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Carmona CA, Miller Ferguson N. Taking a Breather From Pulmonary Aspiration and a Multidrug Ingestion. Clin Pediatr (Phila) 2024; 63:1467-1472. [PMID: 38158825 DOI: 10.1177/00099228231221341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Carlos A Carmona
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Nikki Miller Ferguson
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
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2
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Pollack BE, Barbaro RP, Selewski DT, Carlton EF. Lactic acidosis and multisystem organ failure following ibuprofen overdose requiring haemodialysis. Drug Ther Bull 2023:dtb.2022.244281.rep. [PMID: 36649974 DOI: 10.1136/dtb.2022.244281.rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Blythe E Pollack
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Erin F Carlton
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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3
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Finsterer J. Transient tunnel vision and altered consciousness after a single dose of ibuprofen. J Int Med Res 2022; 50:3000605221126660. [PMID: 36173005 PMCID: PMC9528012 DOI: 10.1177/03000605221126660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although neurological/ophthalmologic side effects including headache, vertigo, somnolence, paresthesia, optic neuritis, and optic neuropathy are listed as side effects in the medication guidelines for ibuprofen, transient tunnel vision and altered consciousness after a single dose of ibuprofen have not been reported. The patient was a 48-year-old man who experienced sudden-onset tunnel vision for a few seconds, followed by an altered state of consciousness for 20 minutes, during which he was communicating with his boss in an altered manner, 15 minutes after having taken 200 mg of ibuprofen. After awakening, he required 2 to 3 hours to return to his premorbid condition. No tongue biting or secessus occurred. Because his blood pressure, blood tests, blood gas analysis, electrocardiography, and electroencephalography results were normal and cerebral magnetic resonance imaging only showed non-specific spots in the subcortical white matter, the condition was attributed to ibuprofen. This case shows that a single dose of ibuprofen can cause severe side effects in the form of tunnel vision and altered consciousness. In some patients, single doses of ibuprofen may cause severe side effects.
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Man AM, Piffer A, Simonetti GD, Scoglio M, Faré PB, Lava SAG, Bianchetti MG, Milani GP. Ibuprofen-Associated Hypokalemia and Metabolic Acidosis: Systematic Literature Review. Ann Pharmacother 2022; 56:10600280221075362. [PMID: 35135381 DOI: 10.1177/10600280221075362] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Ibuprofen is a widely used nonsteroidal anti-inflammatory drug, which has been occasionally associated with hypokalemia and metabolic acidosis. The objective of this report is to analyze the literature on this issue and to address the underlying pathophysiology. DATA SOURCES Excerpta Medica, the National Library of Medicine, and Web of Science were searched from inception to July 16, 2021. STUDY SELECTION AND DATA EXTRACTION Papers reporting individually documented humans on ibuprofen with hypokalemia, acidosis, or both were retained. Data were extracted using a checklist. DATA SYNTHESIS For the final analysis, we evaluated 41 reports describing 50 cases (26 males and 24 females; 36 adults and 14 children) with often profound hypokalemia, acidosis, or both after ingestion of ibuprofen. Twenty-six cases were acute and 24 long term. Hypokalemia and acidosis occurred not only after ingestion of very high doses but also after ingestion of moderately high or even normal doses of ibuprofen. Laboratory values consistent with an excessive urinary potassium excretion or an altered urinary acidification were often disclosed in most cases. Discontinuation of ibuprofen resulted in a resolution of hypokalemia and acidosis within days in 47 cases. The course was lethal in 3 cases. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review highlights potentially fatal side effects of ibuprofen and can help doctors who are confronted with such a situation. CONCLUSIONS These data highlight the potential of ibuprofen to occasionally induce hypokalemia and acidosis of renal origin. Discontinuation of ibuprofen results in a resolution within days.
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Affiliation(s)
- Anca M Man
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Arianna Piffer
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Martin Scoglio
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
| | - Pietro B Faré
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Mario G Bianchetti
- Università della Svizzera Italiana, Lugano, Switzerland
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Pollack BE, Barbaro RP, Selewski DT, Carlton EF. Lactic acidosis and multisystem organ failure following ibuprofen overdose requiring haemodialysis. BMJ Case Rep 2022; 15:e244281. [PMID: 35131772 PMCID: PMC8823053 DOI: 10.1136/bcr-2021-244281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 11/04/2022] Open
Abstract
A 17-year-old man was admitted to the paediatric intensive care unit 2 hours following an intentional ingestion of unknown substances. In the first 23 hours of hospitalisation, lactate levels remained elevated at 2-4 mmol/L, during the 24th hour, he developed lactic acidosis with lactate levels increasing from 4 to 16 mmol/L. His neurological status declined, requiring orotracheal intubation. Central and arterial access were obtained, and vasoactive infusions were initiated for haemodynamic support. Due to increasing lactate levels (maximum level >24 mmol/L) and haemodynamic instability, a dialysis line was inserted, and continuous renal replacement therapy (CRRT) was initiated. The lactic acidosis resolved over 10 hours. Serum ibuprofen level subsequently resulted at 841 µg/mL (reference range 10-50). Few reported cases discuss the sequela of large quantity ibuprofen ingestion leading to severe lactic acidosis and multiorgan system failure. Early intervention with CRRT may reverse acidosis, stabilise haemodynamics and halt secondary organ failure.
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Affiliation(s)
- Blythe E Pollack
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Erin F Carlton
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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6
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Li S, Ge W, Suryoprabowo S, Liu J, Kuang H, Zhu J, Liu L, Xu C. A paper-based sensor for rapid and ultrasensitive detection of ibuprofen in water and herbal tea. Analyst 2021; 146:6874-6882. [PMID: 34633393 DOI: 10.1039/d1an01533h] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
As the use of non-steroidal anti-inflammatory drugs (NSAIDS) increases, their side effects have also attracted attention. Ibuprofen is one of the most widely-used NSAIDs. In this study, we screened the highly-sensitive and specific antibody 6E10, with an IC50 of 1.92 ng mL-1, and a linear range of 0.53-6.97 ng mL-1. In this study, we developed a rapid lateral flow immunochromatographic assay (ICA) strip method to detect ibuprofen in water or herbal tea. The cut-off limit of the strip is 10 ng mL-1 in water, and concentrations as low as 1 ng mL-1 can be detected in herbal tea samples, with the results obtained by the naked eye within 6 min. All the data were confirmed by high performance liquid chromatography-quadrupole time of flight-mass spectrometry (HPLC-QTOF-MS). This lateral-flow ICA strip is thus a rapid tool for on-site detection and screening of ibuprofen in water and herbal tea.
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Affiliation(s)
- Shaozhen Li
- State Key Lab of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China.
| | - Wenliang Ge
- Wuxi No. 2 People's Hospital, Wuxi, 214002, Jiangsu, People's Republic of China.
| | - Steven Suryoprabowo
- State Key Lab of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China.
| | - Jie Liu
- State Key Lab of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China.
| | - Hua Kuang
- State Key Lab of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China.
| | - Jianping Zhu
- State Key Lab of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China.
| | - Liqiang Liu
- State Key Lab of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China.
| | - Chuanlai Xu
- State Key Lab of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China.
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7
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Chiu MH, Jaworska N, Li NL, Yarema M. Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis. Case Rep Crit Care 2021; 2021:6695967. [PMID: 34336301 PMCID: PMC8289598 DOI: 10.1155/2021/6695967] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/28/2021] [Indexed: 01/22/2023] Open
Abstract
Acetaminophen overdose is one of the most common causes of acute hepatic failure in the developed world. There is strong evidence for N-acetylcysteine (NAC) as a safe and effective antidote for acetaminophen toxicity. However, there is less clarity in the management of massive overdoses (acute, single ingestions > 500 mg/kg with 4-hour equivalent concentrations ~6000 μmol/L) which are often associated with metabolic acidosis and multiorgan dysfunction. In such ingestions, the role of adjuvant treatments such as fomepizole and extracorporeal removal is unclear. We present a case of a 20-year-old female presenting with an acute ingestion of over 120 grams (1764.7 mg/kg) and an acetaminophen concentration of 5880 μmol/L who developed refractory shock, decreased level of consciousness, and metabolic acidosis requiring mechanical ventilation and vasopressor support. She was treated with gastric decontamination with activated charcoal, IV NAC, fomepizole, and hemodialysis. The patient had complete clearance of acetaminophen by 32 hours after presentation and normalization of her acid base and hemodynamic status without any organ failure. This case highlights the potential benefit of a triple strategy of NAC, fomepizole, and early hemodialysis in massive acetaminophen overdose, potentially sparing complications of prolonged intubation and ICU hospitalization.
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Affiliation(s)
- Michael H. Chiu
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Natalia Jaworska
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Nicholas L. Li
- Department of Medicine, Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Mark Yarema
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
- Poison and Drug Information Service, Alberta Health Services, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
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Upadhyay A, Amanullah A, Joshi V, Dhiman R, Prajapati VK, Poluri KM, Mishra A. Ibuprofen-based advanced therapeutics: breaking the inflammatory link in cancer, neurodegeneration, and diseases. Drug Metab Rev 2021; 53:100-121. [PMID: 33820460 DOI: 10.1080/03602532.2021.1903488] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Ibuprofen is a classical nonsteroidal anti-inflammatory drug (NSAID) highly prescribed to reduce acute pain and inflammation under an array of conditions, including rheumatoid arthritis, osteoarthritis, dysmenorrhea, and gout. Ibuprofen acts as a potential inhibitor for cyclooxygenase enzymes (COX-1 and COX-2). In the past few decades, research on this small molecule has led to identifying other possible therapeutic benefits. Anti-tumorigenic and neuroprotective functions of Ibuprofen are majorly recognized in recent literature and need further consideration. Additionally, several other roles of this anti-inflammatory molecule have been discovered and subjected to experimental assessment in various diseases. However, the major challenge faced by Ibuprofen and other drugs of similar classes is their side effects, and tendency to cause gastrointestinal injury, generate cardiovascular risks, modulate hepatic and acute kidney diseases. Future research should also be conducted to deduce new methods and approaches of suppressing the unwanted toxic changes mediated by these drugs and develop new therapeutic avenues so that these small molecules continue to serve the purposes. This article primarily aims to develop a comprehensive and better understanding of Ibuprofen, its pharmacological features, therapeutic benefits, and possible but less understood medicinal properties apart from major challenges in its future application.KEY POINTSIbuprofen, an NSAID, is a classical anti-inflammatory therapeutic agent.Pro-apoptotic roles of NSAIDs have been explored in detail in the past, holding the key in anti-cancer therapies.Excessive and continuous use of NSAIDs may have several side effects and multiple organ damage.Hyperactivated Inflammation initiates multifold detrimental changes in multiple pathological conditions.Targeting inflammatory pathways hold the key to several therapeutic strategies against many diseases, including cancer, microbial infections, multiple sclerosis, and many other brain diseases.
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Affiliation(s)
- Arun Upadhyay
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Jodhpur, Rajasthan, India
| | - Ayeman Amanullah
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Jodhpur, Rajasthan, India
| | - Vibhuti Joshi
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Jodhpur, Rajasthan, India
| | - Rohan Dhiman
- Laboratory of Mycobacterial Immunology, Department of Life Science, National Institute of Technology, Rourkela, Odisha, India
| | - Vijay Kumar Prajapati
- Department of Biochemistry, School of Life Sciences, Central University of Rajasthan, Ajmer, Rajasthan, India
| | - Krishna Mohan Poluri
- Department of Biotechnology, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India
| | - Amit Mishra
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Jodhpur, Rajasthan, India
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9
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Wolff E, Bandt C, Bolfer L. Treatment of ibuprofen intoxication with charcoal haemoperfusion in two dogs. N Z Vet J 2020; 68:255-260. [PMID: 32151229 DOI: 10.1080/00480169.2020.1740111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Case history: Two dogs presented separately to the Small Animal Hospital, University of Florida (Gainsville, FL, USA) for ingestion of ibuprofen. The first dog ingested 561.8 mg/kg ibuprofen in addition to paracetamol and caffeine and vomited prior to admission. This patient also received fluid therapy for 8 hours prior to charcoal haemoperfusion. The second dog ingested 500 mg/kg of ibuprofen and the owners induced vomiting with hydrogen peroxide prior to presentation. Due to the severity of clinical signs, both patients were treated with charcoal haemoperfusion.Clinical findings: The concentrations of ibuprofen in the blood of the dogs prior to treatment were 478 and 301 mg/L. During the treatment ibuprofen concentrations were reduced by 95.8% and 45.5%, respectively, with no treatment side effects and minimal clinical signs after treatment.Diagnosis: Toxicity due to ingestion of ibuprofen toxicity that was successfully treated with charcoal haemoperfusion.Clinical relevance: In the cases described here minimal benefit was seen after 3 hours of treatment using one haemoperfusion cartridge. This is in contrast to a previously published report in which dogs were treated for 6 hours with two charcoal haemoperfusion cartridges. This suggests that one cartridge may be sufficient. The amount of ibuprofen ingested was not a reliable predictor of the concentration in blood at the initiation of treatment. Charcoal haemoperfusion is an effective means of reducing plasma concentrations of ibuprofen, however, its use may be limited by its cost and availability.
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Affiliation(s)
- Eds Wolff
- Affiliated Veterinary Specialists, Maitland, FL, USA
| | - C Bandt
- Small Animal Teaching Hospital, University of Florida, Gainesville, FL, USA
| | - L Bolfer
- Small Animal Teaching Hospital, University of Florida, Gainesville, FL, USA
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Smith ZR, Horng M, Rech MA. Medication‐Induced Hyperlactatemia and Lactic Acidosis: A Systematic Review of the Literature. Pharmacotherapy 2019; 39:946-963. [DOI: 10.1002/phar.2316] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Zachary R. Smith
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan
| | - Michelle Horng
- Department of Pharmacy Services The University of Texas MD Anderson Cancer Center Houston Texas
| | - Megan A. Rech
- Department of Pharmacy Loyola University Medical Center Maywood Illinois
- Department of Emergency Medicine Stritch School of Medicine Loyola University Chicago Chicago Illinois
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11
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Bagherian Rad N, Rahimi M. Pattern of NSAID Poisoning in a Referral Poisoning Center of Iran: Solutions to Reduce the Suicide. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2019; 18:249-257. [PMID: 32802104 PMCID: PMC7393050 DOI: 10.22037/ijpr.2019.111720.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
NSAIDs are nonsteroidal anti-inflammatory drugs, thus, they will provide analgesic, antipyretic, anti-inflammatory, antiplatelet effects. Severe poisoning and death because of acute intoxication can occur by ingestions of more than 400 mg/kg. This cross-sectional retrospective study was carried out in on all patients referred to Loghman Hakim Hospital from 2011 to 2016. Grouping of our patients was based on the amount of NSAID ingestion, Type of NSAID, patient's conscious level according to Reed Scaling criteria, suicide attempt, and gender. Data were analyzed using the SPSS software. A P-value of 0.05 or less was considered to be statistically significant. The period prevalence of NSAID poisoning was 0.14% and the incidence was 3.816/100,000/year. The uppermost number of poisoning were seen in 2012 (20.96%). Mean age was 23.75 ± 9.76 years and most of the intoxications were seen in females (66.37%). Of the patients, 140 (61.13%) had ingested less than 200 mg/kg, and 9.17% committed suicide having a mortality rate of 0.43%. The most common NSAIDs that had been used were Ibuprofen (73.79%). Of patients, 83.4% underwent through common complications of NSAID poisoning. We find significant relationship between the type of NSAID and higher sodium, BUN, ALT, ALP, CPK levels in men, and higher LDH level in women. Besides, we found substantial correlation between using short-acting NSAIDs and female gender, suicide action, arrival to the hospital less than 12 h, amounts under 200 mg/kg, hospitalization longer than 12 h, and presentation of loss of consciousness.
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Affiliation(s)
- Nazanin Bagherian Rad
- Department of Toxicology and Pharmacology, Islamic Azad University of Medical Sciences, Tehran, Iran.
| | - Mitra Rahimi
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding author: E-mail:
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12
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Anderson C, Lynch T, Gupta R, Lim RK. Refractory Hypotension Caused by Prazosin Overdose Combined With Acetaminophen and Naproxen Toxicity: A Case Report and Review of the Literature. J Emerg Med 2018; 55:e141-e145. [PMID: 30287134 DOI: 10.1016/j.jemermed.2018.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/10/2018] [Accepted: 09/01/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric exposure to prazosin is unusual because it is most commonly indicated for the treatment of hypertension. Prazosin's increase in popularity as a treatment for posttraumatic stress disorder makes it important for emergency physicians to be aware of how to manage potential toxic ingestion because of prazosin overdose. CASE REPORT A 16-year-old, 76-kg female presented after ingesting 110 mg of prazosin, 209.3 g of acetaminophen, and 55 g of naproxen. She was admitted to the pediatric intensive care unit for rapidly deteriorating hypotension (lowest blood pressure 47/19 mm Hg) refractory to aggressive fluid resuscitation and infusions of epinephrine and norepinephrine each at 0.5 mcg/kg/min. Stabilization of blood pressure was eventually achieved, and associated with use of a vasopressin infusion of 0.004 units/kg/min. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because of the increasing exposure of children to prazosin, clinicians should be aware of the pharmacology behind alpha-1 antagonist overdose and consider treatment options, such as vasopressin, when hypotension is resistant to standard fluid and catecholamine therapy.
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Affiliation(s)
- Cory Anderson
- Department of Pediatrics at Schulich School of Medicine, University of Western Ontario, and the Children's Health Research Institute, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Timothy Lynch
- Department of Pediatrics at Schulich School of Medicine, University of Western Ontario, and the Children's Health Research Institute, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Ronish Gupta
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rodrick K Lim
- Department of Pediatrics at Schulich School of Medicine, University of Western Ontario, and the Children's Health Research Institute, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
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13
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Ibuprofen plasma concentration profile in deliberate ibuprofen overdose with circulatory depression treated with therapeutic plasma exchange: a case report. BMC Pharmacol Toxicol 2017; 18:81. [PMID: 29233194 PMCID: PMC5728060 DOI: 10.1186/s40360-017-0187-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 12/05/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Inquiries relating to ibuprofen overdose have more than tripled in the last ten years in our poison control center. Although the vast majority of cases have a benign clinical course, there are few severe or even fatal cases present with refractory circulatory failure. CASE PRESENTATION We describe a case of a 48 year-old male with suicidal mono-ingestion of approximately 72 g ibuprofen. Despite an initial rapid spontaneous drop in the total ibuprofen plasma concentration (IPC) from 550 to 275 mcg/mL within the first 5 h after admission, the patient developed a circulatory failure, refractory to aggressive fluid resuscitation and high doses of vasopressors. Due to ibuprofen's favorable pharmacokinetics (>95% bound to albumin, low volume of distribution) and in the absence of specific therapeutic alternatives thereby avoiding escalating vasopressor doses, therapeutic plasma exchange (TPE) for extracorporeal elimination of ibuprofen was considered as a therapeutic rescue option. An improvement of hemodynamics with a significant reduction of vasopressors was observed with TPE-initiation. However, neither the observed IPC-profile nor a pharmacokinetic (PK) simulation provided evidence for a quantitative effective elimination of ibuprofen by TPE. Based on PK-modeling we calculated an overall ibuprofen half-life of 17.2 h for the entire observation period over 5 days. CONCLUSIONS To our knowledge this is the first report of a severe ibuprofen-mono intoxication treated with TPE and providing serial IPCs over a period of five days, indicating an estimated fivefold overall-elimination half-life of 17.2 h. Despite TPE clinically improved persistent hemodynamic instability, this procedure was neither consistent with the observed IPC-profile nor correlated with a meaningful quantitative elimination of ibuprofen.
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14
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Sheridan DC, Hendrickson RG, Lin AL, Fu R, Horowitz BZ. Adolescent Suicidal Ingestion: National Trends Over a Decade. J Adolesc Health 2017; 60:191-195. [PMID: 27889404 DOI: 10.1016/j.jadohealth.2016.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Suicide attempts by adolescents most commonly involve the overdose of medications. To date, there has been little information on the over-the-counter or prescription medicines that adolescents ingest for self-harm. Identification of medications chosen in suicide attempts may help guide anticipatory guidance to parents by primary care providers and Poison Centers in prevention programs. METHODS This was a retrospective observational study using the American Association of Poison Control Center's National Poison Data System. Data were collected on patients aged 13-19 years old at the time of their substance ingestion, between the years 2004 and 2013 and that were coded as reason for ingestion of "intentional-suspected suicide." RESULTS During the 10-year study period, there were 390,560 poison center calls for intentional-suspected suicide in the United States between 2004 and 2013, accounting for 80.3% of all "intentional" ingestion calls in the adolescent population. Over the entire age range, the most common substance ingested included acetaminophen (10.9%), ibuprofen (9%), selective serotonin reuptake inhibitors (7.7%), atypical antipsychotic (6%), and antihistamines (5%). The most common medications coded as resulting in major clinical effects or death were antidepressants and atypical antipsychotics. CONCLUSIONS Adolescent ingestion choices for suicide attempts have remained relatively consistent over the past 10 years. However, there was a recent decrease in selective serotonin reuptake inhibitor ingestions. The most common medications used in an overdose attempt were ibuprofen and acetaminophen. Further preventative efforts are needed in this at-risk population from multiple providers at various levels.
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Robert G Hendrickson
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; Oregon Poison Center, Portland, Oregon
| | - Amber L Lin
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; School of Public Health, Oregon Health & Science University, Portland, Oregon
| | - Rongwei Fu
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; School of Public Health, Oregon Health & Science University, Portland, Oregon
| | - B Zane Horowitz
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; Oregon Poison Center, Portland, Oregon
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Arens A, Smollin C. Case Files of the University of California, San Francisco Medical Toxicology Fellowship: Seizures and a Persistent Anion Gap Metabolic Acidosis. J Med Toxicol 2016; 12:309-14. [PMID: 27079645 PMCID: PMC4996787 DOI: 10.1007/s13181-016-0547-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 03/25/2016] [Accepted: 03/30/2016] [Indexed: 10/22/2022] Open
Affiliation(s)
- Ann Arens
- Department of Emergency Medicine, University of California, 1001 Potrero Ave, San Francisco, CA 94110 USA
- California Poison Control Systems, 1001 Potrero Ave, SFGH 5, San Francisco, CA 94110 USA
- Veteran’s Affairs Hospital, 4150 Clement St, San Francisco, CA 94121 USA
| | - Craig Smollin
- Department of Emergency Medicine, University of California, 1001 Potrero Ave, San Francisco, CA 94110 USA
- California Poison Control Systems, 1001 Potrero Ave, SFGH 5, San Francisco, CA 94110 USA
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16
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most widely used classes of medications in children. Despite a reported positive safety profile, NSAIDs have been associated with toxicities in both overdose and routine use. Most children with NSAID overdoses are asymptomatic and should be managed conservatively, whereas a small number may present with severe symptoms. We review NSAID exposures in children and strategies for their clinical evaluation and management.
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Al-Abri SA, Anderson IB, Pedram F, Colby JM, Olson KR. Massive naproxen overdose with serial serum levels. J Med Toxicol 2015; 11:102-5. [PMID: 24756481 DOI: 10.1007/s13181-014-0396-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Massive naproxen overdose is not commonly reported. Severe metabolic acidosis and seizure have been described, but the use of renal replacement therapy has not been studied in the context of overdose. CASE DETAILS A 28-year-old man ingested 70 g of naproxen along with an unknown amount of alcohol in a suicidal attempt. On examination in the emergency department 90 min later, he was drowsy but had normal vital signs apart from sinus tachycardia. Serum naproxen level 90 min after ingestion was 1,580 mg/L (therapeutic range 25-75 mg/L). He developed metabolic acidosis requiring renal replacement therapy using sustained low efficiency dialysis (SLED) and continuous venovenous hemofiltration (CVVH) and had recurrent seizure activity requiring intubation within 4 h from ingestion. He recovered after 48 h. DISCUSSION Massive naproxen overdose can present with serious toxicity including seizures, altered mental status, and metabolic acidosis. CONCLUSION Hemodialysis and renal replacement therapy may correct the acid base disturbance and provide support in cases of renal impairment in context of naproxen overdose, but further studies are needed to determine the extraction of naproxen.
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Affiliation(s)
- Suad A Al-Abri
- California Poison Control System, San Francisco Division, University of California, UCSF Box 1369, San Francisco, CA, 94143-1369, USA,
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Balestracci A, Ezquer M, Elmo ME, Molini A, Thorel C, Torrents M, Toledo I. Ibuprofen-associated acute kidney injury in dehydrated children with acute gastroenteritis. Pediatr Nephrol 2015; 30:1873-8. [PMID: 25895445 DOI: 10.1007/s00467-015-3105-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 03/17/2015] [Accepted: 03/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) induce acute kidney injury (AKI) in volume-depleted patients; however the prevalence of this complication is likely underestimated. We assessed the impact of ibuprofen exposure on renal function among dehydrated children with acute gastroenteritis (AGE) to further characterize NSAID-associated AKI. METHODS Over a 1-year period dehydrated children with AGE (n = 105) were prospectively enrolled and grouped as cases, presenting with AKI (n = 46) or controls, not presenting with AKI (n = 59). AKI was defined by pediatric RIFLE (pRIFLE) criteria. RESULTS Among the children enrolled in the study, AKI prevalence was 44 %, and 34 (54 %) of the 63 patients who received ibuprofen developed renal impairment. Relative to the controls, children presenting with AKI were younger (median age 0.66 vs. 1.74 years; p < 0.001) and received ibuprofen more frequently (74 vs. 49 %, p = 0.01). After adjusting for the degree of dehydration, ibuprofen exposure remained an independent risk factor for AKI (p < 0.001, odds ratio 2.47, 95 % confidence interval 1.78-3.42). According to the pRIFLE criteria, 17 patients were at the 'risk' stage of AKI severity, 24 were at the 'injury' stage, and five were at the 'failure' stage; none required dialysis. Distribution of patients within categories was similar regardless of ibuprofen exposure. All cases fulled recovered from AKI. CONCLUSIONS Ibuprofen-associated AKI was 54 % in our cohort of dehydrated children with AGE. Drug exposure increased the risk for developing AKI by more than twofold, independent of the magnitude of the dehydration.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, 1270, Ciudad Autónoma de Buenos Aires, Argentina,
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19
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Bolfer L, McMichael M, Ngwenyama TR, O'Brien MA. Treatment of Ibuprofen Toxicosis in a Dog with IV Lipid Emulsion. J Am Anim Hosp Assoc 2014; 50:136-40. [DOI: 10.5326/jaaha-ms-5979] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 3 yr old spayed female mixed-breed dog weighing 19.4 kg was evaluated for ingestion of 1,856 mg/kg (180 tablets) of ibuprofen, a human formulated nonsteroidal anti-inflammatory drug (NSAID). At the time of presentation, the patient was alert and hypersalivating, but her mental status rapidly declined to obtunded, stuporous, and then comatose within 30 min of presentation. Initial treatment included supportive therapy with prostaglandin analogs and antiemetics. An IV lipid emulsion (ILE) was administered as a bolus, followed by a constant rate infusion. Clinical signs began to improve approximately 3 hr after completion of the lipid infusion. The patient required supportive care for 3 days before discharge. This case report demonstrates the use of ILE for treatment of ibuprofen toxicosis in a dog. ILE infusion may be a therapeutic option for patients with toxicosis due to lipid-soluble drugs.
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Affiliation(s)
- Luiz Bolfer
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL (L.B.); and Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, IL (M.M., T.N., M.O.)
| | - Maureen McMichael
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL (L.B.); and Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, IL (M.M., T.N., M.O.)
| | - Thandeka R. Ngwenyama
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL (L.B.); and Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, IL (M.M., T.N., M.O.)
| | - Mauria A. O'Brien
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL (L.B.); and Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, IL (M.M., T.N., M.O.)
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21
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Hypokalaemia and Renal Tubular Acidosis due to Abuse of Nurofen Plus. Case Rep Crit Care 2012; 2012:141505. [PMID: 24826329 PMCID: PMC4010031 DOI: 10.1155/2012/141505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 08/22/2012] [Indexed: 02/05/2023] Open
Abstract
Nurofen Plus is a common analgesic containing ibuprofen and codeine. We present a case of a 38-year-old lady who developed renal tubular acidosis with severe hypokalaemia, after chronic abuse of Nurofen Plus tablets. She presented with confusion and profound biochemical abnormalities requiring critical care admission for electrolyte replacement. Ibuprofen causes renal tubular acidosis due to its effects on carbonic anhydrase activity.
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22
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Hunter LJ, Wood DM, Dargan PI. The patterns of toxicity and management of acute nonsteroidal anti-inflammatory drug (NSAID) overdose. Open Access Emerg Med 2011; 3:39-48. [PMID: 27147851 PMCID: PMC4753966 DOI: 10.2147/oaem.s22795] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Indexed: 11/25/2022] Open
Abstract
The nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for their analgesic, anti-inflammatory and antipyretic actions. They are commonly taken in overdose in many areas of the world. The majority of patients with acute NSAID overdose will remain asymptomatic or develop minor self-limiting gastrointestinal symptoms. However, serious clinical sequelae have been reported in patients with acute NSAID overdose and these include convulsions, metabolic acidosis, coma and acute renal failure. There appear to be some differences between the NSAIDs in terms of the relative risk of these complications; in particular mefenamic acid is most commonly associated with convulsions. The management of these serious clinical features is largely supportive and there are no specific antidotes for acute NSAID toxicity.
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Affiliation(s)
- Laura J Hunter
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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23
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Page CB, Wilson PA, Foy A, Downes MA, Whyte IM, Isbister GK. Life‐threatening hypokalaemia associated with ibuprofen‐induced renal tubular acidosis. Med J Aust 2011; 194:614. [DOI: 10.5694/j.1326-5377.2011.tb03123.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 04/14/2011] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Aidan Foy
- Calvary Mater Newcastle, Newcastle, NSW
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