Wednesday, May 08, 2013

The Association Between Acetaminophen (PCM / Crocin) and Asthma .... Should Its Pediatric Use Be Banned?

Expert Review of Respiratory Medicine
Expert Rev Resp Med. 2013;7(2):113-122. 


During the last few decades, a huge epidemiological effort has been made all over the world in order to cast some light on the origin of asthma (or 'wheezing disorders' as a general term) and its recent increase in prevalence. The focus on genetic factors has failed to show any genetic signal strong enough to be seriously considered, and the tiny genetic signals found have never been appropriately replicated. The focus on environmental factors has provided some variable signals on the role of infections, allergens and bacterial substances, the direction of which have curiously varied from protecting to inducing asthma. The only environmental factor that has launched a large and consistent epidemiological signal, found in almost every epidemiological study addressing the issue, is previous acetaminophen exposure, which consistently increases the prevalence and clinical manifestations of every wheezing disorder under study. Is acetaminophen a real asthma promoter or an innocent bystander?


Too liberal use of acetaminophen in children should no longer be recommended. In the general pediatric population there is a good deal of epidemiological evidence suggesting that acetaminophen exposure increases wheezing disorders prevalence, and while awaiting the results of appropriate randomized clinical trials evaluating this intervention, yet to be designed and carried out, it seems reasonable to limit acetaminophen exposure to clinical settings where no alternatives exist, that is, when ibuprofen is not appropriate. In wheezing children, this recommendation is more strongly evidence based: this intervention (avoiding acetaminophen by using ibuprofen) has proved to decrease wheezing morbidity in this population in a large and well-designed clinical trial.
However, acetaminophen banning in the general pediatric population does not seem appropriate yet, because this intervention has not been properly evaluated to date and there are clinical situations in which children and pediatricians are devoid of an appropriate alternative antipyretic and analgesic drug. Moreover, banning or drug withdrawal is a regulatory issue and only regulatory agencies, with their wide access to safety databases, can accomplish this complex task. The time has come for them to do their part.
We cannot avoid the already classic ending: we are in urgent need for well-designed clinical trials evaluating the effect of avoiding acetaminophen exposure in children on wheezing disorders prevalence and morbidity. Pediatric community: please, move on!
Comment: It is time for pediatricians to at least start using plain Ibuprofen (without PCM) in children who have wheeze.

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