Nonsteroidal Anti-inflammatory Agent Toxicity Treatment & Management

  • Author: Timothy J Wiegand, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 20, 2010
 

Prehospital Care

  • Initial assessment requires the clinician to assess for the secure airway, breathing, and circulation (ABCs).
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Emergency Department Care

Management of acute NSAID poisoning is essentially supportive and symptomatic.

  • Initial stabilization: Follow the ABC protocol.
  • GI decontamination
    • Syrup of ipecac is no longer recommended and should not be administered for NSAID overdose in any circumstances.
    • If the patient has no clinical evidence of a perforated viscous, decontaminate with activated charcoal (AC). The patient should be able to protect airway (eg, normal mental status, preserved gag reflex, absence of vomiting) in order to prevent aspiration of charcoal. Activated charcoal may not be warranted in patients presenting later than 1-4 hours post ingestion. No evidence exists that empiric administration of activated charcoal in drug overdose improves clinical outcome.
    • Orogastric lavage may be indicated in massive overdoses after recent exposure, especially in the patients that are intubated.
    • No specific antidotes for NSAID poisoning exist. Patients with significant toxicity who develop severe acidosis may require supportive treatment with intravenous sodium bicarbonate.
  • Elimination enhancement
    • Because NSAIDs are highly protein bound, hemodialysis may not help clear the drug from the blood, but it may be indicated in patients who develop acute renal failure as a complication of the ingestion.
    • Acute renal failure is usually corrected after a few days.
    • There is no role for urinary alkalinization or forced diuresis in the setting of NSAID toxicity or overdose. Use of sodium bicarbonate to treat metabolic acidosis depends upon the etiology and patient characteristics. Careful attention to the patient’s volume status and renal function during hydration is essential to avoid iatrogenic complications, particularly in patients with adverse drug reactions and medical comorbidities that may have predisposed them to NSAID toxicity such as congestive heart failure.
    • Sodium bicarbonate is not a specific antidote for NSAID toxicity; however, it should be considered in addition to other supportive cares in an acidotic patient. Transient acidosis in mild-moderate NSAID toxicity typically is self-limited and improves rapidly. Lactic acidosis in the setting of tissue hypoperfusion and multisystem organ failure may be refractory to bicarbonate administration and aggressive supportive cares aimed at restoring normal tissue oxygenation and perfusion are key. Hemodialysis against an alkaline bath may facilitate correction of acid-base and electrolyte abnormalities as well as facilitate management of volume status in the critically ill patient.
  • Extracorporeal membrane oxygenation (ECMO) has been used successfully to treat refractory hypotension from massive ibuprofen overdose.[6]
  • Hemodialysis may be considered for the correction of severe acidosis. Because of the large volume of distribution, it is not feasible for the removal of circulating NSAIDs/metabolites.
  • Seizures induced by NSAIDs tend to be short lived. Seizures should be treated with benzodiazepines or with other GABAergic drugs such as barbiturates or propofol.
  • H2-antagonists and proton pump inhibitors (PPIs) may prevent GI irritation, but their usefulness in this situation is unproven.
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Consultations

Consult the regional poison control center (800-222-1222) for additional information and patient care recommendations. Medical toxicologists – ABMS (American Board of Medical Subspecialties) certified physicians are on-call to assist with patient management through the regional poison control center.

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Contributor Information and Disclosures
Author

Timothy J Wiegand, MD  Director, Ruth A Lawrence Poison and Drug Information Center, Associate Clinical Professor of Medicine and Emergency Medicine, University of Rochester Medical Center and Strong Memorial Hospital

Timothy J Wiegand, MD, is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Jingjing Hu, MD  Attending Physician, Department of Internal Medicine, Maine Medical Center, Portland

Disclosure: Nothing to disclose.

Michele B Delenick, MD  Hospitalist, Maine Hospitalist Service, Department of Internal Medicine, Maine Medical Center, Portland

Michele B Delenick, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Lance W Kreplick, MD, FAAEM, MMM  Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Neesha Suresh Desai, MD, MPH, Gregory S Johnston, MD, Carlyn Ko, MD, and Fred Tilden, MD, to the development and writing of this article.

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Profile of single-substance NSAID exposures from 2007 American Association of Poison Control Centers National Poison Data System (AAPCC NPDS).
Age profile of single-substance exposures from 2007 American Association of Poison Control Centers National Poison Data System (AAPCC NPDS).
Table 1. Chemical Classifications of NSAIDs
NSAID Drug ClassMaximum Daily DoseHalf-LifeCommentsClinical Symptoms
Salicylates



Examples: Aspirin and other salicylates, eg, sodium or magnesium salicylate (not covered in this article), diflunisal (Dolobid) – not metabolized to salicylic acid



1500 mg8-12 hSalicylates: See Toxicity, Salicylate for discussion of acetylsalicylic acid toxicitySalicylates: See Toxicity, Salicylate



Diflunisal: This NSAID commonly causes drowsiness, vomiting, and diarrhea.



Hyperventilation, tachycardia, diaphoresis, tinnitus, disorientation, stupor, coma, cardiopulmonary arrest, and fatality are rarely observed and occur only with doses exceeding 15 g.



The lowest reported dose resulting in fatality is 15 g.



Pyrazolones



Examples: Phenylbutazone



600 mg50-100 hPyrazolones: Phenylbutazone (Butazolidin), one of the most toxic NSAIDs



Symptoms of mild poisoning include nausea, abdominal pain, and drowsiness.



Severe poisoning has multisystem effects that, early on, include the GI system (eg, nausea, vomiting, diarrhea), CNS (eg, dizziness, seizures, coma), the cardiovascular system (eg, pulmonary edema, arrest), metabolic and respiratory acidosis, and electrolyte abnormalities.



Delayed severe toxicity (2-7 d) includes renal, hepatic, and hematologic dysfunction.



Although the pyrazolones have been withdrawn from the market, phenylbutazone is available from veterinary sources and from other countries (eg, it has presented in southwestern United States)



Fenamates (anthranilic acids)



Examples: Meclofenamate (Meclomen), mefenamic acid (Ponstel)



1000 mg2 hThese drugs have not been studied thoroughly, but they have caused vomiting, diarrhea, muscle twitching, and seizures. Most patients recover completely within 24 h. Myoclonus, muscle twitching, or seizures are characteristic of symptomatic overdose. Seizures may be focal or general. In one series, 20% of 54 patients who developed abnormal neuromuscular activity described as, "twitching" developed seizures (generalized, grand mal, tonic-clonic).
Acetic acids



Examples:



Diclofenac (Voltaren),



etodolac(Lodine),



indomethacin (Indocin),



ketorolac (Toradol, Sprix),



sulindac (Clinoril)



PO ketorolac daily dosage limit is 40 mg. Not to exceed daily dose of 126 mg for intranasal ketorolac (63 mg/24 h if older than 65 y). Total cumulative ketorolac (any administration route) should not exceed 5 days in a row. Typically 8-30 hSulindac is a prodrug. Peak concentrations may be delayed 2-5 h.Sulindac overdoses are very rare, but case reports have shown effects on renal function. Indomethacin poisoning can cause headache, lethargy, disorientation, seizure, nausea, vomiting, and GI bleeding. Seizures were reported in the case of a 6-year-old who ingested, "a bottle" of indomethacin.



Diclofenac can cause nausea, vomiting, tinnitus, hallucinations, and acute renal failure (3 cases).



COX-2 inhibitors



Examples: Celecoxib



400 mg -celecoxib3-11 hConsidered to be relatively safeOnly available Cox-2 inhibitor in the US
Propionic acids Examples:



Ibuprofen (Motrin, Advil), naproxen (Naprosyn, Anaprox), carprofen (Rimadyl), ketoprofen (Orudis)



For ibuprofen- 3200 mg and T1/2 3 h



For naproxen-



1500 mg and T1/2 12-17 h



Severe toxicity reported mainly in children and can occur in ingestions of 400 mg/kg or more; symptoms include seizures, apnea, hypertension, and renal and hepatic dysfunction Headache, tinnitus, drowsiness, nausea, vomiting, and abdominal pain are the most common symptoms, and commonly appear within 4 h of ingestion.



In a retrospective case series of 126 patients with ibuprofen overdose, 19% of patients developed symptoms, predominantly CNS depression and GI upset, typically within 4 h. In a prospective study of 45 adults and 39 pediatric patients, all patients who became ill did so within 4 h. In this study, coma, apnea, and/or metabolic acidosis occurred in 9% of adults and 5% of children. Ingestions of more than 400 mg/kg of ibuprofen are associated with seizures, apnea, hypotension, bradycardia, metabolic acidosis, and renal and hepatic dysfunction.



Oxicams Examples:



Piroxicam (Feldene)



20 mg45-50 hOccasionally, these NSAIDs can cause dizziness, blurred vision, seizures, and coma.
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