difficult decisions

In a busy out patient clinic you may not be in a position to go in depth about all cases.
Common problems ll be disposed fast,
cases which needs workup ll be admitted.
Cases previously admitted and worked up we ll  through their discharge notes fast.
Few of them visiting frequently  are too familiar, and we may not check the note book in detail.
Here i am posting  a mistake i made in the last context  even though it was not a major one.

This case in fact is a dilemma in decision making also.Hence a share few points i learned from managing him

Four and half year old boy came to OP with history of contact with chickenpox.
He was on regular follow up since he was diagnosed as Kawasaki disease with involvement of coronary arteries. He was managed in the usual lines with Intravenous gamma globulin 2 gm per kg and aspirin.As the coronary arteries were dilated on follow up ECHO he was put continuing low dose aspirin 3 mg per kg daily.
Aspirin, a time tested drug was used in the last century for many conditions,but now it is one drug used in very limited conditions. All the benefits,adverse problems are well established.Most of the conditions where we were using aspirin is now treated with drugs with better safety profile.
 Since we knew about Reyes syndrome and the predisposing factors we were reluctant to use it unless it is inevitable.Rheumatic fever and Kawasaki diseases are few examples where we cant do without it.
When we put a patient on aspirin we ll ensure the following points

• Use the lowest ,essential dose
• Use the shortest time essential
• Avoid other hepatotoxic drugs

If possible try to prevent chicken pox and influenza,which are well known factors which may precipitate Reyes syndrome
This patient  used to come every month for review.Chances of Reyes syndrome is low on continuous low dose therapy with Aspirin.
When they visited last month, i thought of giving varicella and influenza vaccines.Both the vaccines are not given in National schedule they have to purchase.As they were poor,we  planned to give in the next visit.
Our plan was to Stop aspirin,put him on clopidogrel and Give  vaccine and keep few more days in hospital for observation.
What about influenza vaccine? Cost of the vaccine is 500 rupees only,compared to varicella vaccine which is costlier. Why not give benefit of both?
According to literature both vaccine can be given in same sitting,without problems
But he is on aspirin.When we give varicella and influenza vaccines in a patient on aspirin all the three risk factors are coming in simultaneously. Literature does not say anything about such a situation. So we decided to keep a four week gap between the two vaccines.
These were the plans.
But,
 they now present earlier than expected with a contact with varicella,close contact.

What are the problems ? What are the options?

Problem , he is likely to develop varicella, increasing the chance of Reyes syndrome
Options, Post exposure prophylaxis with vaccine is beneficial.

• One dose of varicella vaccine given within 72 hours gives more then 70 percent protection and if at all failure occurs the seriousness of illness ll be mild
• If given after 72 hours up to 5 days it may not prevent, but it ll modify the severity

1. But here, he is on aspirin.

• Giving vaccine while he is on aspirin also the risk of Reyes syndrome is there
• A least 72 hours of gap after stopping aspirin is needed before vaccination.
• But by that time benefit of post exposure prophylaxis is decreases.

What did we decide?

• Stop aspirin
• Put on clopidogrel 1 mg/kg once daily
• Gave varicella vaccine after 72 hours.Whatever little benefit( modify the severity,it not preventing totally) without compromising safety was the basis of decision.

Next day my post graduate came to me with his previous details, which i did nt go through during his visit in OP as his details i thought i was thorough.
In fact he was admitted for Kawazaki and had Intravenous gamma globulin 2 gm per kg six months back.

So what?

When ever we give a vaccine ask the following questions

• Is it relevant in our settings?
• Is it time tested. Safety and efficiency proved?
• what is the cost ? Is it worth the amount spent for it , especially when the patient is poor
• is there any contra indications in individual case? eg allergy to any component,previous reactions,any medical conditions he suffer which increases risk or make the vaccine inefficient.
• Here all the above questions are answered YES, but the last clause

In a situation when he had high dose Intravenous immunoglobin,the efficiency of the vaccine may be less. Ideally in the above context gap of 11 months is recommended.
The gap between a blood product and a vaccine varies between three monghs and 11 months depending on the blood product used, the dose and the vaccine used.
There wont be any harm. But he wont get the maximum benefit for the money spent.

So how to proceed?

Any way we need to give two doses of varicella vaccine .The schedule of varicella vaccine which we follow is as follows

• Below five years.First dose after one year , second at five year
• Above that age up to 13 years.two doses with a gap of 3 months in between
• Above 13 years two doses , gap between of four weeks is enough.

Few points to be considered in the above schedule

• One dose gives around 70-80 percent protection, with two doses protection is above ninety percent.
• With two doses at least ten years protection is there
• With one dose there is chance of break through varicella, which is mild
• So in a child who get the first dose at one year there is higher chance of breakthrough varicella before he get the second dose which he gets only at 5 years.

The above situation i mentioned is not applicable for my child, who did nt have any vaccine earlier

So,what is our plan?

To observe him for next two weeks, to call him to report if any lesion occurs. Protection by post exposure prophylaxis is not gurarenteed due to two reasons, 1. It was given after 72 hours 2. vaccine may not work as expected as he had immunoglobulin
continue on clopidogrel

How long?

For next five months
Why five months?
We need to give next dose of varicella in the right time, ie keeping a gap of 11 months counting from the time when he had Intravenous gamma globulin. Gap between the two doses is not three months here
in between , ie after four week we ll give influenza vaccine
Six weeks after the second dose of varicella vaccine, we ll restart aspirin instead of clopidogrel.So totally for the next six months he ll be on clopidogrel. Experience with clopidogrel in this age group is good.Few people following cardiac surgery eg ASD closure put on dual therapy with aspirin plus clopidogrel routinely. We pediatricians experience with these group of drugs are less.