Medication Summary
The goals of pharmacotherapy are to reduce morbidity, prevent complications, and reduce the toxic levels of drug. No specific antidotes for nonsteroidal anti-inflammatory drug (NSAID) poisoning exist.
GI decontaminant
Class Summary
These agents may bind and limit absorption of NSAIDs from the GI tract.
Activated charcoal (Liqui-Char)
Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.
For maximum effect, administer within 30 min of ingesting poison. Risk/benefit assessment may be favorable for AC up to 4 hours after exposure. Consult with poison control center.
Alkalinizing agents
Class Summary
These agents are used to accelerate excretion of the drug.
Sodium bicarbonate (Neut)
Sodium bicarbonate is indicated for the treatment of recalcitrant acidosis (pH < 7).
Tables
NSAID Drug Class |
Maximum Daily Dose |
Half-Life |
Comments |
Clinical 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 mg |
8-12 h |
Salicylates: See Toxicity, Salicylate for discussion of acetylsalicylic acid toxicity |
Salicylates: 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 mg |
50-100 h |
Pyrazolones: Phenylbutazone (Butazolidin), one of the most toxic NSAIDs Symptoms of mild poisoning include nausea, abdominal pain, and drowsiness; no longer approved for human use in the US. |
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 Although the pyrazolones have been withdrawn from the market, phenylbutazone is available from veterinary sources and from other countries (eg, it has presented in southwestern United States) |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 mg |
2 h |
These 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). |
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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 h |
Sulindac 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 -celecoxib |
3-11 h |
Considered to be relatively safe |
Only 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 |
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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 mg |
45-50 h |
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Occasionally, these NSAIDs can cause dizziness, blurred vision, seizures, and coma. |
