Fatality after deliberate ingestion of sustained-release ibuprofen: a case report

Targeting Pathways and Integrated Approaches to Treat Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic symmetrical systemic disorder that not only affects joints but also other organs such as heart, lungs, kidney, and liver. Approximately there is 0.5%-1% of the total population affected by RA. RA pathogenesis still remains unclear due to which its appropriate treatment is a challenge. Further, multitudes of factors have been reported to affect its progression i.e. genetic factor, environmental factor, immune factor, and oxidative factor. Therapeutic approaches available for the treatment of RA include NSAIDs, DMARDs, enzymatic, hormonal, and gene therapies. But most of them provide the symptomatic relief without treating the core of the disease. This makes it obligatory to explore and reach the molecular targets for cure and long-term relief from RA. Herein, we attempt to provide extensive overlay of the new targets for RA treatment such as signaling pathways, proteins, and receptors affecting the progression of the disease and its severity. Precise modification in these targets such as suppressing the notch signaling pathway, SIRT 3 protein, Sphingosine-1-phosphate receptor and stimulating the neuronal signals particularly efferent vagus nerve and SIRT 1 protein may offer long term relief and potentially diminish the chronicity. To target or alter the novel molecules and signaling pathway a specific delivery system is required such as liposome, nanoparticles and micelles and many more. Present review paper discusses in detail about novel targets and delivery systems for treating RA.

Transient tunnel vision and altered consciousness after a single dose of ibuprofen

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.

Ibuprofen-Associated Hypokalemia and Metabolic Acidosis: Systematic Literature Review

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.

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.

Effect of ibuprofen entrapment procedure on physicochemical and controlled drug release performances of chitosan/xanthan gum polyelectrolyte complexes

The effect of the entrapment procedure of a poorly water soluble drug (ibuprofen) on physicochemical and drug release performances of chitosan/xanthan polyelectrolyte complexes (PECs) was investigated to achieve controlled drug release as the ultimate goal. The formation of PECs for two drug entrapment procedures (before or after the mixing of polymers) at pH 4.6 and 5.6 and three chitosan-to-xanthan mass ratios (1:1, 1:2 and 1:3) was observed by continuous decrease in conductivity during the PECs formation and increased apparent viscosity and hysteresis values. The most extensive crosslinking was observed with ibuprofen added before the PECs formation at pH 4.6 and chitosan-to-xanthan mass ratio 1:1. The PECs prepared at polymers' mass ratios 1:2 and 1:3 had higher yield and drug entrapment efficiency. DSC and FT-IR analysis confirmed ibuprofen entrapment in PECs and the partial disruption of its crystallinity. All ibuprofen release profiles were similar, with 60-70% of drug released after 12 h, mainly by diffusion, but erosion and polymer chain relaxation were also included. Potentially optimal can be considered the PEC prepared at pH 4.6, ibuprofen entrapped before the mixing of polymers at chitosan-to-xanthan mass ratio 1:2, which provided controlled drug release by zero-order kinetics, high yield, and drug entrapment efficiency.

Pattern of NSAID Poisoning in a Referral Poisoning Center of Iran: Solutions to Reduce the Suicide

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.

Soy Protein Microparticles for Enhanced Oral Ibuprofen Delivery: Preparation, Characterization, and In Vitro Release Evaluation

The objective of this work was to evaluate soy protein isolate (SPI) and acylated soy protein (SPA) as spray-drying encapsulation carriers for oral pharmaceutical applications. SPI acylation was performed by the Schotten-Baumann reaction. SPA, with an acylation rate of 41%, displayed a decrease in solubility in acidic conditions, whereas its solubility was unaffected by basic conditions. The drug encapsulation capacities of both SPI and SPA were tested with ibuprofen (IBU) as a model poorly soluble drug. IBU-SPI and IBU-SPA particles were obtained by spray-drying under eco-friendly conditions. Yields of 70 to 87% and microencapsulation efficiencies exceeding 80% were attained for an IBU content of 20 to 40% w/w, confirming the excellent microencapsulation properties of SPI and the suitability of the chemical modification. The in vitro release kinetics of IBU were studied in simulated gastrointestinal conditions (pH 1.2 and pH 6.8, 37°C). pH-sensitive release patterns were observed, with an optimized low rate of release in simulated gastric fluid for SPA formulations, and a rapid and complete release in simulated intestinal fluid for both formulations, due to the optimal pattern of pH-dependent solubility for SPA and the molecular dispersion of IBU in soy protein. These results demonstrate that SPI and SPA are relevant for the development of pH-sensitive drug delivery systems for the oral route.

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.

Nonsteroidal Anti-Inflammatory Drug Toxicity in Children: A Clinical Review

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.

Salbutamol sulfate absorption across Calu-3 bronchial epithelia cell monolayer is inhibited in the presence of common anionic NSAIDs

PURPOSE

The aim of this study was to characterize the permeability kinetics of salbutamol sulfate, a commonly used β2-agonist in the treatment of asthma exacerbation, across Calu-3 respiratory epithelial cell monolayers in the presence of non-steroidal anti-inflammatory drugs (NSAIDs), as they have been implicated to be able to modulate organic cation transporters (OCTs).

METHODS

Calu-3 cell monolayers were grown in a liquid covered culture (LCC) configuration on 0.33 cm(2) Transwell polyester cell culture supports. Monolayers, cultured between 11 and 14 days were evaluated for epithelial resistance, tight junction integrity, and expression of OCT using Western blot analysis. The transport of salbutamol across the monolayer was studied as a function of concentration. Directional transport was investigated by assessing apical-basal (a-b) and basal-apical (b-a) directions. The influence of a non-specific OCT inhibitor (tetraethylammonium, TEA) and three NSAIDs (aspirin, ibuprofen, and indomethacin) on the uptake of salbutamol was studied.

RESULTS

The flux of salbutamol sulfate increased with increasing concentration before reaching a plateau, suggesting the involvement of a transport-mediated uptake mechanism. Western blot analysis detected the presence of OCT1-3 and N1 and N2 sub-types, suggesting the presence of functioning transporters. The apparent permeability (P(app)) of 0.1 mM salbutamol across the epithelial monolayer displayed directional transport in the a-b direction which was inhibited by ˜70% in the presence of TEA, suggesting OCT-mediated uptake. Likewise, the uptake of 0.1 mM salbutamol was decreased in the presence of all the three NSAIDs, supporting a mechanism whereby NSAIDs inhibit absorption of salbutamol across the bronchial epithelium via effects on the OCT transporters.

CONCLUSION

This study demonstrates that NSAIDs influence the uptake kinetics of salbutamol in an in vitro Calu-3 cell system.

Acute Ibuprofen intoxication: report on a case and review of the literature

A fatality following the ingestion of ibuprofen is reported. Ibuprofen is a prototypical nonsteroidal anti-inflammatory drug widely prescribed as an analgesic, anti-inflammatory, and antipyretic agent. To date, there are few case reports of fatal overdose with ibuprofen, following ibuprofen self-poisoning or accidental overdose. We report the case of a 51-year-old man with medical history of psychiatric disease, who was brought to the emergency department by ambulance with a chief complaint of having taken large amounts of drugs in a suicide attempt.Multiple empty containers of medications (ibuprofen, meloxicam, celecoxib, risperidone, citalopram, ketorolac, bromazepam) were found at the scene. He died 4 hours after admission to the emergency department, despite vigorous supportive care. Toxicological analyses were performed using a gas chromatography/mass spectrometry technique. The estimated ibuprofen concentration in the plasma was 600 μg/mL; gastric content was 200 μg/mL for this compound. Our report describes results of the forensic investigation and discuss the review of the literature.

The patterns of toxicity and management of acute nonsteroidal anti-inflammatory drug (NSAID) overdose

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.

Polyuria, acidosis, and coma following massive ibuprofen ingestion

Ibuprofen was the first over-the-counter nonsteroidal anti-inflammatory drug available in the United States. Despite being a common agent of ingestion, significant toxicity in overdose is rare. We report a case of a massive ibuprofen ingestion who developed polyuria, acidosis, and coma but survived, despite having a serum ibuprofen concentration greater than previous fatal cases. A 19-year-old man ingested 90 g (1,200 mg/kg) ibuprofen. He was initially awake and alert, but his level of consciousness deteriorated over several hours. Seven hours following the ingestion, he was intubated and mechanically ventilated secondary to loss of airway reflexes. He developed a lactic acidosis and polyuria, which lasted for nearly 24 h. His serum creatinine peaked at 1.12 mg/dL. An ibuprofen level drawn 7 h postingestion was 739.2 mg/L (therapeutic 5-49 mg/L). We describe a case of a massive ibuprofen overdose characterized by metabolic acidosis, coma, and a state of high urine output who survived with aggressive supportive care. This case is unique in several ways. First, ibuprofen levels this high have only rarely been described. Second, polyuria is very poorly described following ibuprofen ingestions.

An overview of clinical pharmacology of Ibuprofen

Ibuprofen was the first member of Propionic acid derivatives introduced in 1969. It is a popular domestic and over the counter analgesic and antipyretic for adults and children. Ibuprofen has been rated as the safest conventional NSAID by spontaneous adverse drug reaction reporting systems in the UK. This article summarizes the main pharmacological effects, therapeutical applications and adverse drug reactions, drug-drug interactions and food drug interactions of ibuprofen that have been reported especially during the last 10 years.

Ibuprofen-induced hypersensitivity syndrome

Ibuprofen is a widely used antipyretic and analgesic nonsteroidal antiinflammatory drug (NSAID). With the aging of the population, there will be a significant increase in the prevalence of painful degenerative and inflammatory rheumatic conditions. This increase likely will lead to a parallel increase in the use of NSAIDs, including ibuprofen. The primary effect of the NSAIDs is to inhibit cyclooxygenase (prostaglandin synthase), thereby impairing the ultimate transformation of arachidonic acid to prostaglandins, prostacyclin, and thromboxanes. Although in the majority of cases it is safe, this NSAID, ibuprofen, can produce an unpredictable, idiosyncratic, type B reaction that may pose a major concern in clinical practice. Type B reactions are known to occur in susceptible individuals. The true hypersensitivity reaction (HSR) is a systemic disease defined by the triad of fever, rash, and internal organ involvement that starts 1 day to 12 weeks after the initiation of therapy. HSR has limited the therapeutic use of many drugs, including ibuprofen. Hypersensitivity syndrome associated with ibuprofen is a host-dependent drug reaction that is idiosyncratic in nature. This reaction likely is caused by a combination of metabolic and immunologic factors. Immune mediated components, such as T-cell and their products cytokines and chemokines, can exacerbate cellular responses and create complex pathways that lead to a variety of clinical manifestations. Our review presents an ibuprofen-induced clinical manifestation of hypersensitivity syndrome and the necessity of wisely monitoring the patients clinically and by laboratory investigations when prescribing this drug.

Enteric coating of ibuprofen tablets (200 mg) using an aqueous dispersion system

Ibuprofen is a propionic acid derivative that belongs to the class NSAIDs. Major adverse reactions associated with Ibuprofen are related to GIT and include peptic and mucosal ulcers, dyspepsia, severe gastric pain and bleeding, that results in excessive treatment failure. The goal of this study was to develop enteric coated ibuprofen tablets in order to avoid gastric mucosal irritation, diffusion of drug across mucosal lining and to let active ingredient be absorbed easily in small intestine. The formulation was developed and manufactured through the direct compression process, the simplest, easiest and most economical method of manufacturing. Enteric coating was done using an Opadry white subcoating and an aqueous coating dispersion of Acryl-Eze. Enteric coated formulation was subjected to disintegration and dissolution tests by placing in 0.1 M hydrochloric acid for 2 h and then 1 h in phosphate buffer with a pH of 6.8. About 0.04% of drug was released in the acidic phase and 99.05% in the basic medium. These results reflect that ibuprofen can be successfully enteric coated in order to prevent its release in the stomach and facilitate rapid release of the drug in the duodenum, due to the presence of superdisintegrant. Formulating this enteric coated tablets could increase patient compliance by decreasing adverse drug reactions (ADR S) associated with Ibuprofen therapy.

A report of two deaths from massive ibuprofen ingestion

INTRODUCTION

Ibuprofen is a commonly used non-steroidal anti-inflammatory drug. While the vast majority of exposures to the drug do not result in significant morbidity, we are reporting 2 fatalities that resulted from massive ibuprofen ingestion. CASE 1: A 17-year-old girl presented to the emergency department (ED) following an ibuprofen overdose; she was unresponsive with a metabolic acidosis and hypothermic. Her serum ibuprofen concentration was 352 microg/mL: the therapeutic range is 10-50 microg/mL. Despite intensive supportive care and continuous veno-venous hemofiltration, she expired. CASE 2: A 49-year-old man presents to the ED with a history of divalproex sodium and ibuprofen ingestion. He was unresponsive, hypotensive, and had a significant metabolic acidosis. His serum ibuprofen concentration was 260 microg/mL and serum valproate concentration was 560 microg/mL: the therapeutic range is 50-100 microg/mL. In spite of supportive care and hemodialysis, he expired.

DISCUSSION

We will describe 2 cases of ibuprofen overdose characterized by cardiovascular collapse, acidosis, and hypothermia despite the use of vasopressors and renal replacement therapy. Although rarely reported, massive ibuprofen overdose may result in refractory multisystem organ failure and death.

Ibuprofen: A Journey from Prescription to Over-the-Counter Use

Ibuprofen was the first non-aspirin non-steroidal antiinflammatory drug (NSAID) to be approved for over-the-. counter (OTC) use and is widely considered to be the best tolerated drug of its class. Low-dose, OTC ibuprofen has been used for pain relief for over 30 years without any obvious major health issues. However, there is no clear differentiation between the OTC and prescription doses of ibuprofen, and their respective effects. Adverse reactions to ibuprofen appear to be dose and duration dependent, and this may be the reason for the observed tolerability of the drug at OTC doses. OTC ibuprofen is at least as effective as aspirin and more effective than paracetamol. The tolerability concerns associated with higher dose NSAIDs currently do not apply to low-dose, short-term use of ibuprofen for common pain. Ibuprofen is associated with the least risk of GI complications compared with other NSAIDs and is considered relatively benign in overdose. This review will aim to distinguish the safety of OTC or non-prescription use of ibuprofen from its prescription use.