2 August 2009

Avoid Aspirin in Persons with possible Influenza Infection to Avoid “Reye’s Syndrome” with Brain and Liver Damage

Given the ongoing influenza pandemic with the H1N1/2009 virus in the southern and northern hemispheres it is timely to emphasize to the general public the critical importance of avoiding all aspirin-containing substance= s (e.g., aspirin or Pepto Bismol (bismuth subsalicylate) in persons less than 19 yea= rs of age who could possibly have influenza infection in order to avoid severe= and sometimes fatal “Reye’s syndrome.”

This advice has appeared on the US CDC and World Health Organization (WHO) H1N1 pandemic flu websites, as cited below, but warrants a much hi= gher level of visibility for the general public worldwide in order to preven= t Reye’s Syndrome during the ongoing influenza pan= demic.

The US National Institutes of Health (NIH) defi= nes Reye’s Syndrome, and briefly discusses the lack of a cure and the oft= en serious prognosis, on its website for the National Institute of Neurological Disorders and Stroke (NINDS) as follows below at: www.ninds.nih.gov/disorders/reyes_syndrome/reyes_syndrome.htm

“What is Reye's Syndrome?

Reye's syndrome (RS) is primarily a children's disease, although it can occur at any age. It affects all organs of the body but is most harmful to the brain and the liver--causing an acute increase of pressure within the brain and, often, massive accumulations of fat in the l= iver and other organs. RS is defined as a two-phase illness because it generally occurs in conjunction with a previous viral infection, such as the flu or chicken pox. The disorder commonly occurs during recovery from a viral infection, although it can also develop 3 to 5 days after the onset of the viral illness. RS is often misdiagnosed as encephalitis, meningitis, diabet= es, drug overdose, poisoning, sudden infant death syndrome, or psychiatric illn= ess. Symptoms of RS include persistent or recurrent vomiting, listlessness, personality changes such as irritability or combativeness, disorientation or confusion, delirium, convulsions, and loss of consciousness. If these sympt= oms are present during or soon after a viral illness, medical attention should = be sought immediately. The symptoms of RS in infants do not follow a typical pattern; for example, vomiting does not always occur. The cause of RS remai= ns a mystery. However studies have shown that using aspirin or salicylate-contai= ning medications to treat viral illnesses increases the risk of developing RS. A physician should be consulted before giving a child any aspirin or anti-nau= sea medicines during a viral illness, which can mask the symptoms of RS. <= /o:p>

Is there any treatment?

There is no cure f= or RS. Successful management, which depends on early diagnosis, is primarily a= imed at protecting the brain against irreversible damage by reducing brain swell= ing, reversing the metabolic injury, preventing complications in the lungs, and anticipating cardiac arrest. It has been learned that several inborn errors= of metabolism mimic RS in that the first manifestation of these errors may be = an encephalopathy with liver dysfunction. These disorders must be considered in all suspected cases of RS. Some evidence suggests that treatment in the end stages of RS with hypertonic IV glucose solutions may prevent progression of the syndrome.

What is the prognosis?

Recovery from RS is directly related to the severity of the swelling of the brain. Some people recover completely, while others may sustain varying degrees of brain damage. Those cases in which the disorder progresses rapidly and the patient lapses into a coma have a poorer prognosis than those with a less severe course. Statisti= cs indicate that when RS is diagnosed and treated in its early stages, chances= of recovery are excellent. When diagnosis and treatment are delayed, the chanc= es for successful recovery and survival are severely reduced. Unless RS is diagnosed and treated successfully, death is common, often within a few day= s.” (NINDS/NIH).

The US Centers for Disease Control and Prevention (CDC) included the following advice on May 13, 2009 in its guidance for clinicians for the treatment of the novel (now pandemic) influenza A (H1N1) under a section titled “Speci= al considerations for children” as follows:

“Aspirin or aspirin-containing products (e.g. bismuth subsalicylate – Pepto Bismol) should not be administered to any confirmed or suspected ill case of novel influenza H1N1 virus infection aged 18 years old and younger due to the risk of Reye syndr= ome. For relief of fever, other anti-pyretic medications such as acetaminophen or non- steroidal anti-inflammatory drugs are recommended”.

The CDC has also included the following advice = in its July 16, 2009 “Home Care Guidance: Physician Directions to Patient/Pa= rent”

Take medications for symptom relief as needed for fever and pain such as acetaminophen (Tylenol®) and ibuprofen (Advil®, Motrin®, Nuprin ®), and cough medicine. The= se medicines do not need to be taken regularly if your symptoms improve.
Do not give aspirin (acetylsalicylic acid) or products that contain aspirin (= e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers 18 years old or younger.

Similarly, the WHO included in its updated 11 June 2009 on the new influenza A (H1N1) virus the following advice regarding treatment: “Supportive care at hom= e - resting, drinking plenty of fluids and using a pain reliever for aches - is adequate for recovery in most cases. (A non-aspirin pain reliever should be used by children and young adults because of the risk of Reye's syndrome.)&= #8221;

Given the global spread of this pandemic influenza (H1N1) 2009 it is important to make this information available and familiar on a world-wide scale, to the general public, in addition to the health care community. This risk communi= cation can be facilitated by National public health organizations around the world= as well as the World Health Organization and its regional offices.

Daniel R. Lucey, MD, MPH

EROne Institutes, Department of Emergency Medic= ine

Washington Hospital Center= , Washingto= n, D.C.

Georgetown University Medical Center

Department of Microbiology and Immunology<= /o:p>

Website for this posting: www.BePast.org (requires IE)=

DRL23@Georgetown.edu