Angioedema and acute asthma attack due to the unexpected occurrence of aspirin in an over‐the‐counter cold preparation

Abstract

Three recent reports of illnesses caused by drugs1,2 or ethnic remedies3 have highlighted the potential hazards of self-medication.4 It is clear that iatrogenic illness may be caused not only by the doctor,5 but also by the patient,1,2 by unqualified ‘pharmacists‘,2 by traditional practitioners,3, or, as illustrated by the case described here, by family members acting as advisors. A 16-year-old boy was admitted to our hospital with the first attack of periorbital oedema 4 hours after he was given one tablet of ‘Cortal For Adults’ (acetylsalicylic acid 500mg, caffeine 30mg) by his mother for the treatment of a common cold. He had a history of asthma, now in remission, and skin rash after eating seafood. For 2 days before admission, he also received ‘expectorant stimulant mixture’ (ammonium bicarbonate, ipecacuanha tincture) from an out-patient clinic to be taken as required. He had taken this mixture before without any adverse effects. Since childhood, his mother often treated his common cold with ‘Cortal For Children’ (acetaminophen 80mg/day). On this occasion, his mother thought it was more appropriate to give him the adult preparation since he was 16 years old. He arrived in the emergency department 1 hour after the onset of symptoms. His blood pressure was 130/76mmHg and pulse 120 beats/min. There was marked periorbital swelling but no stridor or wheeze. He was given chlorpheniramine 10mg intramuscularly. When he arrived in the ward 1 hour later, chest examination showed diffuse expiratory rhonchi. Peak expiratory flow rate (PEF) before treatment was 140l/min. He was given a single intramuscular injection of 1ml of adrenaline (1:1000), hydrocortisone 100mg every 8 hours, nebulised salbutamol every 4 hours and chloropheniramine 10mg intravenously, followed by 4mg orally three times per day. One hour later, his PEF had increased to 240l/min. By day 2, his rhonchi had subsided and both his PEF (340l/min) and periorbital oedema had improved. Hydrocortisone was replaced by oral prednisolone 30mg daily. He was discharged on day 3, with the following medication: chlorpheniramine 4mg three times per day; beclomethasone diproprionate 250%g/puff two puffs twice daily; salbutamol 2 puffs twice daily. Both he and his mother had been warned of the danger of self-medication and the need for him to avoid aspirin. He was asked to carry a medical note with details of his medical history. The patient had angioedema and an acute asthma attack precipitated by an over-the-counter cold preparation, which was believed to be ‘safe’ by both the patient and his mother. However, neither of them realised that the two ‘Cortal’ preparations had different contents. There may be several reasons for self-medication of drugs and herbal medicines.2 Some people find that it is more convenient to buy their treatment (over-the-counter preparations) from a chemist. In countries where the health system is mainly structured around private general practice consultation fees may prevent visits to the doctor. The lack of a warning in the package insert of possible adverse effects and the need to consult a doctor may both play a role in adverse effects due to self-administration of medication. There is an obvious need for educating the general public about the danger of self-medication without medical advice.