The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.
Letter to the Editor
Editor, – I disagree with the statement in the medicinal mishap (Aust Prescr 2014;37:24-5) that only one route of administration for paracetamol should be charted when treating children.
It is neither inappropriate nor unsafe. It reduces the flexibility of the nurses to decide whether the intravenous or oral route is used. The child may initially require intravenous then oral dosing (much cheaper) when suitable. The doses and dosing intervals are the same for the oral and the intravenous formulations. Rectal doses are higher, but it would not be unsafe to prescribe paracetamol ‘IV/PO/PR’. Certainly ‘IV/O’ is perfectly acceptable. It is not practical to prescribe per rectum paracetamol in doses that are not in multiples of 125 mg.
Secondly, there is not enough room on the current standardised medication chart (which needs to be revised) to include the generic and the brand name (which is often not known to the prescribing doctor).
Editor, – The medicinal mishap makes the statement that writing up paracetamol IV/PO/PR is unsafe. Compared to what, may I ask? Compared to writing it up on three separate sections of the chart? Writing it up on one section, I feel, makes it less likely that multiple doses are given and the daily maximum is exceeded. Postoperatively, I know that initially my patients will require intravenous administration and will progress to oral when their gut function recovers.
Madlen Gazarian, Anna Drew and Alexandra Bennett, the authors of the medicinal mishap, comment:
We thank Dr Lumsden and Dr McLaren for their correspondence and appreciate the opportunity to provide important clarifications about NSW Therapeutic Advisory Group’s (TAG) guidance on intravenous paracetamol.1,2
First, a fundamental principle of good therapeutics is to prescribe medicines by specifying only one route. Reasons include different indications and doses appropriate for the same medicine administered by different routes. This principle is highlighted well by paracetamol but also applies to other medicines such as morphine.
Our article recommended that intravenous paracetamol be reserved for ‘short-term treatment of mild–moderate pain when enteral administration is not possible’. In addition, we recommended that treatment is reviewed daily and the intravenous prescription discontinued as soon as it is no longer needed. This is also an important risk-management strategy which eliminates exposure to potential ongoing risk (for example, 10-fold overdoses) when there is no additional efficacy benefit from intravenous over enteral administration.
Second, a general principle for safe paediatric prescribing is that prescribers ‘check the basis for the dose calculation in a current paediatric prescribing reference or other up-to-date, evidence-based medicines information resource’. Current national3 and international4 paediatric dosing references and NSW TAG’s own guidance1,2 recommend different individual doses, dose intervals and maximum safe daily doses for intravenous, oral and rectal paracetamol for different indications. For these reasons we re-emphasise that ‘prescribing paracetamol IV/PO/PR is inappropriate and unsafe’.
While acknowledging the national inpatient medication chart could be improved, our recommendation to ‘specify the brand name in addition...’ could be accommodated by the current paediatric chart by writing the brand name in the ‘Pharmacy/Additional information’ section.
- NSW Therapeutic Advisory Group. Paracetamol use: a position statement of the NSW Therapeutic Advisory Group Inc. Sydney: NSW TAG: 2008.
- NSW Therapeutic Advisory Group. Intravenous paracetamol use. Addendum to the 2008 ‘Paracetamol use’ position statement of the NSW Therapeutic Advisory Group . Sydney: NSW TAG; 2012.
- Paracetamol monograph. In: AMH Children’s Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2014.
- Joint Formulary Committee. Paracetamol (Acetaminophen). 2014. British National Formulary (online). London: BMJ Group and Pharmaceutical Press; 2014.