Letters to the Editor

Acetaminophen Toxicity in Children

TO THE EDITOR: As the manufacturer of Tylenol acetaminophen products, we would like to correct the potentially misleading information in your recent summary of the American Academy of Pediatrics policy statement on acetaminophen toxicity.¹

The report² states: "While a specific toxic threshold has been difficult to establish because of variable factors (e.g., inaccurate information about ingested dose, use of sustained-release formulation), severe hepatotoxicity appears to be linked to cumulative toxicity associated with repeated doses rather than a single overdose." This statement implies that any dose of acetaminophen may result in toxicity. The recommended single dose of acetaminophen for children is 10 to 15 mg per kg. It is well documented that hepatotoxicity in children has not been associated with acute overdosages below 150 mg per kg.³ In fact, serious toxicity or fatalities have been extremely infrequent following an acetaminophen overdose in young children, possibly because of differences in the way children metabolize acetaminophen.

In addition, the statement leads the reader to believe that acetaminophen toxicity may occur from repeated (therapeutic) doses. This is not true. The overwhelming weight of credible data shows that acetaminophen toxicity does not occur at therapeutic doses.

MARY ELLEN MORTENSEN, M.D., M.S.
McNeil Consumer & Specialty Pharmaceuticals
7050 Camp Hill Rd.
Fort Washington, PA 19034-2299

REFERENCES

1. American Academy of Pediatrics Committee on Drugs. Acetaminophen toxicity in children. Pediatrics 2001;108:1020-4.
2. AAP policy on acetaminophen toxicity in children. [Clinical Briefs] Am Fam Physician 2001;64:1907.
3. Smilkstein MJ. Acetaminophen. In: Goldfrank's Toxicologic emergencies. 6th ed. Stamford, Connecticut: Appleton & Lange, 1998:541-68.

EDITOR'S NOTE: Although American Family Physician accurately paraphrased the AAP policy statement, we realize that the wording regarding repeated dosing of acetaminophen could be misinterpreted. Acetaminophen toxicity should not occur after repeated administration within standard dosing ranges and intervals. Repeated overdosing can result in the toxic effects mentioned in the "Clinical Briefs" item.

Consider the Cost When Prescribing Antibiotics

TO THE EDITOR: I enjoyed reading Drs. Oliphant and Green's comprehensive review entitled "Quinolones: A Comprehensive Review."¹ However, the premise that "Levofloxacin is an excellent first-line agent in the treatment of prostatitis" from the article and repeated in the "Clinical Quiz" may be misleading. I consider the cost of a treatment regimen in my empiric use of antibiotics in my practice. (I also use histamine H₂ blockers as first-line treatment for gastroesophageal reflux disease instead of proton pump inhibitors.)

Most of the patients I see with acute prostatitis respond nicely to doxycycline ($15; 100 mg twice daily for 14 days) or trimethoprim-sulfamethoxazole (TMP-SMX; $25; 800 mg twice daily for 14 days). I reserve levofloxacin (Levaquin; $135; 500 mg once daily for 14 days) for treatment failures (of which I have few) or for more serious infections. Of course, if a urethral culture can be obtained, treatment may be modified.

We, as physicians and managers of health care, need to be acutely aware of the economic implications of our decisions, especially in these difficult financial times.

H. PHILIP SACHS, M.D.
754 Cherokee St.
Marietta, GA 30060

REFERENCE

1. Oliphant CM, Green GM. Quinolones: a comprehensive review. Am Fam Physician 2002;65:455-64.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.