No evidence for practice of alternating doses of paracetamol and ibuprofen
in children with fever
The practice of alternating doses of paracetamol with ibuprofen to help control fever cannot be safely recommended, say researchers.
The practice originated in the 1970s when alternating doses of paracetamol
and aspirin were used to produce a more rapid and sustained reduction
in fever. When aspirin use was associated with the development of Reye’s
syndrome in children, practitioners began to recommend alternating ibuprofen
with paracetamol instead.
The researchers say that this change was made without sufficient evidence,
and that parents instructed to use the combined regimen may become confused,
potentially leading to overdose. In addition, the authors say, renal
toxicity can occur as a result of ibuprofen inhibiting glutathione production,
which is needed to prevent accumulation of paracetamol in the renal medulla.
Catrin Barker, principal pharmacist, medicines information, Alder Hey
Hospital, Liverpool, told The Journal; “We do not recommend [alternating
paracetamol with ibuprofen] as routine practice because of a lack of
evidence. However, there may be individual patients in whom it is necessary.”
Current guidelines produced at Alder Hey hospital recommend using paracetamol
as first line and changing to ibuprofen if paracetamol is ineffective.
The guidelines state: “Once you have switched to ibuprofen – stick
with it. Do not restart paracetamol.”
The researchers recommend that nurses and other health care providers
only use one single antipyretic medication in febrile children, and ensure
that the child is receiving an age-appropriate therapeutic dose. If the
use of either paracetamol or ibuprofen and additional non-pharmacological
methods of fever reduction have failed, the practitioner is encouraged
to proceed with caution when recommending alternating antipyretic therapy
(Pediatric
Nursing 2003;29:379).
Research proposals The Department of Health has recently called
for research proposals on the use of paracetamol and ibuprofen for
treating fever in children. The call forms part of the NHS Health
Technology Assessment programme.
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