Aspirin Should Be Avoided in This Patient with G6PD Deficiency
Aspirin is contraindicated in patients with G6PD deficiency and should be avoided in this 2-year-old boy presenting with acute hemolytic crisis. 1
Clinical Presentation Confirms G6PD Deficiency
This child's presentation is classic for acute hemolytic crisis in G6PD deficiency:
- Acute jaundice with dark urine indicates intravascular hemolysis 2
- Anemia (Hb 9 g/L) with elevated reticulocytes (3%) demonstrates active red blood cell destruction and compensatory bone marrow response 2
- Positive family history of severe neonatal jaundice requiring exchange transfusion strongly suggests inherited G6PD deficiency 2
- Fever as a trigger - infections are well-documented precipitants of hemolytic crises in G6PD-deficient patients 3, 4
Why Aspirin Must Be Avoided
Aspirin is explicitly contraindicated in G6PD deficiency according to the American Family Physician guidelines, which list "G6PD-deficiency" as a specific contraindication for aspirin use 1. This is because:
- Aspirin is a potent oxidant that can overwhelm the reduced antioxidant capacity in G6PD-deficient red blood cells 5, 3
- The Mediterranean variant of G6PD deficiency (common in the patient's geographic origin) typically causes more severe hemolytic reactions than the African variant 5, 2
- Administering aspirin during an active hemolytic crisis could precipitate life-threatening hemolysis 5
Safety Profile of Other Medications
Ibuprofen (Option C) - Safe to Use
- Recent systematic review found ibuprofen to be safe in children with G6PD deficiency, with extremely low incidence of hemolysis (approximately 1/100,000 affected children per year) 6
- A prospective study showed no evidence of hemolysis from perioperative NSAID exposure in G6PD-deficient children at high risk 6
- While ibuprofen appears on some medium-risk lists, the evidence does not support avoiding it 6
Amoxicillin (Option B) - Safe to Use
- Penicillins are not among the seven definitively contraindicated medications in G6PD deficiency 5, 7, 4
- The comprehensive evidence-based review found no solid evidence to prohibit penicillin use in normal therapeutic doses 4
- Penicillin-related concerns in CKD guidelines relate to crystalluria and neurotoxicity at high doses in renal failure, not G6PD deficiency 1
Acetaminophen (Option D) - Safe to Use
- Not listed among contraindicated medications for G6PD deficiency 5, 7, 4
- The definitive list of only seven contraindicated medications includes: dapsone, methylthioninium chloride (methylene blue), nitrofurantoin, phenazopyridine, primaquine, rasburicase, and tolonium chloride 5, 7, 4
- Acetaminophen does not appear on this evidence-based list 4
Critical Management Principles
The most effective strategy is preventing further hemolysis by avoiding oxidative stressors 3. In this acute presentation:
- Immediate discontinuation of any potential oxidant drugs is essential 3
- Monitor for signs of worsening hemolysis: increasing jaundice, darkening urine, falling hemoglobin, rising indirect bilirubin 2
- Screening confirmation should be performed, though G6PD levels may be falsely elevated during acute hemolysis, requiring repeat testing after 3 months 2
- Patient and family education about avoiding oxidant triggers is crucial for preventing future crises 2, 3
Common Pitfall to Avoid
Many medications have been wrongly cited as causing hemolysis because they were administered during infection-related hemolytic episodes 4. The fever in this case suggests infection as the primary trigger, but aspirin remains contraindicated regardless of the precipitating cause 1.
Answer: A. Aspirin