exclusions for selfcare (see next slide) Yes Medical referral Yes Nondrug measure ± antipyretic agent based on patient factors and preferences No Fever resolved after 24 hours No Oral temperature > 38.3 ℃ No Patient > 2 years of age? No Yes Fever resolved after 3 days of treatment ? No Medical referral Yes D/C therapy Yes 18 Exclusion for self management • Patient > 3 month of age with rectal temperature ≥ 104 ℉ (40℃) • Children < 3 month of age with rectal temperature ≥ 100.1 ℉ (38℃) • Sever symptom of infection that are not self-limiting • Risk of hyperthermia • Impaired oxygen utilization (e.g., CV or pulmonary diseases) • Impaired immune function (e.g., HIV , cancer) • CNS damage ( head trauma, stroke) • Children with history of febrile seizures or seizures 12/16/23 19 Exclusion for self management- continue • Patients > 2 years of age with fever that persist > 3 days with or without treatment • Child who develops spots or rash • Child who is very sleepy, irritable or hard to wake up • Child who is vomiting and cannot keep down fluids • Child with reported diarrhea • Children < 2 years of age with fevers that persist >24 hour 12/16/23 20 Nonpharmacologic Therapy Adequate fluid intake to prevent dehydration. Sponging or baths have limited utility in the management of fever. Wearing lightweight clothing, removing blankets, maintaining a comfortable room temperature of approximately 68.0 ℉ (20.0 ℃). 12/16/23 21 Pharmacologic Therapy (Antipyretics ) All antipyretics decrease the production of PGE2 by inhibiting the cyclooxygenase (COX) enzyme. NSAIDs including aspirin inhibit the COX enzyme in both the peripheral nervous system and CNS, whereas acetaminophen mainly inhibits the COX enzyme in the CNS. Although NSAIDs and acetaminophen are safe and effective when taken at low doses for short-duration therapy, they should not be used for more than 3 days to treat fever without medical referral for further evaluation to determine the underlying cause 12/16/23 22 Product Selection Guidelines • Select the appropriate treatment option based on the previously collected patient data • Age is an important consideration in the utilization and/or selection of an antipyretic, particularly for neonates. • Treatment of choice is usually a single-entity antipyretic • Treatment should focus on the primary cause rather than on the temperature reading 12/16/23 23 Acetaminophen • Acetaminophen shows reduction of approximately 1°F- 2°F within 30 minutes to 1 hour, with maximum reduction usually within 2 hours • Dose: • Adult ranges from 325 mg to 1000 mg every 4–6 hours, up to a maximum of 4000 mg daily. • Children: 10–15 mg/kg every 4–6 hours Maximum of 5 doses/day • Adverse effects: nausea, hepatotoxicity, and skin rash (rare). It is well-tolerated when recommended doses are not exceeded 12/16/23 24 Non-steroidal anti-inflammatory drugs (NSAIDs) • Individual patients may report a better response to one NSAID than to another for reasons that are unclear. Using an alternative NSAID may be effective when patients have previously failed to get relief from an NSAID • Ibuprofen show reduction of approximately 1°F-2°F within 30 minutes to 1 hour, with maximum reduction usually within 2 hours • It’s unclear whether acetaminophen or NSAIDs (e.g., ibuprofen) are superior in treating fever. Data suggest ibuprofen may provide a slight benefit with a quicker onset and longer duration of action 12/16/23 25 Non-steroidal anti-inflammatory drugs (NSAIDs) – continue • Ibuprofen dose: • Adult dosing ranges from 200 to 400 mg every 4–6 hours, up to a maximum of 1200 mg daily. • Children: 5–10 mg/kg per dose every 6–8 hours, with a maximum of 4 doses per day • Adverse effects: heartburn, dyspepsia, anorexia, epigastric pain, bleeding and bruising, and increased blood pressure • NSAIDs can be taken with food or milk to decrease stomach irritation 12/16/23 26 Salicylates • Aspirin may be considered for use as an antipyretic, but generally, risks outweigh benefits • Aspirin should be used only in children older than 6 months; because of the risk of Reye’s syndrome, children and teenagers who have or are recovering from chicken- pox or influenza-like symptoms should not use aspirin or aspirin-containing products. • Adverse effects: nausea, vomiting, bleeding, and dyspepsia 12/16/23 27 Special populations Pregnancy • Acetaminophen crosses the placenta but is considered safe for pregnancy and is the first-line treatment for conditions that required oral systemic analgesics • Aspirin and NSAIDs should be avoided, if possible, especially in third trimester Breastfeeding • Acetaminophen appears to be safe • Aspirin and NSAIDs should be avoided if possible 12/16/23 28 Special populations (continue) Paediatric patients • Children 12 years of age or younger should be dosed by body weight (mg/kg) • Naproxen is not indicated for children 12 years of age or younger Geriatric patients • Acetaminophen is generally recognized as the agent of choice • Aspirin and NSAIDs should be avoided if possible 12/16/23 29 General recommendations • Overtreatment of fever for viral and bacterial infections may be harmful • Non-prescription analgesics and antipyretics typically take ½ to 1 hour to begin to decrease discomfort and lower body temperature • Consideration of a more convenient dosing frequency may improve adherence, especially in children who have difficulty taking medicine: • Ibuprofen is administered every 6–8 hours • Naproxen is usually administered every 12 hours • Acetaminophen is administered every 4–6 hours 12/16/23 30 General recommendations- continue • Consider the patient in selecting the antipyretic and dosage form: consideration of palatability may improve outcomes and adherence in children • To avoid incorrect dosing of liquid dosage forms, instruct caregivers to use only the calibrated measuring device provided with the medication, which should be used only with the accompanying medication • Completely chew chewable tablets, then drink a full glass of water 12/16/23 31 Reading material • Handbook of non-prescription drugs: an interactive approach to selfcare. 20th Edition, 2021 (Chapter 6: Fever) 12/16/23 32 Any questions? 12/16/23 33 Thank you 12/16/23 34