Functional adrenal insufficiency complicating an overdose of naproxen and ibuprofen

Lactic acidosis and multisystem organ failure following ibuprofen overdose requiring haemodialysis

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.

Ibuprofen plasma concentration profile in deliberate ibuprofen overdose with circulatory depression treated with therapeutic plasma exchange: a case report

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.