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Nonopioids

Nonopioids include any medications that are used for analgesia and are nonnarcotic. Nonopioids can be given alone to manage mild to moderate pain, or may be used in conjunction with an opioid in a coanalgesic manner.

ACETAMINOPHEN

Uses: Mild to moderate pain relief and fever reduction

Prophylactic use at the time of vaccination is not recommended because of reduced antibody response.

          Oral administration:

               Loading dose 20 to 25 mg/kg

               Maintenance dose 12 to 15 mg/kg/dose

          Rectal suppository:

               Loading dose 30 mg/kg

               Maintenance dose 12 to 18 mg/kg/dose

Note: Rectal administration may lead to toxicity because peak levels may vary widely and may take longer to take effect than oral doses (Birmingham et al., 1997).

          Maintenance intervals: For term infants—every 6 hours

               Preterm equal to or greater than 32 weeks postmenstrual age (PMA)—every 8 hours

               Preterm less than 32 weeks PMA—every 12 hours

               Monitoring: Assess for signs and symptoms pain; monitor temperature; assess liver function

Adverse effects: Liver toxicity may occur with excessive doses or therapeutic doses given for more than 48 hours and may lead to symptoms, such as rash, thrombocytopenia, leukopenia, and neutropenia in children.

Pharmacology:

          Nonnarcotic analgesia and antipyretic

          Peak serum concentration occurs approximately 60 minutes after an oral dose (rectal is variable and prolonged)

          Extensively metabolized in the liver, primarily through sulfation with a small amount of glucuronidation; metabo­lites and any unchanged drug are excreted via the kidneys

          Elimination half-life is approximately 3 hours in term neonates, 5 hours in preterm neonates greater than 32 weeks, and up to 11 hours in neonates born earlier than 32 weeks. Elimination is prolonged in patients with liver dysfunction.

Treatment of toxicity: Administration of N-acetylcysteine (NAC) 150 mg/kg in 5% dextrose or one half normal saline (NS) given intravenously (IV) over 60 minutes (loading dose). Followed by 50 mg/kg in 5% dextrose or one half NS over a 4-hour period, then 100 mg/kg in 5% dextrose or one half NS over a period of 16 hours. NAC should be continued until clinical and biochemical markers of hepatic injury improve and acetaminophen ­concentration is below the limits of detection. NAC solution concentrations of 40 mg/mL have been used to avoid fluid ­overload and hyponatremia in the neonate (Neofax, 2011).

Acetaminophen is not recommended after immunization in the first months of life as it may blunt the effect of certain ­immunizations by reducing the body’s natural inflammatory response (Prymula et al., 2009).

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

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