Fever control in G6PD deficiency

[a_zed24]

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NSAIDs can generally be administered to patients with favism in a usual therapeutic dose. However, if hemolysis occurs, the NSAID should be discontinued. What if a patient with favism and uncontrolled fever shows hemolyisis upon administration of NSAIDs? How can we manage their fever in that instance? We can't give NSAIDs but, if left untreated, fever could cause brain damage. Any thoughts?

Thanks in advance!

 

[Tenk]

Umm tylenol?

 

[longhaul3]

Tylenol is my go to for fever 100% of the time anyway unless it's contraindicated. Strongly prefer it to NSAIDs. In fact I can't remember ever ordering an NSAID for a patient for fever.

 

[a_zed24]

Thank you @Tenk and @longhaul3 ! I'm sorry, I've written NSAIDs but I meant to include Acetaminophen as well (I know many references do not regard it as NSAID... my bad!). However, I've read in some articles that even Acetaminophen could cause hemolytic anemia in patients with G6PD deficiency (like this one: http://www.cych.org.tw/pharm/MIMS Summary Table-G6PD.pdf )... so if that is the case, what's the protocol? Can cold normal saline IV be a valuable alternative? What about COX-2 inhibitors? Would they cause hemolysis in patients with G6PD deficiency as well?

 

[longhaul3]

Aren't the cox2 inhibitors also NSAIDs? Much more so than Tylenol is.

In an outpatient setting I would say supportive care with ice packs, etc.

In an ICU setting, cooling blankets, maybe cold bladder irrigation, cooling central line, etc. Cooled NS is an option. If it's an infectious fever then treat the source; if it's a central fever you can try to treat sympathetic storm with propranolol, clonidine, etc. I recently had a guy with a brainstem bleed who was storming to 108F, HR 250s, SBP 280s.

The real answer is call hematology.

 

[a_zed24]

Aren't the cox2 inhibitors also NSAIDs? Much more so than Tylenol is.

In an outpatient setting I would say supportive care with ice packs, etc.

In an ICU setting, cooling blankets, maybe cold bladder irrigation, cooling central line, etc. Cooled NS is an option. If it's an infectious fever then treat the source; if it's a central fever you can try to treat sympathetic storm with propranolol, clonidine, etc. I recently had a guy with a brainstem bleed who was storming to 108F, HR 250s, SBP 280s.

The real answer is call hematology.

Makes sense... Thanks again!

 

[OneTwoThreeFour]

The only evidence I see for acetaminophen and hemolysis in G6PD is in rare cases of intentional overdose. We give medications with potentially dangerous side effects all the time-cephalosporins in pcn allergic patients, for example. Blood transfusions. Fluids in sickle cell patients. All cost/benefit analysis.

 

[BigRedBeta]

We can't give NSAIDs but, if left untreated, fever could cause brain damage. Any thoughts?

Going to push back on this one. Elevated temperatures to the degree that cause brain injury are exceedingly rare except in the cases of environmental factors that prevent heat loss. We're talking about temps over 107 for extended periods of time before a person is likely to suffer neurologic impairment. @longhaul3's example is one of those rare cases because of the established brain injury and the impaired temperature regulation related to the neuro storming. But in otherwise intact normal brains, I would not consider hyperthermia the larger risk over the ongoing hemolysis. Fevers are super uncomfortable for sure, but ultimately unlikely to be of significant harm.

My practice in the Pediatric ICU for active cooling measures has changed over time, but now focuses only on situations in which trying to manage the metabolic demands of fever leads to significant improvement - the patient in septic shock on pressors, the child with heart failure who can't compensate, the traumatic brain injury. But otherwise, for the awake kid is going to be more miserable with ice packs in their arm pts than just rigoring through the fever.

 

[WheezyBaby]

Going to push back on this one. Elevated temperatures to the degree that cause brain injury are exceedingly rare except in the cases of environmental factors that prevent heat loss. We're talking about temps over 107 for extended periods of time before a person is likely to suffer neurologic impairment. @longhaul3's example is one of those rare cases because of the established brain injury and the impaired temperature regulation related to the neuro storming. But in otherwise intact normal brains, I would not consider hyperthermia the larger risk over the ongoing hemolysis. Fevers are super uncomfortable for sure, but ultimately unlikely to be of significant harm.

My practice in the Pediatric ICU for active cooling measures has changed over time, but now focuses only on situations in which trying to manage the metabolic demands of fever leads to significant improvement - the patient in septic shock on pressors, the child with heart failure who can't compensate, the traumatic brain injury. But otherwise, for the awake kid is going to be more miserable with ice packs in their arm pts than just rigoring through the fever.

Yep, my only addition to this would be the possibility of rhabdo with sustained rigors for hours, but I still wouldn't do any significant active cooling for that. I've only had one patient with an infectious temperature high enough that I was concerned about it from a needing active cooling standpoint, and even that one was mid/high 106 something and I think ultimately ended up just getting external cooling and maybe some coolish saline. Everything else is neuro dysfunction / exposure / ingestion related

 

[SurfingDoctor]

If a fever causes brain damage (even brain death)... no amount of NSAIDs or Tylenol are gonna prevent that. I've seen it a handful of times and yes... the temp just goes up despite what you throw at it. It's probably some genetic predisposition if I had to guess. I'm not suggesting one doesn't try... just don't be surprised by the outcome.

 

[ValeRx]

We give medications with potentially dangerous side effects all the time-cephalosporins in pcn allergic patients, for example.

The chance of cross-sensitivity reaction is fairly low with this. So much so that it's rarely even a concern. The alternative is a much stronger abx like clindamycin but then you run the risk of pseudomembranous colitis.

 

[OneTwoThreeFour]

The chance of cross-sensitivity reaction is fairly low with this. So much so that it's rarely even a concern. The alternative is a much stronger abx like clindamycin but then you run the risk of pseudomembranous colitis.

That's the point. So is profound hemolysis with tylenol in G6PD patients.