Flu and Fever: Friend or Foe?: When to Treat?

I'll probably take a fever-reducing agent

When I'm over 102.

But that's a long ways away, as I'm not even 55 yet! ;-)

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by: Bronco Bill @ Sun Aug 30, 2009 at 22:34:27 PM UTC

snort!

BB you crack me up! ;-)

I take it (and my kids take it) only if we are uncomfortable to the point of not being able to rest, or if the fever is very high.  

I prefer to use cool cloths and let the fever burn itself out, rather than fever reducers. My main reason is that they are also pain relievers and I don't want to mask pain that may be an indication of something else that is wrong.

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by: kristikaylene @ Sun Aug 30, 2009 at 22:45:27 PM UTC

[ Parent ]

rarely

I rarely take a fever reducing medicine prefering to sweat it out with cool drinks and a sheet on the bed..never use aspirin as I have a family history of abdominal bleeding. I would be more likely to treat son for fever and certainly did when he was little.. calpol, cool drinks, tepid sponging.. that sort of thing.

Re your point about absence of fever in severe cases.. I was talking this over with OH.. when our cows get ill, he'd rather see a high temp than an animal with no or low temp.. the high temp is an indication that the animal is making some attempt to treat itself and with support usually gets better.. those with no temperature but the same signs of udder inflammation are by and large more sick, and likely to develop the complications of toxic mastitis, one of which is often a rapid decline and death.

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by: coldethyl @ Sun Aug 30, 2009 at 23:14:15 PM UTC

I do have a legitimate question/comment

When I caught the flu about 5 years ago (seasonal), I had a fever of about 103. My doc told me to take one Excedrin tab, then in 4 hours take a Tylenol, then 4 hours later repeat the Excedrin, then 4 hours after take a Tylenol. She practically guaranteed that by the next morning the fever would break. She was right.

Would the same thing work with A(H1N1) in the case of a high fever? (Obviously with other NPIs)...

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by: Bronco Bill @ Mon Aug 31, 2009 at 00:13:35 AM UTC

Interesting -

I have heard of alternating doses of Tylenol and aspirin, or Tylenol and ibuprofen, but in a regular dose and NOT two medicines that both contained acetaminophen (Tylenol and Excedrin both have acetaminophen).  Perhaps that's why your doc specified one tab each time.  This is the first I've ever heard of an alternating 1 tablet dose regimen.

I had a tropical fever years ago with a temp of 103.9F for more than a month - and that was with fever reducing medicine every four hours.  Sometimes fever can be your friend, but sometimes it can be dangerous in its own right.

People do need to be judicious in their use of acetaminophen containing products - daily max dose is now 4000 mg, but there has been talk of lowering the max dose to 3000 mg per day, due to the danger of liver damage.

And never wash the acetaminophen down with a beer, wine, or liquor - that's asking for liver damage, and it's a rough way to die.  You also have to be aware that many cold symptom relief preparations also contain acetaminophen - the stuff seems to be everywhere.

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by: Clawdia @ Mon Aug 31, 2009 at 01:23:10 AM UTC

[ Parent ]

I offer many apologies...

DW just corrected me...it was Excedrin and Advil...acetaminophen and Ibuprofen. That makes more sense.

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by: Bronco Bill @ Mon Aug 31, 2009 at 01:39:28 AM UTC

[ Parent ]

An interesting concept

(3)  Heat - sensitive viruses and bacteria often do NOT trigger a fever, as a way of protecting themselves.  As the H1N1 Swine Flu has demonstrated that one-third of patients in Mexico, sick enough to be hospitalized, had no fever, and almost one-half of the patients in Chile had no fever, then wouldn't it be logical that fever could be a treatment for the H1N1 and improve the patient's survival ?

I did something when I had this flu that up to this time I chose not to post or describe.  I'm was afraid it might be just the wrong thing for many folks, and maybe it was the wrong thing for me.  

I did not have a fever, but felt bad.  I would consider it a mild case.  Both of my sons had a fever.  But I did not.  At this time we were having 100 degree F. heat outside and my vegetable garden was going to suffer badly unless it was watered.  I grow a very big garden, and it brings in a small but important portion of our income.  So, as I was feeling ill, I stood outside in the sun watering.  Sometimes I was in the shade, but often in the sun.  At times it felt oddly good to me to do so.  But I also knew it might be bad for me.  For better or worse, I did this several days while I was sick.  I also took hot baths, until I was sweating profusely.  Maybe I was not the smartest of folks to have done this, but what if I inadvertently was doing something which actually helped?

It is an interesting concept to add heat with this flu when fever is not present.  I don't recommend it, because it might be exactly the wrong thing, but it is still interesting.  

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by: Okieman @ Mon Aug 31, 2009 at 01:12:18 AM UTC

Heat to fight a virus

Okieman,  I go for the heat when I feel poorly.  Go sit in my 400 gallons of stored water called a spa until I have sweat running down my face.  I figure it's the best way to fight off those little nasties.  

Plus all that time you were in the heat of the sun you were soaking up Vit D!!  

Not silver or sage, just a blend of colors!

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by: silversage @ Mon Aug 31, 2009 at 01:35:50 AM UTC

[ Parent ]

Yeah

The vitamin D issue came to mind also.  I know it is important for the immune system and there has been much discussion of it on the flu blogs.

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by: Okieman @ Mon Aug 31, 2009 at 01:40:59 AM UTC

[ Parent ]

Wonder If I Had H1N1 Last Fall?

I got really sick in September last year.  No cough but had aches and pains like flu.  Went to the Dr. because my husband way dying from Cancer and I got an Antibiotic and I got my husband Tamiflu.  

I had a cough for over a month and went through a second course of Anitbiotics.  Was weak and really sick for over a week.  But I had NO Fever through this whole mess.

I do not run to the Dr and get anitbiotics normally, I was just scared my husband would die early if he got what I had...it was that bad.  

I usually do not treat a fever because I know it kills the virus/bacteria,  I use it for being uncomfortable.

By the way the Tamiflu may have worked my husband did not get sick.

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by: FluMom @ Mon Aug 31, 2009 at 02:50:24 AM UTC

H1N1 last winter

FluMom, I have wondered similarly if I and others I know had it in January/February of this year.  I had all the symptoms and additionally seemed to get better than get sick again. It was never very bad except for a couple of days where my head and throat were really troublesome.  

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by: WitchMisspelled @ Tue Sep 01, 2009 at 11:47:15 AM UTC

[ Parent ]

Flu last December/January

My sis got the flu last December, I got it in January.  We both had all the classic H1N1 symptoms.  We both wondered if this could have been some early version of H1N1 - everything right down to the relapse was the same.  

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by: LA Escapee @ Tue Sep 01, 2009 at 19:17:03 PM UTC

[ Parent ]

Routine Influenza Surveillance Weekly Reports Tell You What Is Circulating.

Individuals who had flu last season probably did not have pandemic H1N1 but rather seasonal influenza. The US does routine surveillance. If you are curious which strains were common the week you were sick, go to this site  http://www.cdc.gov/flu/weekly/...  and select the week you were sick.  You will then see which types were detected through routine surveillance. Up until April the pandemic H1N1 would have been considered an untypable A. A seasonal H1N1 was circulating that had a good match to the vaccine but was resistant to tamiflu.  An H3N2 was also circulating that was not a good match to the vaccine. And if you are elderly every year is a pandemic which is precisely the reason I like to see health care workers vaccinated against seasonal influenza. That is the perfect excuse for me to provide a link to a favorite video about seasonal influenza and the need to be immunized.  http://www.youtube.com/watch?v... It is a great song with a great message.
 

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by: Public_Health_Networker @ Wed Sep 02, 2009 at 00:33:48 AM UTC

[ Parent ]

Cases of Flu with No Fever - Possible Explaination

Argumentation is reasoning tested by doubt http://www.thegreatcourses.com... so now that I have some time I hope I am forgiven for my arguing with my own diary by commenting on my friend's statement:

As the H1N1 Swine Flu has demonstrated that one-third of patients in Mexico, sick enough to be hospitalized, had no fever, and almost one-half of the patients in Chile had no fever, then wouldn't it be logical that fever could be a treatment for the H1N1 and improve the patient's survival ?

.
I went looking for the origin of these two statistics and I found just two sources http://www.nytimes.com/2009/05... and http://isidpresidentspov.blogs... but from the same highly credible physician.  However if you look closer, they are not scientific surveys which examined patient histories in depth and in both countries the presence or absence of fever was on admission to the hospital (which presumably could still be influenced by anti-pyuretics).  More important it was the milder cases  which did not eventually develop fever.  The milder cases could have simply have recovered by the time the anti-pyuretics wore off.  (And certainly there have always been individuals who develop immunity after mild or undetectable influenza illnesses in the past.)  Given these unknowns I definitely would NOT advocate for inducing a fever in those who genuinely have no fever. However not inducing fever is very different from treating a fever. Treating a fever might have too unintended consequences.  One, it could decrease the bodies natural ability to fight the virus and two, it could increase the transmission of influenza by allowing people to continue with their daily business instead of staying in bed.  

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by: Public_Health_Networker @ Tue Sep 01, 2009 at 01:48:48 AM UTC

When to Treat?

How high should a fever be allowed to go before it is dangerous to an adult? And is an alcoholic hot toddy good or bad with a fever? My DH had the flu as a child and was given a Moonshine toddy (believe it or not,but he lived in the south.)He said his fever broke and he nearly drown in the sweat! I would NEVER consider such a thing for a child,but what about for an adult?  

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by: finalride @ Tue Sep 01, 2009 at 13:53:53 PM UTC

How should a fever be allowed to go?

That is a really good question and a great flu wiki topic. I would appreciate hearing what other think. To my knowledge no one has done a randomized control trial with H1N1 and therefore we don't know the magnitude of any benefit.  Therefore it is very important to minimize any risk.  And of course the answer depends in part on the general condition of the individual (and what is causing the fever).  Fever in pregnant women can be particularly problematic for the fetus and so they should have priority for any antiviral agents and follow their OB's advice on fever management. Otherwise advice about treating fever seems very varied.  The MayoClinic site seems to take a nice middle of the road approach.  http://www.mayoclinic.com/prin...

Don't treat fevers below 102 F (38.9 C) with any medications unless advised to do so by your doctor. If you have a fever of 102 F (38.9 C) or higher, your doctor may suggest taking an over-the-counter medication, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others). Adults may also use aspirin. But don't give aspirin to children. It may trigger a rare, but potentially fatal, disorder known as Reye's syndrome. Also, don't give ibuprofen to infants younger than 6 months of age.

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by: Public_Health_Networker @ Wed Sep 02, 2009 at 02:26:41 AM UTC

[ Parent ]

How should a fever be allowed to go?

I am trying to pin down things such as how high my temp should go before dangerous because I would probably let the fever work. But also I am making notes to let DH know when he needs to get me to a hospital if I am severely ill.
It is just the 2 of us and although many of us as mothers have taken care of our little ones, he has very little experience of taking care of a sick person.  

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by: finalride @ Wed Sep 02, 2009 at 14:58:17 PM UTC

[ Parent ]

How should a fever be allowed to go?

to clarify my remarks about moms taking care of sick little ones,I want to say that many dads take care of them as well.But DH came into our lives when my son was a teen. Although he is a great stepdad and has the patience of Job,he did not have to deal with much illness when our son was that age. I did not mean to say that only women knew how to take care of sick loved ones,just that my DH needs a little advice in that deptment.  

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by: finalride @ Wed Sep 02, 2009 at 16:04:05 PM UTC

[ Parent ]

FEVER AS A TREATMENT: DEHYDRATION REQUIRES THAT IT BE BROUGHT DOWN OR THE PATIENT PUT ON AN IV

     I am PHN's friend who first raised the question of fever as a treatment. It is my hope to locate scientific research on the subject: Where are the specific details about  what temperature is useful against a virus, BEFORE it becomes counter-productive? I would like info from different countries for comparison. In the US, physicians and the CDC recommend OTC medicines if it would make the patient more comfortable to lower their fever.
    DEHYDRATION IS LIFE THREATENING.  It would negate any good that a fever might do, by the damages caused by dehydration. If an adult or child cannot   consume enough fluids, this would require the temp be brought down by a warm sponge bath or pills. Or,the person should be put on an IV.
    Few people have been trained to CHART(record by time, temp, intake/output,observations of condition) whenever they are caring for a sick family member at home. Some people don't know how to read a thermometer or do not have one. If the caregiver does not measure how much liquids a sick person is drinking over X hours, and if they do not know to look for symptoms of dehydration, then a well-meaning convert to fever as a treatment, could do more HARM than good.  No doubt these anxieties explain the widespread use of  fever-lowering drugs.
   On the other hand, if letting a fever run its course, would help a person fight off the H1N1 virus, then we need to know it.  We need to know the detailed protocol for doing it right, WITHOUT damage to the patient. This would also be true for the person with no fever, who maybe needs  one.

We know fever is bad for babies, pregnant women, frail elderly, or ones with heart disease, people at risk for stroke and others. I suspect the needed research has been done, and got lost on a shelf, somewhere.

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by: Negley55 @ Wed Sep 02, 2009 at 03:34:45 AM UTC

I'd like to ask this question again

from the top diary.  

What research has been done on the value and dangers of using fever therapy?

I haven't done a literature search.  Does anyone know what is the latest wisdom on the proven (as opposed to theoretical) downsides of reducing fever?  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Wed Sep 02, 2009 at 17:51:55 PM UTC

Interesting abstract on a fever treatment study.

I tried a literature search and the only thing solid that I came up with so far is this study (note 40 decrees C - 104 degrees F) -
http://www.ncbi.nlm.nih.gov/pu...
The effect of antipyretic therapy upon outcomes in critically ill patients: a randomized, prospective study.
Schulman CI, Namias N, Doherty J, Manning RJ, Li P, Alhaddad A, Lasko D, Amortegui J, Dy CJ, Dlugasch L, Baracco G, Cohn SM.

Division of Trauma and Surgical Critical Care, University of Miami Leonard M. Miller School of Medicine, Miami, Florida 33101, USA. carl@miami.edu

Despite the large body of evidence suggesting a beneficial role of fever in the host response, antipyretic therapy is commonly employed for febrile critically ill patients. Our objective was to evaluate the impact of antipyretic therapy strategies on the outcomes of critically ill patients.

The aggressive group received acetaminophen 650 mg every 6 h for temperature of >38.5 degrees C and a cooling blanket was added for temperature of >39.5 degrees C. The permissive group received no treatment for temperature of >38.5 degrees C, but instead had treatment initiated at temperature of >40 degrees C, at which time acetaminophen and cooling blankets were used until temperature was <40 degrees C

There were 131 infections in the aggressive group and 85 infections in the permissive group (4 +/- 6 vs. 3 +/- 2 infections per patient, p = 0.26). There were seven deaths in the aggressive group and only one death in the permissive group (p = 0.06, Fisher Exact Test). The study was stopped after the first interim analysis due to the mortality difference, related to the issues of waiver of consent and the mandate for minimal risk. CONCLUSIONS: Aggressively treating fever in critically ill patients may lead to a higher mortality rate.

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by: Public_Health_Networker @ Thu Sep 03, 2009 at 00:05:10 AM UTC

[ Parent ]

Well done, PHN

Normally when a clinical trial is stopped early due to overwhelming differences in the treatment responses such that it would be unethical to continue, there is quite a fuss about it! This study was reported in 2005, so there really should have been some follow-up work in infectious diseases in otherwise healthy people by now.  

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by: Ruby Murray @ Thu Sep 03, 2009 at 00:14:38 AM UTC

[ Parent ]

OK, so I'm not a medic

but the page Okieman links to talks about lukewarm baths. This I think would be considered "aggressive treatment" in the paper PHN found.

I had a quick look in PubMed and couldn't find any RCTs but there were three or four reviews. I skimmed this one from 1998 and it seems very clear, and is also interesting in that it raises possible dangers of "external cooling" for people with heart or lung problems. I am wondering if this "cold pressor response" could be responsible for the mortality in the treated group in the 2005 study?

http://archinte.ama-assn.org/c...

I think it is really something that we need to get the bottom of before our loved ones get sick.

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by: Ruby Murray @ Thu Sep 03, 2009 at 00:36:32 AM UTC

[ Parent ]

Review of Literature re External Cooling in ICU

First, in relation to the Schluman study, doesn't it matter what the cause(s) of the critical illness are?

That study (at least from the abstract portions available) doesn't say what caused these critical illnesses, so I'm not sure how informative it can be on the more specific question posed here concerning treatment of not just the flu but this flu.

That study is referenced in a review of literature related to external cooling methods for use in the ICU that contains some interesting points:

But definitive implications for nurses are difficult to formulate. That's because during infection, fever allows the immune system to work best, and suppression of it may be harmful, resulting in a more severe and long-lasting infection. On the other hand, patients with severe cardiorespiratory disorders or sepsis may be unable to compensate for the increased metabolic demands of fever; in such cases, the benefits of physical antipyresis may outweigh its detrimental effects.

In nonsedated critically ill patients, physical antipyresis can lead to adverse effects such as shivering, discomfort, and worsening hemodynamic instability. Thus, physical antipyresis should be avoided during the chill phase of fever; during the other two phases, it should be combined with appropriate compensatory measures (insulating wraps for the extremities) or antipyretic agents.

http://www.nursingcenter.com/l...

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

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by: Into The Woods @ Thu Sep 03, 2009 at 01:39:33 AM UTC

[ Parent ]

Abstracts Related to Fever Treatment

One problem is that many studies take the need to decrease fever (or not decrease fever) as a given. The following two articles tried to look at the evidence and  basically conclude that more studies are needed because the conventional wisdom of trying to get temperatures down in ICU's may be wrong.

1) http://www.ncbi.nlm.nih.gov/pu...

2) http://www.ncbi.nlm.nih.gov/pu...

This article takes it as a given that fevers don't need to be dropped and examines parental reasons for this phobia.  http://pediatrics.aappublicati...

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by: Public_Health_Networker @ Thu Sep 03, 2009 at 00:36:35 AM UTC

[ Parent ]

thanks for the citation

I'll look them up later.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Thu Sep 03, 2009 at 16:06:39 PM UTC

[ Parent ]

What Temps Kill (A)H1N1 ?

Fever is discussed over at our Flu Wiki.

http://www.fluwiki.info/pmwiki...

The page has a lot of good information that is worth reviewing, but raises an intersting threshold question that comes up over there with reference to H5N1('bird flu'):

Allowing a fever to continue untreated will not be beneficial in a bird flu infection. The internal body temperature of a bird is approximately 108 degrees F. The H5N1 strain of influenza survives in this environment. The human body would suffer brain damage at this temperature.

Do we know what temperatures at which (A)H1N1 does not survive? (Or what duration it survives at such temps?)

These studies were done on H5N1 both in reference to how long it would survive in the environment at different temps (shorter at higher temps) but also in reference to killing it in meat that is being cooked.

I don't remember seeing anything like that for (A)H1N1 which would seem to be a threshold question.

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

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by: Into The Woods @ Thu Sep 03, 2009 at 00:22:29 AM UTC

Even on H5N1, Most Research I Find is On Outside the Body

The human H5N1 influenza A virus polymerase complex is active in vitro over a broad range of temperatures, ...

http://vir.sgmjournals.org/cgi...

Avian influenza virus (H5N1); effects of physico-chemical factors on its survival
...
H5N1 virus lost infectivity after 30 min at 56°C, after 1 day at 28°C but remained viable for more than 100 days at 4°C. Acidic pH (1, 3) and basic pH (11, 13) were virucidal after 6 h contact time; however virus retained infectivity at pH 5 (18 h), 7 and 9 (more than 24 h). UV light was proved ineffectual in inactivating virus completely even after 60 min. Soap (lifebuoy®), detergent (surf excel®) and alkali (caustic soda) destroyed infectivity after 5 min at 0.1, 0.2 and 0.3% dilution. All commercially available disinfectants inactivated virus at recommended concentrations. Results of present study would be helpful in implementing bio-security measures at farms/hatcheries levels in the wake of avian influenza virus (AIV) outbreak.

http://www.pubmedcentral.nih.g...

Survial of HPAIV H5N1 in Different Kinds of Water
http://www.fao.org/docs/eims/u...

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

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by: Into The Woods @ Thu Sep 03, 2009 at 01:02:11 AM UTC

[ Parent ]

Temperatures and influenza, Changes needed to "flu wiki" section on fever ?

"Into The Woods" pointed me to the wiki section on fever
http://www.fluwiki.info/pmwiki...
In particular these statements bother me:

Allowing a fever to continue untreated will not be beneficial in a bird flu infection. The internal body temperature of a bird is approximately 108 degrees F. The H5N1 strain of influenza survives in this environment. The human body would suffer brain damage at this temperature.

Fever does more than necessarily kill the infectious agent directly: it also causes the production of interferon and does other good stuff. In addition I want to point out that influenza is a virus.  Viruses are not whole cells like bacteria are. Viruses can only multiply when they are in the host cell. So it is not necessarily the virus survival that matters but the infected cells survival. This is a subject (cell apoptosis) that I have not studied fully but for those interested in learning more here is a start:  http://www.ncbi.nlm.nih.gov/pu...   So I don't believe that the fact that the H5N1 infects birds (with their high resting temperature) says anything about whether fever is beneficial or not in a person infected with H5N1. Please let me know if I am wrong.

(I do believe that temperature is very important in the survival of the virus outside the human body as well as initial entry into the human body but that is the subject of a different diary - http://www.newfluwiki2.com/dia...

Give Acetaminophen (Tylenol) for fever over 101.0 degrees F (38.33 degrees C.). For adults and children over 95 lbs., use two tablets (650 mg or 1000 mg total dose). For smaller adults and children under 95 lbs, administer according to the dosage chart below.

If we accept that we really don't know the impact of fever on specific strains of influenza than  the advice to give tylenol for fevers over 101 should be altered.

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by: Public_Health_Networker @ Sat Sep 05, 2009 at 19:46:39 PM UTC

[ Parent ]

Personally, I agree with you,

(and I was hoping someone would raise this point when I linked to it earlier). I also raised the issue in one of the prepping threads, together with the question of whether viral voiding should be suppressed with Pepto-Bismal.

However, is it not unethical to change current guidelines without good evidence to the contrary? I think the advice could usefully be changed to reflect the two schools of thought - antipyretic treatment such as paracetamol and ibuprofen may be used to ease symptoms such as aches and fever however some scientists believe that the body's high temperature helps to destroy the virus more quickly.  

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by: Ruby Murray @ Sat Sep 05, 2009 at 20:28:11 PM UTC

[ Parent ]

Good Questions

Just to clarify, the referenced page came up in my search and other than it's inclusion on the flu wiki page I have no strong inclination (nor professional basis for one) in advocating any specific position.  

I think we need to question everything we have from the past, to confirm what this flu merits in treatment today vs what may have been recommended either in years gone by or relating to other flu viruses.  

I encourage additional review and discussion on the issue and will share any additional resources I find.

ITW

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

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by: Into The Woods @ Sat Sep 05, 2009 at 23:45:26 PM UTC

[ Parent ]

From a herbalist's point of view

The traditional (old models of herbal medicine) guidance suggests that a fever can be supported (allowed) if the patient is not weak, too young, too old to handle the stress of a fever. So if someone is weakened already and not strong enough, many of today's herbalists would guard against using herbs to help support a fever.

If the fever is too high it is dangerous and therefore must be cooled down. I'm not giving numbers here because it can depend on the age and health of the person.

Most herbalists today will not use NSAIDS (non-steroidal antiinflammatory drugs) or aspirin for colds and flu because of the belief that these drugs will lengthen symptoms and interfere with recovery. No double-blind studies, just experience and historical information. Paul Ewald included some studies that support this in his book, Evolution of Infectious Disease.

That said, the classic herb that herbalists use to help support a fever is yarrow (Achillea millefolium) leaf/flower hot tea. Yarrow will NOT give someone a fever. Herbs can't create or cause a fever. Yarrow contains volatile oils that help encourage expectoration of perspiration from the skin. It helps to cool the heat inside the body, so to speak. It's very bitter. Bitter herbs are seen as cold or cooling and are used for hot infections like influenza.

You can give someone yarrow tea till the cows come home and if the fever isn't ready to break, it won't. So the decision to wait and see while using herbs is a cautious one. The patient should never be left for long periods if they have a high fever. You can exhaust someone this way and so it's a touchy situation.

Most people don't remember how to do these things anymore. We rely so much on doctors. But when the doctor is busy or the hospital full, what then?

I look forward to more of this discussion and I'll try finding more on this topic from herbal texts. Best to all.

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by: phytosleuth @ Thu Sep 03, 2009 at 13:28:22 PM UTC

Is it possible to do an Internet Based Randomized Voluntary Trial of Fever Reducers?

So far I have not seen any good evidence that lowering fever is helpful or necessary (with the possible exception of pregnancy where fetal outcomes are impacted)   In addition. there is evidence that fever is helpful to controlling infection but not to H1N1 specifically. But what we really need are randomized clinical trials.    Who would fund such a study?  If the survival were improved with anti-febrile agents than the drug manufactures would have an incentive to pay for and publish them. But if the results were likely to be negative and anti-febrile agents caused poorer outcomes, would these studies be funded and/or published if conducted internal to the company? Therefore I wonder if it is possible to do a internet trial where people certify that they have a fever of greater than 100.5 and select the symptoms that they have (cough, sore throat, rash neck stiffness).  They add their age weight and underlying conditions.  They then select if they wish to be randomized to either anti-febrile agents or not treatment and will be assigned a treatment. (Individuals who are clearly biased and wish to make the choice themselves can be enrolled in the non-randomized sections. ) Each person (or their designated caregiver)  than either enters their maximum temperature, symptoms. side effects and complications daily .  The date, city and whether they have any specific diagnosis or diagnostic tests would also be added (along with whether they took antiviral agents.  With such a system, a large trial could be conducted very inexpensively and quickly.  I think the biggest problem that must be addressed would be individuals entering erroneous information repeatedly in order to influence the outcome of the study. What other problems do readers for see?  

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by: Public_Health_Networker @ Sat Sep 05, 2009 at 01:03:50 AM UTC

drug companies

If the survival were improved with anti-febrile agents than the drug manufactures would have an incentive to pay for and publish them.

Actually, Tylenol etc are all off patent.  There's not enough profit in generic drugs for companies to pay for trials, especially for an illness that their product is already being used.  Funding is only forthcoming if there are significant returns.

It's a very interesting idea you are proposing.  I see a few places where major errors can make the data invalid, in addition to the points you made.  One is the study will not be blinded.  Second is the lack of clear objectively measurable endpoints.   Flu is a rather non-specific illness, symptom-wise, so it will be difficult to compare self-reported symptoms (ie getting better/well is not a binary event like pregnant vs not pregnant!).  Unless of course you measure mortality.  But then those who become seriously ill will be admitted to hospital, so they can't continue to update their symptoms.  How do you tell which incomplete profile is just someone dropping out vs someone who was hospitalized or died?

Even assuming hypothetically that someone else will fill in the data, then you have the problem of changing observer in mid-stream.  Plus, it's unrealistic to expect hospitals and ICUs to follow through with the protocol.  Doctors are overworked and they just prescribe what comes to their mind.  In that setting, anyone who has a significant temperature will be prescribed fever reducers.  Which means you have lost a case to the study.  It also probably means ALL or most severe cases will have to be excluded from the final analysis of results, which kinda defeats the purpose, I suspect...

It's a difficult problem.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Sat Sep 05, 2009 at 01:22:15 AM UTC

[ Parent ]

Problems?

It's a really interesting idea and I would love to be able to do it but the biggest problem is sample size. One option would be to compare the mean time to complete resolution of symptoms in each group. This would be easy using online reporting but I guess this would require at least 400 participants. Looking at complications such as hospitalisations, second sickening and deaths would be really interesting but would put the sample size required into the thousands.

Randomisation online to treatment/no treatment would be easy enough but the results would suffer hugely from not being blinded, as SusanC points out.

Then there is the illness causing the fever - given the huge number of RTIs "going round", without any form of objective clinical assessment such a trial could be accused of comparing apples with pears.

No matter how many lurkers there are on the site I don't see there being enough of us to answer these questions to our own satisfaction, which is the best we could achieve, given that no journal would touch it with a bargepole! :-)

Compliance is an issue, as you say: if participants chose their group and reported their own behaviour they would be likely to adjust their responses to suit their own beliefs. A post-hoc epidemiological study would be more reliable, if that data were available somewhere.

Question: there was a site where people were asked to report whether they had H1N1 - does anyone remember what it's called?

 

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by: Ruby Murray @ Sat Sep 05, 2009 at 21:20:43 PM UTC

[ Parent ]

RESEARCH STUDIES ON THE VALUE/HAZARDS OF FEVER AS A TREATMENT

FEVER remains the humble soldier on the front lines, doing what it can, under the handicap of fever phobia.  It is continually being weakened and undermined by the patients or caregivers, who want to bring it down at its first appearance.

One study even found that pediatricians are almost as afraid of fever as the more ignorant caregivers.  And while the greatest danger of fever is the complication of dehydration; a well hydrated patient is probably going to benefit from a couple of days of fever up to 102 degrees F.

Rather than try to do the research ourselves, we need to light a fire under the CDC and NIH and get THEM to answer the tough questions. They have so far neglected to do their job.  It is truly disgusting that the latest guidelines from CDC spends an entire page  advising people on the use of fever-lowering drugs and NOT one word about the benefits of a well-hydrated fever for fighting a flu virus such as H1N1.  But fever has no lobbyists, and there will be no expensive tv ads devoted to promoting its benefits for the immune system's efforts to fight off the attack of a viral infection.

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by: Negley55 @ Sun Sep 06, 2009 at 18:16:53 PM UTC

Fever: It Gets You Back in the Game

But fever has no lobbyists, and there will be no expensive tv ads devoted to promoting its benefits for the immune system's efforts to fight off the attack of a viral infection.

LOL.  Can't you just imagine the ads:  

Fever.  

It gets you

Back in the Game.

In a couple of tubs where tubs would never be.

A slimmer waste and tighter abs.

More (or less) hair (according to your need.)

Hot.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

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by: Into The Woods @ Thu Sep 10, 2009 at 18:58:34 PM UTC

[ Parent ]

Antipyretic Therapy And Duration Of Ilness

Effect of Antipyretic Therapy on the Duration of Illness in Experimental Influenza A, Shigella sonnei, and Rickettsia rickettsii Infections
Author(s): Karen I. Plaisance, Pharm.D. 1 | Suneel Kudaravalli, Pharm.D. 2 | Steven S. Wasserman, Ph.D. 3 | Myron M. Levine, M.D. 4 | Philip A. Mackowiak, M.D. 5
doi: 10.1592/phco.20.19.1417.34865

Abstract
Study Objectives. To determine whether antipyretic therapy prolongs the course of experimental influenza A, Shigella sonnei, and Rickettsia rickettsii infections.

Design. Retrospective observational study.

Setting. University Center for Vaccine Development.

Subjects. Fifty-four volunteers with experimentally induced influenza A, 45 with S. sonnei, and 21 with R. rickettsii infections participated.

Intervention. Subjects from the six influenza A studies were challenged intranasally. If they met certain criteria, they were offered aspirin or acetaminophen for symptomatic relief. Subjects from the three Shigella studies were challenged with the bacteria and then given trimethoprimsulfamethoxazole. Acetaminophen also could be administered. In the one R. rickettsii trial, subjects were inoculated intradermally and treated with tetracycline. Again, acetaminophen was administered for symptomatic relief.

Measurements and Main Results. Data, excerpted from subjects' study records, were evaluated using Wilcoxon tests, Spearman's correlation coefficients, and multiple regression analysis. Two-tailed hypotheses with a p value of 0.05 were used for all of the analyses. There was a striking correlation between antipyretic therapy and duration of illness in subjects infected with influenza A and S. sonnei, but not R. rickettsii.

Conclusion. Multivariate analysis suggested that antipyretic therapy prolonged illness in subjects infected with influenza A, but its use was the result of prolonged illness in those infected with S. sonnei. The precise nature of these relationships requires a prospective, randomized, placebocontrolled trial.

http://www.atypon-link.com/PPI...

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by: Okieman @ Thu Sep 10, 2009 at 15:44:22 PM UTC

So, fever reducers prolong illness

At least according to this study.  The links posted above in this diary seemed to address the issue in critically ill patients.  This one appears to address duration of illness in what is probably more typical infections.

I found this article while searching for information concerning influenza and shigella co-infection. Part of Papua New Guinea is experiencing a concurrent outbreak within the same geographical region, with deaths.

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by: Okieman @ Thu Sep 10, 2009 at 15:49:17 PM UTC

[ Parent ]

Okay my method is not very "scientific"

But fever reduces for my family are largely dependent on how the person is acting/feeling vs the actual temperature.  Soemtimes my kids get wiped out with low fevers but are perfectly fine with high ones - and vice versa.  If they clearly arent' themselves and/or are very uncomfortable with aches/headaches then out comes the Motrin bottle.  

Same for me -- sometimes I can power through a fever, other times I am miserable.  

DH - a big weenie.  Takes advil at the first sign of anything!

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by: LauraB @ Thu Sep 10, 2009 at 19:58:47 PM UTC

sorry about typos - spazz today

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by: LauraB @ Thu Sep 10, 2009 at 19:59:16 PM UTC

[ Parent ]

induced fever

I currently have symptoms of what is likely mild-to-moderate H1N1.  I found this thread interesting because I didn't realize this virus does not (by necessity) ALWAYS generate fever. I've been fitting into this category over the last few days--I've felt all the fever aches, pains, alternating chills and heat--MINUS an actual thermometer display as evidence.  It was very odd.  And then I took a hot shower, a HOT shower (trying to combat the shivers).  Within the hour, my temp had shot up to 101.8.  Did I somehow 'kickstart' an internal mechanism being otherwise masked by the virus, do you suppose?  (You should know that scalding hot showers are basically a norm for me...this is NOT a typical reaction!)  Thoughts?

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by: froggy @ Sun Oct 25, 2009 at 21:00:54 PM UTC