Aim To audit whether dose banded paracetamol provides adequate clinical dosing in light of increases in average age based weights of children.
Method All patients discharged with paracetamol over a two week period were included in the study. The standard is to discharge all patients requiring paracetamol suspension with ‘as per bottle’ recommendations as these follow MHRA approved dose banding.1 Those requiring tablets receive a dose of 15 mg/kg rounded to the nearest half a tablet up to a maximum of 1 g per dose. The aim is for all patients to receive therapeutic dosing.
Therapeutic dosing was defined as a dose of 40 mg–75 mg/kg/day, based on regular use of BNFc recommended doses of 10–20 mg/kg/dose2 with a revision of the maximum daily dose to 75 mg/kg/day due to toxic thresholds for chronic administration.2 3 As a secondary measure patients were assessed against a total daily dose of below 150 mg/kg/day which Toxbase defines as may cause serious toxicity.3
Results Within two weeks 104 patients were supplied paracetamol, 98 patients received suspension and six tablets. All patients discharged on tablets received therapeutic dosing.
83% (81/98) of patients discharged on paracetamol suspension received therapeutic dosing with dose banding, 11% (11/98) received <40 mg/kg/day and 6% (6/98) >75 mg/kg/day. No patients received a dose which would be associated with a risk of severe toxicity (>150 mg/kg/day). Of the patients who received a dose greater than 75 mg/kg/day all these fell into the 6 months 2 year category and 75% of patients between 3–6 months received sub-therapeutic doses.
Conclusion Dose banding analgesia ‘as per the bottle’ provides convenient and consistent dosing advice for patients and carers but does not always provide accurate enough dosing for patients leaving hospital. Some patients receiving dose banded paracetamol may have received little benefit from therapy and a number of patients would have triggered a referral to hospital with possible paracetamol toxicity, the risk of which increases with prolonged courses. Patients particularly at risk of non-optimal dosing were those below two years old and between six and 12 years.
We would strongly recommend a large outcome study to see if theory and practice are in line with each other, as converting to mg/kg dosing brings its own risks into practice.
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