Paracetamol

Paracetamol is often used in children to treat pyrexia, post-operative pain and other mild to moderate pain (e.g. due to `teething'). However, prescribing for children under three months old,

A double-blind, randomised controlled trial compared paracetamol with placebo in preventing adverse reactions to diptheria-tetanus-pertussis and polio (DTP-polio) vaccine.⁹ The incidence of fever, systemic and local reactions were recorded in 382 infants aged two to six months receiving the primary vaccination regimen. Seventy children aged 18 months were also assessed after receiving the DTP-polio booster.

Among infants aged two to six months, there were statistically significant reductions in the incidence of both local and systemic reactions compared with placebo. These included fever greater than 38^oC, local redness, fretfulness, crying and anorexia. However, among the 18 month olds, there was no significant difference in results, possibly because the sample size was too small in this age group.

Paracetamol is a relatively safe drug when given at normal therapeutic doses. However, overdose can prove fatal, and there is only a narrow margin between safe and toxic levels. It is, therefore, important that nurses prescribing paracetamol offer suitable advice to parents regarding its correct use, and ascertain that other products containing paracetamol are not being taken at the same time (see table 2).

Aspirin

The Committee on Safety of Medicines (CSM) recommends that aspirin, and aspirin containing products, should not be used in children under twelve years of age due to an association with Reye's syndrome.¹⁰ This is an acute illness which can be fatal. It presents with profuse vomiting, neurologic impairment, deterioration in consciousness and personality changes.

Although there is no definitive evidence regarding the association between Reye's syndrome and aspirin, there has been a sharp decline in the number of cases seen. This has paralleled the decrease in the use of aspirin in children.⁶

Despite this warning, aspirin does have a role in the treatment of some paediatric illnesses where antiplatelet or anti-inflammatory effects are required, e.g. post cardiac surgery or for juvenile rheumatoid arthritis. However, it is unlikely that prescribing nurses will encounter these children, as they would be managed by paediatricians.

Parents should be advised that aspirin is not a suitable medicine for minor illnesses in children under twelve. However, nurse prescribers may decide to recommend ibuprofen or prescribe paracetamol as an alternative.

Prescribing for the elderly

Due to age related changes in blood flow to organs, protein binding and body composition, drug distribution is usually different in older people compared with younger adults or children.¹¹ In addition, elderly patients often take a variety of medications to manage their multiple diseases. As a result, the elderly are at greater risk of adverse drug reactions and drug interactions. Therefore, old people, especially the very old, require special consideration from prescribers.¹⁰

Prescribing nurses should check all patient medication and over the counter products prior to prescribing, in order to avoid interacting drugs (see table 1).

Paracetamol

In the elderly, paracetamol is a safe alternative to aspirin¹² and has a lower risk of causing side-effects. Care should be taken when prescribing paracetamol in those who are alcohol dependent or malnourished as metabolism of paracetamol is impaired. Those with liver disease can suffer acute, life threatening injury even when using therapeutic doses of paracetamol.¹³

Accidental overdoses have occurred in patients using two or more preparations containing paracetamol.¹² Paracetamol and other combination products containing paracetamol are widely available to buy over the counter (see table 2). Prescribing nurses must ensure that the patient is not already using another paracetamol containing product before making a prescribing decision.

Aspirin

Bleeding associated with aspirin (and other NSAIDs) is more common in the elderly, who are at greater risk of a serious or fatal gastro-intestinal (GI) bleed.¹⁰ This may be because chronic pain conditions are commonly seen in the elderly.¹⁴ In addition, adverse GI effects of NSAIDs are estimated to cost the NHS around £251 million each year.¹⁵