Aspirin Should Be Avoided in This Child with G6PD Deficiency
Aspirin is explicitly contraindicated in G6PD deficiency and should be avoided in this 2-year-old boy presenting with acute hemolytic crisis. 1
Clinical Reasoning
This child's presentation is classic for acute hemolytic crisis secondary to G6PD deficiency:
- Sudden onset jaundice, fever, and dark urine (hemoglobinuria) 2
- Anemia (Hb 9 g/L) with reticulocytosis (3%) indicating active hemolysis 2
- Positive family history (brother with severe neonatal jaundice requiring exchange transfusion) 3
- Symptoms appearing 24-72 hours after exposure to a precipitating factor 2
Medication Safety Profile in G6PD Deficiency
Absolutely Contraindicated: Aspirin (Answer A)
Aspirin is explicitly contraindicated in G6PD deficiency because it can overwhelm the reduced antioxidant capacity in G6PD-deficient red blood cells. 1 This medication acts as an oxidative stressor that can precipitate or worsen acute hemolysis in affected patients.
Controversial: Ibuprofen (Answer C)
Ibuprofen presents a moderate risk in G6PD deficiency. While NSAIDs are listed among drugs that can cause hemolysis 4, and ibuprofen was documented as a precipitating factor in 0.8% of hemolytic episodes in one Egyptian study 2, it is not on the absolute contraindication list like aspirin. However, given safer alternatives exist, caution is warranted.
Generally Safe: Acetaminophen (Answer D)
Acetaminophen is not listed among contraindicated medications in G6PD deficiency and represents the safest antipyretic/analgesic option for this child 5, 1.
Amoxicillin Consideration (Answer B)
Penicillins, including amoxicillin, are not among the contraindicated medications in G6PD deficiency and can be used in normal therapeutic doses. 1 While one case report documented severe hemolysis after amoxicillin exposure 6, this represents an extremely rare occurrence. Cephalosporins and penicillins are mentioned in general drug evaluation lists 4, but amoxicillin specifically is considered safe in standard guidelines 1.
High-Risk Medications to Absolutely Avoid
The following medications are definitively contraindicated and should never be used 5, 1:
- Dapsone - potent oxidant causing methemoglobinemia and hemolysis 5
- Methylene blue (methylthioninium chloride) - causes severe hemolytic anemia 5
- Primaquine - contraindicated in severe deficiency 5
- Rasburicase 1
Clinical Pitfalls
- Do not test G6PD levels during acute hemolysis - reticulocytes and young RBCs may contain near-normal enzyme levels, potentially masking deficiency and causing false-negative results 7
- Wait at least 50 days after any blood transfusion before performing enzyme assays 7
- The severity varies by genetic variant: Mediterranean variant causes life-threatening hemolysis, while African variant produces milder, self-limited hemolysis 5, 7
Immediate Management Priorities
For this child's acute hemolytic crisis:
- Immediately discontinue any potential oxidative stressors 8
- Supportive care with hydration 8
- Monitor hemoglobin levels closely 4
- Consider transfusion if hemoglobin drops below 7-8 g/dL with symptoms 4
- Provide folic acid supplementation (1 mg daily) 4
The correct answer is A (Aspirin) - this is the medication that must be strictly avoided in G6PD deficiency.