NSAIDs and flu
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2345 (Published 15 June 2009) Cite this as: BMJ 2009;338:b2345
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Dear Sir,
In 2000, Plaisance et al proved that the use of paracetamol increased
viral shedding and significantly prolonged the duration of influenza. (1)
In 1992, (2)Shalabi et al, showed that acetaminophen seriously
inhibits polymorphonuclear leukocytes, and scavenges available HOCl...
paralysing the MPT-H2)2-Cl- antimicrobial system of PMNs and inhibited
superoxide anion generation as well as degranulation of PMNs. Given, as
Shalabi says, that PMN's play a crucial role in fighting bacterial, viral
and parasitic infections, why is paracetamol used during infectious
fevers?
Four years later, Shalabi et al again pointed out that the higher the
temperature, the more severely acetaminophen inhibited bacterial activity
of PMNs. (3)
The medical literature since 1975 is replete with articles showing
that reducing fever during many different infections increases both
complications and mortality.
Even WHO admits this. (4)
So why does every single country recommend paracetamol
(acetaminophen) for routine treatment of any influenza, or indeed, any
infection at all?
Meanwhile back in the UK in 2004 (5), Eccles et al state that:
"Despite the lack of clinical data on the safety and efficacy of
analgesics for the treatment of colds and flu symptoms a case can be made
that these medicines are safe and effective for treatment of these common
illnesses."
Perhaps the question should also be asked as to why any deaths,
potentially augmented, or even caused by the use of antipyretics
inhibitting parts of the immune system... are then used to justify the
roll-out of a vaccine?
Hilary Butler.
(1)Pharmacotherapy. 2000 Dec;20(12):1417-22. PMID: 11130213
(2) Immunopharmacology. 1992 Jul-Aug;24(1):37-45. PMID: 1333457
(3)Biopharm Drug Dispos. 1996 Aug;17(6):501-9. PMID: 8866041
(4) Evidence on the use of paracetamol in febrile children. Bull World
Health Organ [online]. 2003, vol.81, n.5, pp. 367-372. ISSN 0042-9686.
doi: 10.1590/S0042-96862003000500011.
http://www.scielosp.org/scielo.php?script=sci_abstract&pid=S0042-
96862003000500011&lng=en&nrm=iso&tlng=en
(5) J Clin Pharm Ther. 2006 Aug;31(4):309-19. Review.
PMID: 16882099
Competing interests:
None declared
Competing interests: No competing interests
Julius Wagner-Jauregg won the Nobel prize in 1927 for developing an
effective treatment for syphilis which entailed deliberately infecting
patients with malaria. This research suggests that fever may be a
beneficial response to infection. The 2007 NICE guideline on feverish
illness in children under five(1)reviewed the sparse evidence on using
antipyretic medicines, which seems to indicate that artificially lowering
a fever may reduce the immune response and prolong illness. NICE therefore
recommended "Do not routinely give antipyretic drugs to a child with fever
with the sole aim of reducing body temperature".
A small trial on the use of antipyretics in an intensive care unit(2)
was stopped because the mortality rate was 16% in the treated group and 1%
in the group from whom antipyretics were withheld.
The existing evidence suggests that antipyretics should be avoided in
patients with pandemic flu, and yet the Health Protection Agency continues
to recommend their routine use(3). We urgently need more research into the
potential harmful effects of antipyretic medicines. When will the large-
scale randomised controlled trials be done?
References:
1. Feverish illness in children - Assessment and initial management in
children younger than 5 years. NIHCE guideline 47, 2007.
http://www.nice.org.uk/nicemedia/pdf/CG47QuickRefGuide.pdf, accessed
15/7/2009
2. The Effect of Antipyretic Therapy upon Outcomes in Critically Ill
Patients: A Randomized, Prospective Study. Schulman CI, Namias N, Doherty
J, Manning RJ, Li P, Alhaddad A et al. Surgical Infections. Winter 2005,
6(4): 369-375. doi:10.1089/sur.2005.6.369.
3. Summary of prescribing guidance for the treatment and prophylaxis of
influenza-like illness: Treatment Phase, Appendix Five ver 1.5. Health
Protection Agency, 2009.
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1243581475043, accessed
15/7/09
Competing interests:
None declared
Competing interests: No competing interests
Yet another death after paracetamol.
Dear Sir,
The silence following previous queries, is resounding.
Yet, we continue to read stories like this, daily, from all around
the world:
"The Ministry of Health says expectant mums who get symptoms should
stay home and limit contact with others especially if they are ill, drink
plenty of fluids, call their GP or healthline for advice and treat fever
straight away with paracetamol." (1)
so it's natural to then read:
"... the mother-of-two Alma Palmer had been sent home from hospital
with paracetamol, a day before collapsing and being airlifted to the
mainland.
"I am angry with the hospital," her grandfather Roderick Geesu was
quoted as saying. "She went to the hospital and instead of giving her a
thorough check-up they gave her a packet of Panadol (paracetamol)." (2)
No doubt the experts will say that OF COURSE all deaths had been
taking paracetamol. Standard protocol. "So of course paracetamol has
NOTHING to do with the deaths."
Right????
Like Dr Johnson says, when will large scale randomised trials begin?
Why is it, that standard advice flies in the face of both medical
literature, principles of immunology, and common sense?
Where is the evidence based science to justify such routine
pronouncements? And "coincidental" dismissals?
Hilary Butler.
(1) http://tvnz.co.nz/health-news/swine-flu-fears-pregnant-women-
2851450
(2) http://www.bangkokpost.com/news/asia/149784/australia-trials-flu-
vaccine-as-world-toll-leaps
Competing interests:
None declared
Competing interests: No competing interests