Antipyretic effect of parenteral paracetamol (propacetamol) in pediatric oncologic patients: a randomized trial

The antipyretic efficacy and safety of propacetamol compared with dexibuprofen in febrile children: a multicenter, randomized, double-blind, comparative, phase 3 clinical trial

BACKGROUND

We aimed to compare the antipyretic efficacy, safety, and tolerability between oral dexibuprofen and intravenous propacetamol in children with upper respiratory tract infection (URTI) presenting with fever.

METHODS

Patients aging from 6 months to 14 years admitted for URTI with axillary body temperature ≥ 38.0 °C were enrolled and randomized into the study or control group. Patients in the study group were intravenously infused with propacetamol and subsequently oral placebo medication was administered. Patients in the control group were intravenously infused with 100 mL of 0.9% sodium chloride solution without propacetamol and then oral dexibuprofen was administered. We checked the body temperature of all patients at 0.5 h (hr), 1 h, 1.5 h, 2 h, 3 h, 4 h, and 6 h after oral placebo or dexibuprofen had been applied.

RESULTS

A total of 263 patients (125 in the study group) were finally enrolled. The body temperatures of patients in the study group were significantly lower until 2 h after administration (37.73 ± 0.58 vs 38.36 ± 0.69 °C (p < 0.001), 37.37 ± 0.53 vs 37.88 ± 0.69 °C (p < 0.001), 37.27 ± 0.60 vs 37.62 ± 0.66 °C (p < 0.001), 37.25 ± 0.62 vs 37.40 ± 0.60 °C (p = 0.0452), at 0.5 h, 1 h, 1.5 h, and 2 h, respectively). The two groups showed no significant differences in terms of the range of body temperature decrease, the Area Under the Curve of body temperature change for antipyretic administration-and-time relationship, the maximum value of body temperature decrease during the 6 h test period, the number of patients whose body temperature normalized (< 37.0 °C), the mean time when first normalization of body temperature, and the development of adverse events including gastrointestinal problem, elevated liver enzyme, and thrombocytopenia.

CONCLUSIONS

Intravenous propacetamol may be a safe and effective choice for pediatric URTI patients presenting with fever who are not able to take oral medications or need faster fever control.

TRIAL REGISTRATION

CRIS KCT0002888 . Date of registration: July 31st, 2013.

Recent Advances in Pediatric Use of Oral Paracetamol in Fever and Pain Management

Paracetamol is a common analgesic and antipyretic drug for management of fever and mild-to-moderate pain in infants and children, and it is considered as first-line therapy for the treatment of both according to international guidelines and recommendations. The mechanism of action of paracetamol is complex and multifactorial, and several aspects of the pharmacology impact its clinical use, especially in the selection of the correct analgesic and antipyretic dose. A systematic literature search was performed by following procedures for transparent reporting of systematic reviews and meta-analyses. To maximize efficacy and avoid delays in effect, use of the appropriate dose of paracetamol is paramount. Older clinical studies using paracetamol at subtherapeutic doses of ≤10 mg/kg generally show that it is less effective than non-steroidal anti-inflammatory drugs (NSAIDs). However, recent evidence shows that when used at dose of 15 mg/kg for fever and pain management, paracetamol is significantly more effective than placebo, and at least as effective as NSAIDs. Paracetamol 15 mg/kg has a tolerability profile similar to that of placebo and NSAIDs such as ibuprofen and ketoprofen used for short-term treatment of fever. However, when used at repetitive doses for consecutive days, paracetamol shows lower risk of adverse events compared to NSAIDs. Also, unlike NSAIDs, paracetamol is indicated for use in children of all ages. Overall, clinical evidence qualifies paracetamol 15 mg/kg a safe and effective option for treatment of pain and fever in children.

Antipyretic efficacy and tolerability of a single intravenous dose of the acetaminophen prodrug propacetamol in children: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Propacetamol is an acetaminophen prodrug that was available in Europe as an IV formu lation for the treatment of pain and fever for some time. One gram of propacetamol is hydrolyzed in blood to release 0.5 g of acetaminophen and pharmacologically inactive N,N-diethylglycine.

OBJECTIVE

This study compared the antipyretic efficacy and tolerability of IV propacetamol and placebo after a single administration in children with acute fever of infectious origin. The study was performed in anticipation of an application for US registration.

METHODS

This was a double-blind, placebo-controlled trial in which patients with a body temperature (tympanic probe) of 38.5 degrees C to 41 degrees C were randomized to receive propacetamol 30 mg/kg IV or a placebo of identical appearance, both administered as 15-minute infusions. Temperature was measured at baseline, 0.5 hour after drug administration, and hourly thereafter for 6 hours or until use of rescue medication. The primary efficacy variable was the change in body temperature at each evaluation time compared with baseline. Secondary efficacy variables included the number of children requiring rescue medication and the time to remedication; the number of children with a body temperature <38 degrees C during the evaluation period and the time to reach this temperature; maximal body temperature reduction; and the weighted sum of changes in body temperature over the evaluation period. Tolerability was assessed based on changes in vital signs, monitored for 6 hours after administration of study drug, and adverse events recorded during the 24 hours after administration.

RESULTS

Twenty children received propacetamol and 21 received placebo. Twenty patients were white, 17 black, and 4 Hispanic; their age ranged from 3 to 12 years. The actual mean (SD) dose of propacetamol received was 25.5 (0.6) mg/kg (equivalent to acetaminophen 12.8 [0.3] mg/kg). The reduction in body temperature was significantly greater in the propacetamol group compared with the placebo group at each time point over the 6-hour follow-up period (P < 0.001). Rescue medication was administered to 10.0% of patients in the propacetamol group, compared with 52.4% of those in the placebo group (P = 0.004). The weighted mean (SD) sum of the change in body temperature indicated greater antipyretic efficacy for propacetamol compared with placebo (-7.9 [3.8] degrees C x h vs 0.1 [3.6] degrees C x h, respectively; P < 0.001). There was no difference in the number of patients with treatment-emergent adverse events in the propacetamol and placebo groups (8 [40.0%] and 8 [38.1%]). The incidence of IV-site reactions was 10.0% in the propacetamol group and 9.5% in the placebo group.

CONCLUSIONS

In these 41 children with acute fever of infectious origin, a propacetamol dose of 25.5 (0.6) mg/kg IV had significantly greater antipyretic efficacy than placebo and was equally well tolerated. Comparisons of this preparation with other IV antipyretic medications are needed.

Symptomatic intravenous antipyretic therapy: efficacy of metamizol, diclofenac, and propacetamol

Fever is a common symptom in cancer patients. The most frequent causes of fever are infections, malignancy itself, various medications, transfusions, and allergy. Although it is necessary to treat the cause of fever, if possible, symptomatic fever management is also important. Surprisingly, little attention is paid to this topic in the medical literature, despite the fact that it is a very frequent problem. In order to support symptomatic fever therapy, we wanted to study the patients' discomfort accompanying fever and the beneficial effects of the symptomatic fever management. To the best of our knowledge, there is an absence of studies in this area, despite the fever discomfort can be an important reason for the antipyretic treatment, mainly in cancer patients. In this non-randomized open label pilot study, three intravenous antipyretics were tested in five groups of patients: diclofenac (75 mg, brief intravenous [IV] infusion) vs. metamizol (2500 mg or 1000 mg, brief IV infusion) vs. propacetamol (2000 mg or 1000 mg, slow IV injection or brief IV infusion). The study included 254 febrile episodes mainly in hemato-oncological patients with axillary temperature at least 38 degrees C. The main study endpoints were: changes in axillary temperature, improvement in patient comfort, and number and nature of adverse events. To support justification for symptomatic fever management in febrile patients, we asked the first 45 study subjects to fill in a questionnaire concerning their opinions about fever, fever-associated discomfort, and relief upon antipyretic therapy. All study medications had a significant antipyretic effect. However, metamizol at the dose 2500 mg was considered as the most effective, while propacetamol at the dose 1000 mg showed the lowest antipyretic efficacy. Concerning tolerability and adverse events, there were significant differences among the treatment groups. Diclofenac and metamizol (both 2500 mg and 1000 mg) were tolerated at best. All tested antipyretics significantly improved comfort in febrile patients. Overall, 87% of patients declared improvement in their comfort after administration of antipyretics. Based on the results of the present study, the choice of the antipyretic drug should depend on the clinical status of patient, contraindications, and potential adverse events and risks of the selected agent. It is advisable to use proparacetamol at the higher dosage and to administer it as a brief IV infusion in order to avoid injection-related adverse events. The symptomatic antipyretic treatment in febrile cancer patients is supported by patients themselves and has a significant role in the complex supportive care. Discomfort of patients during fever episodes may be greater than previously thought.