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FEVER, TYLENOL AND IBUPROFEN What are reasonable guidelines for using these medications? By Myrto Ashe, M.D., M.P.H. The official recommendation for the use of medications that lower fever is to use them only when the temperature reaches 37˚ C, which corresponds to roughly 100.4˚ F, the definition of “fever”. These medications also reduce pain, and so many of us have been inspired to give them to help our kids be more comfortable. Physicians have been repeatedly reassured that Tylenol (which contains acetaminophen) was entirely safe. Ibuprofen, and medications like it (trade names include Advil, Nuprin, Aleve, Motrin) can cause gastrointestinal bleeding and kidney damage, but the risk is fairly small, especially in healthy children. On the other hand, aspirin can cause Reye’s syndrome in children with a fever, a rare but deadly condition. This is why we were told to recommend acetaminophen and ibuprofen instead. We know that overdoses of acetaminophen are deadly. The drug interferes with synthesis of glutathione, the body’s major detoxifier, anti‐oxidant and anti‐
inflammatory substance. If this goes too far, you die of liver failure within days to weeks. Regular doses of acetaminophen were supposed to be harmless. I only began to hear that it could cause a problem in 2010, when I began to study functional medicine. Almost everything we do in functional medicine revolves around getting more glutathione. Using Tylenol definitely would be a step in the wrong direction. Is there any reason to treat a fever? One concern is that the fever might go too high. However, in a 2011 article in the journal Pediatrics, the authors flat out state (1): “There is no evidence that fever itself worsens the course of an illness or that it causes long‐term neurologic complications.” True, people can die of heat stroke, but I guess illness doesn’t make the body’s temperature rise that high. They go on to say: “One safety concern is the effect of acetaminophen on asthma‐related symptoms; although asthma has also been associated with acetaminophen use, causality has not been demonstrated.” Other research suggests that recent acetaminophen use is also related to higher rates of eczema and allergic rhinitis (hay fever). It is possible that what the research picked up is that people were using Tylenol because they were sicker in the first place. However, there is one study where the authors started with kids who already had asthma, and randomized them to either ibuprofen or acetaminophen. The children in the acetaminophen group ended up with more office visits and maybe even more hospitalizations than the children given ibuprofen. Note that there was no group of children who were randomized to “no medicine at all”. That could have been interesting. The whole thing gives a new meaning to the expression “Take a Tylenol and see me in the morning!” This week, in a section entitled “Should Prescribing Habits Change?”, the mainstream online journal Medscape concludes as follows (2): 1. “Acetaminophen is one of the most widely used medications worldwide. Parents give such drugs as acetaminophen to their children even in the absence of documented fever. 2. Epidemiologic studies have demonstrated that acetaminophen increases the risk for wheeze and asthma among children, as did one study of adult women. 3. Systematic reviews confirm a positive relationship between acetaminophen use and the risk for asthma. 4. Adding acetaminophen to ibuprofen alone for pediatric fever seems to provide little additional benefit. 5. The current review suggests that acetaminophen should be avoided in children with asthma or at high risk for asthma. Ibuprofen seems to be a safer choice to treat fever and pain among these children.” Let me disagree with this recommendation on two separate counts. First, is it only children with asthma? Second, what do we know about ibuprofen that might make us question its safety? If one doesn’t understand the mechanism whereby acetaminophen causes problems, one would certainly have to come to a conclusion that sticks very close to the research. The research targeted asthmatic children specifically. It doesn’t necessarily apply to other children. It also doesn’t prove other children are safe. For now, we are left with our thinking cap and not enough research results. But some of the research suggests eczema and allergic rhinitis, along with asthma, are also affected by acetaminophen. And what are these three? A group of diseases that often go together. They are called “atopic illnesses”, and they stem from an overly active immune system. But are any other diseases also related? Do we know? In a 2003 article for the International Archives of Allergy and Immunology (3), researchers explain why they think asthma is a sign of a poorly regulated immune system, which is also the case in autoimmune diseases, like multiple sclerosis, Type I diabetes, thyroid issues, rheumatoid arthritis, and a long list of other diseases, some of them very rare, that altogether, affect 25% of Americans. Wow. Maybe none of these people should be getting Tylenol. It’s not that easy to find a patient who doesn’t have either an atopic illness or thyroid issues or a parent or sibling with these diagnoses. If you do understand about the suppression of glutathione, none of this would surprise you in the least. The immune response leads to inflammation. That’s the definition of the word. But this immune response has to be kept under control. As an anti‐inflammatory substance, glutathione helps regulate the immune system. That’s all, really. The immune system, I’m sorry to say, is also involved in coronary heart disease, stroke, osteoporosis, and kidney stones, breast and prostate cancer, and diabetes too. Kids with autism typically have problems with inflammation. There probably isn’t one disease out there that doesn’t have a strong link to the immune system. Duh! I strongly believe that a reasonably cautious person, given what we know at the moment, if they wanted to be prudent rather than take chances, would avoid using acetaminophen unless absolutely necessary. Okay, then. I hope you didn’t own stock in Ortho‐McNeil‐Janssen. What are our options? IBUPROFEN? Clearly, this is not a benign drug either. I’ll work on it in the next post! BIBLIOGRAPHY (1) Fever and antipyretic use in children. http://www.ncbi.nlm.nih.gov/pubmed/21357332 (2) Acetaminophen and Asthma: A Bad Marriage http://www.medscape.com/viewarticle/762702 (3) Asthma as a Paradigm for Autoimmune Disease http://www.ncbi.nlm.nih.gov/pubmed/14646381