Toxicity of over-the-counter cough and cold medications

Over-the-counter (OTC) cough and cold medications are marketed widely for relief of common cold symptoms, and yet studies have failed to demonstrate a benefit of these medications for young children. In addition, OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time. Physicians often do not inquire about OTC medication use, and parents (or other caregivers) often do not perceive OTCs as medications. We present 3 cases of adverse outcomes over a 13-month period-including 1 death-as a result of OTC cough and cold medication use. We explore the toxicities of OTC cough and cold medications, discuss mechanisms of dosing errors, and suggest why physicians should be more vigilant in specifically inquiring about OTCs when evaluating an ill child.

Ibuprofen overdose: 126 cases

In this study of ibuprofen overdose, symptoms developed in 19% of patients (24 of 126)--in 7% of children (6 of 88) and in 47% of adults (18 of 38). Central nervous system depression, seizures, gastrointestinal disturbances, bradycardia, hypotension, apnea, abnormal renal functions, hematuria, nystagmus, and blurred vision were observed. No patients became symptomatic more than four hours after ingestion. There was no significant difference (P greater than .05) between symptomatic and asymptomatic adult groups in either total milligrams or milligram-per-kilogram amounts ingested by history. Pediatric patients who became symptomatic had a mean ingestion by history of 440 mg/kg; those who remained asymptomatic had a mean ingestion by history of 114 mg/kg (P less than .001). No patients ingesting less than 99 mg/kg by history developed any symptoms. Two children had seizures or apnea and one died. Ibuprofen occasionally may cause serious toxicity in overdose.

Failure of gastric emptying and charcoal administration in fatal sustained-release theophylline overdose: pharmacobezoar formation

We report the case of a fatal theophylline overdose from a sustained-release preparation in a 54-year-old woman. Initial serum theophylline concentration was 31.3 mg/L. Manifestations of mild toxicity cleared in the emergency department after treatment with gastric lavage, charcoal, and a cathartic. A life-threatening overdose was not suspected, and the patient arrested eight hours after discharge from the ED. At autopsy, her serum theophylline concentration was 190.1 mg/L. A white, waxy mass weighing 318.8 g and containing 29 g theophylline, representing the residue of many sustained-release tablets, was found in her stomach. This case reinforces the importance of obtaining repeat serum theophylline levels in patients with sustained-release theophylline overdose. Gastric pharmacobezoar formation should be considered in cases of sustained-release theophylline overdose with rising theophylline levels and patient deterioration, despite adequate gut decontamination.

A prospective, population-based study of acute ibuprofen overdose: complications are rare and routine serum levels not warranted

The availability of ibuprofen without a prescription requires assessment of its acute toxicity in the general population. We report results from a prospective study of 329 cases of ibuprofen overdose from a statewide cohort that were reported to our poison center between April 1985 and November 1986; 85 patients had ibuprofen serum concentrations measured. Gastrointestinal disturbances and central nervous system depression were the most common clinical findings (42% and 30% of patients, respectively), but the severity was mild; only one patient had severe symptoms that could be attributed to ibuprofen. Ibuprofen serum concentrations correlated poorly with gastrointestinal symptoms (r = -.177), central nervous system findings (r = .176), presence of coingestants (r = .078), and presence of potentially life-threatening symptoms (r = .087). We evaluated the usefulness of a previously published nomogram to predict ibuprofen toxicity; the positive predictive value for severe symptoms was 6% for all patients and 0% for patients ingesting ibuprofen alone. We conclude that the frequency of life-threatening complications from ibuprofen overdose is low, the nomogram is not predictive of toxicity, and routine serum concentration determinations are not useful as an adjunct in the management of overdose cases.

Severe hypokalaemia and weakness due to Nurofen misuse

Nephrotoxicity from non-steroidal anti-inflammatory drugs (NSAID) is well recognized. We report a case of severe hypokalaemia and weakness due to renal tubular acidosis in a young woman who was taking 40-60 tablets per day of Nurofen Plus (ibuprofen 200 mg and codeine phosphate 12.8 mg). Proprietary brands of ibuprofen are freely available to the public and those containing codeine may be potentially subject to abuse. This case highlights the need to be aware of this potential and of the life-threatening electrolyte and acid-base disturbances that might be encountered with the widespread availability of these types of NSAID.

Acute poisoning with ibuprofen

1 Seventy five cases of ibuprofen overdose were recorded during a two year survey. 2 Details of the symptoms, treatment and the eventual outcome are known for 64% of the cases. The majority of the patients had no symptoms or only mild symptoms such as nausea or vomiting. 3 In the three cases where more serious symptoms were reported, the role of ibuprofen was not certain. 4 Laboratory analyses available for 13 cases demonstrate that plasma ibuprofen concentrations of up to 704 mg/l could be associated with no symptoms. 5 The data suggest that ibuprofen is of low toxicity in acute overdose and that therapy used should be supportive only.

Acute renal insufficiency in ibuprofen overdose

Since the introduction of ibuprofen as a nonprescription drug in the US, there have been reports of significant toxicity associated with large ingestions (> 400 mg/kg) in both children and adults. Acute renal insufficiency is a rare, reversible effect of ibuprofen overdose documented in adults, but we could find no published pediatric cases. We report a case of a healthy two-year-old boy, without a previous history of renal problems, who developed reversible acute renal insufficiency after a toxic ingestion of approximately 640 mg/kg ibuprofen. By 11 hours, his initially normal creatinine began to rise, reaching a peak value of 181 mmol/L (2.1 mg/dl) by 27 hours. His urinalysis showed moderate microscopic hematuria without the presence of casts or proteinuria. No problems arose with fluid management. Normalization of his renal function occurred by 72 hours. A serum ibuprofen concentration obtained by high-performance liquid chromatography and drawn approximately four hours after ingestion was 1724 mumol (therapeutic serum concentration, 50-250 mumol). This case demonstrates that acute, reversible renal insufficiency can occur in healthy children after a severe overdose of ibuprofen; hence, renal function should be monitored in such instances.

Massive ibuprofen overdose requiring extracorporeal membrane oxygenation for cardiovascular support

OBJECTIVE

Ibuprofen is rarely associated with severe toxicity. We report a massive ibuprofen overdose that resulted in refractory hypotension requiring extracorporeal membrane oxygenation (ECMO) for cardiovascular support.

DESIGN

Individual case report.

SETTING

Pediatric intensive care unit of a tertiary care hospital.

PATIENT

A 14-yr-old male presented with apnea and cardiovascular collapse after a nonaccidental ingestion of approximately 50 g of ibuprofen. His laboratory evaluation demonstrated an anion gap metabolic acidosis and elevated lactate levels.

INTERVENTIONS

The patient required pressor support with norepinephrine, phenylephrine, and vasopressin infusions. Due to refractory hypotension, he was placed on ECMO. His serum ibuprofen level at an estimated 5-10 hrs postingestion was 776 microg/mL (therapeutic 20-30 microg/mL). Urine toxicological screen for drugs of abuse, serum acetaminophen, salicylate, and carboxyhemoglobin levels showed that these levels were not elevated. The patient developed high-output renal failure, pulmonary hemorrhage, and gastric bleeding, all of which resolved by hospital day 3.

MEASUREMENTS AND MAIN RESULTS

ECMO was discontinued on hospital day 4, inotropic support was discontinued, and the patient was extubated on hospital day 5. He was transferred to an inpatient psychiatric unit on hospital day 9 with no identifiable medical sequelae.

CONCLUSIONS

Although ibuprofen overdose typically has few consequences, severe hypotension, renal failure, and gastrointestinal bleeding can occur. We report the first known case of successful ECMO therapy for ibuprofen overdose.

A case-control study of acute ibuprofen toxicity in dogs

A case-control study used data in the National Animal Poison Control Center database to characterize risk factors for gastrointestinal ulceration and acute renal failure subsequent to the acute ingestion of ibuprofen in the dog. For gastrointestinal ulceration (GIU) subsequent to ibuprofen ingestion, four factors differentiated the 116 cases from the 93 controls. Risk of GIU was lower for dogs where the time from ingestion to intervention was known as opposed to missing (adjusted odds ratio (aOR) = 0.12, p = 0.0001). Risk of GIU was also lower for the Labrador breed (aOR = 0.22, p = 0.004). Risk of GIU was higher for each unit of the logarithm of time to intervention (aOR = 2.63, p = 0.0002) and for the German Shepherd breed (aOR = 5.67, p = 0.14). For acute renal failure (ARF) subsequent to ibuprofen ingestion, two factors differentiated the 80 cases from the 64 controls. Risk of ARF was lower for dogs where the time from ingestion to intervention was known as opposed to missing (aOR = 0.15, p = 0.0001). Risk of ARF was higher for each unit of the logarithm of time to intervention (aOR = 2.16, p = 0.01). Although this study failed to describe a dose-response relationship, it appears that there are significant breed differences in susceptibility to GIU subsequent to ibuprofen exposure. Time to intervention was critical for both GIU and ARF outcomes. Dogs, particularly German Shepherds, ingesting even small amounts of ibuprofen, may need to be managed aggressively.

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

INTRODUCTION

Ibuprofen is a nonsteroidal anti-inflammatory drug available over the counter and on prescription for the management of pain and inflammation. Severe toxicity is rare following deliberate self-poisoning with ibuprofen, and patients are usually either asymptomatic or develop only mild gastrointestinal toxicity. Although there have been nine other reported fatalities, co-existent factors have probably contributed to all of these deaths. We report here a fatality from isolated toxicity following self-poisoning with sustained-release ibuprofen.

CASE REPORT

A 26-year-old female presented after deliberate ingestion of up to 105 g sustained-release ibuprofen, with a reduced level of consciousness, severe metabolic acidosis and haemodynamic compromise. Despite intensive supportive management, gut decontamination with multidose activated charcoal and correction of the metabolic acidosis with sodium bicarbonate and haemofiltration, the patient did not survive. The ibuprofen concentration ante mortem on presentation in peripheral blood was 760 mg/l and the concentrations post mortem were 518 mg/l in peripheral blood, 74 mg/kg in liver extract and 116 mg/l in the gastric contents.

DISCUSSION

Most patients with ibuprofen poisoning are either asymptomatic or have mild gastrointestinal symptoms; severe poisoning with ibuprofen is rare. We report the first death related to isolated sustained-release ibuprofen poisoning.

Ibuprofen overdose in adults

A prospective study of 63 ibuprofen overdose cases in adults (14 years or older) reported to the Rocky Mountain Poison and Drug Center between March 1987 and February 1988 was done to determine the incidence of renal injury and utility of timed plasma levels. No serious toxicity was noted. No CNS or other significant toxicity was seen with ingestion of less than 3 g. Two patients with normal serum creatinines had minor elevations of the blood urea nitrogen after ingesting 4 and 4.8 g. Timed plasma levels (125 total) from patients without coingestants from this study (48) and previously published reports (77) were compared with a previously described nomogram. The resulting nomogram revision may be useful in determining which initially asymptomatic patients are likely to remain so. Renal function tests are not routinely required for patients ingesting less than 6 g. Four h of observation is sufficient for asymptomatic patients not requiring psychiatric admission. Plasma ibuprofen levels are not required for proper patient management.

Tissue distribution of ibuprofen in a fatal overdose

A 26-year-old white man was found dead near his home. The decedent had had a history of ibuprofen overdose and had recently received a physician's order for 800 mg ibuprofen every 4 h for back pain. Postmortem examination was performed and was unrevealing except for heavy lungs (1,140 g combined weight) and a brownish-white granular residue in the stomach. Samples of heart blood, femoral blood, liver, brain, and gastric contents were submitted for toxicological analysis. Qualitative screening detected only the presence of ibuprofen. Quantitation of ibuprofen was performed using reverse-phase high-performance liquid chromatography (HPLC) with ultraviolet detection. The analytical column was an Econosphere C-8 column (150 mm, 4.6 mm I.D.) with 5 microns particle size preceded by a C-8 5 microns guard column. The mobile phase was 46% methanol and 54% 0.2 M acetate buffer at a flow rate of 2 ml/min. Fenoprofen was used as an internal standard at 200 mcg/ml. A linear response (r = 0.99) was achieved over a concentration range of 25-600 mcg/ml. Ibuprofen was identified and quantitated in the following tissues: heart blood (518.0 mcg/ml), femoral blood (348.3 mcg/ml), liver (942.1 mcg/g), brain (283.9 mcg/g), and gastric contents (131 mg total).

Unintentional overdose of analgesia secondary to acute dental pain

Three cases of unintentional overdose with simple analgesics are presented. Over a two month period, these patients presented to the accident and emergency (A&E) department with acute dental pain, outside normal working hours, having been unable to access emergency dental care. In one case the patient's reason for attendance was to obtain further supplies of analgesics. The patients required admission for assessment of the severity of the overdose in addition to advice about appropriate use of analgesics and advice on access to dental care. None of the patients required treatment for the overdose. These cases serve as a timely reminder of the importance of taking an accurate drug history in emergency situations. They also raise issues of patient education for self medication and access to emergency dental services outside normal working hours.

Ibuprofen overdose and exposure in utero: results from a postmarketing voluntary reporting system

A voluntary reporting system has been established by the manufacturer of ibuprofen (Motrin) to detect, collect, and document medical events related to its use that were not or could not be obtained by controlled clinical trials, such as data on overdose and fetal exposure. Of over 100 million prescriptions for ibuprofen written in the United States in the last nine years, only 67 cases of overdose or accidental ingestion have been reported, 36 percent of which occurred in children less than three years old. There have been only three reports of fatalities, all in adults. Also during this nine-year period, 50 reports of exposure in utero have been received. However, no abnormalities have been seen in any patient followed up prospectively from exposure through delivery.

Ibuprofen overdose: the first two years of over-the-counter sales

Experience during 14 years of prescription only use indicates that the non-steroidal anti-inflammatory drug (NSAID) ibuprofen is of low toxicity in acute overdose. In August 1983 ibuprofen was licensed for over-the-counter (OTC) use in the UK and it was recognised that this change could have an impact upon the epidemiology of analgesic overdose in this country. The London centre of the National Poisons Information Service (NPIS) began a new prospective survey of ibuprofen overdose at the time of OTC release. The first 2 years of this survey detected a marked increase in enquiries concerning ibuprofen overdose but there was no evidence to contradict the former claims of low toxicity. The importance of continued monitoring is stressed.

Pseudomethemoglobinemia: a case report and review of sulfhemoglobinemia

OBJECTIVES

To see if methemoglobin could potentially be misdiagnosed and the limitation of present cooximeters.

PATIENT

A 17-year-old girl who overingested a combination of cimetidine, acetaminophen, ibuprofen, and naproxen in a suicide attempt.

METHOD

Use of pulse co-oximeters to aid in the diagnosis of suspected sulfhemoglobinemia.

RESULTS

Diagnosis of sulfhemoglobinemia achieved with final confirmation made with gas chromatography. Patient steadily improved with supportive care.

CONCLUSIONS

There is a potential for the diagnosis of methemoglobin with some of the limitations of present co-oximeters. The laboratory diagnosis of sulfhemoglobinemia can be difficult to make.

Serious toxicity in a young child due to ibuprofen

An 18-month-old male presented to the emergency department (ED) for evaluation of lethargy and apnea. Four hours before presentation, the patient was found with an empty bottle of ibuprofen, an ingestion of as much as 7.2 grams (600 mg/kg). The ED course was remarkable for a 30-second tonic-clonic seizure. Laboratory analysis was notable for metabolic acidosis. Four-hour and 7.5-hour serum ibuprofen levels were 640 and 39 microg/mL, respectively. Following treatment, the patient improved and was extubated the next morning. While metabolic acidosis has been frequently described at doses exceeding 400 mg/kg, seizures occurring early in the course of ibuprofen toxicity have been rarely noted.

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.

Acute oliguric renal failure due to ibuprofen overdose

We have described a patient who had acute oliguric renal failure after ingesting a single large overdose of ibuprofen. This patient had no predisposing underlying disease, and subsequently had complete resolution of renal failure.

A comparison of the frequency and severity of poisoning cases for ingestion of acetaminophen, aspirin, and ibuprofen

During 1984, 62,837 cases of human exposure to analgesics were reported to the National Data Collection System of the American Association of Poison Control Centers. We undertook a comparative study of 10,134 cases of human exposure to adult formulations of aspirin, acetaminophen, and ibuprofen from which we found that human exposures to analgesics are a common problem reported to poison control centers. All three analgesics studied appear to have minimal toxicity in children who accidentally ingest the product and report the exposure to a poison control center. Most children were managed without referral to a health care facility and without specific therapeutic intervention, other than palliative measures; only a few children develop symptoms from the exposure. When symptoms developed, most were not life-threatening and the child returned to a preexposure state of health within a short time after the onset of symptoms. In adults, the analgesics appear to be relatively safe--that is, most cases had either no effect or caused only minor symptoms; less than 5% of the patients developed a major effect and less than 0.5% died as a result of their exposure. Because the majority of adults took the analgesic intentionally, the low rate of serious effect is notable. Fewer adult patients who ingested ibuprofen were hospitalized or experienced a major effect as a result of their exposure than patients ingesting aspirin or acetaminophen. No deaths were reported in the ibuprofen group.

Shock, metabolic acidosis, and coma following ibuprofen overdose in a child

OBJECTIVE

To report a child who developed shock, loss of consciousness, and metabolic acidosis following an ibuprofen overdose.

CASE SUMMARY

A 6-year-old boy with no prior medical problems ingested approximately thirty 200-mg tablets of ibuprofen. The patient developed shock, coma, and metabolic acidosis. He was treated successfully with intubation and mechanical ventilation, fluid resuscitation, and decontamination with activated charcoal. The patient was discharged without any clinical sequelae.

DISCUSSION

Serious adverse complications following ibuprofen overdose have been reported rarely in children. We reviewed literature pertaining to the etiology, pharmacology, pathophysiology, and management of complications following ibuprofen overdoses, as well as other case reports.

CONCLUSIONS

Coma, metabolic acidosis, and shock were noted in a child who ingested a large quantity of ibuprofen. These complications have been described rarely in children. We attribute his favorable clinical outcome to early and aggressive intervention consisting of tracheal intubation, fluid resuscitation, and decontamination with activated charcoal. Although ibuprofen overdoses are usually benign, healthcare professionals should be aware of the various potentially serious complications that may occur.

Massive ibuprofen ingestion with survival

OBJECTIVE

To report a massive, 100 g ibuprofen ingestion in an adolescent, with survival.

CASE REPORT

The patient developed coma, metabolic acidosis, and mild thrombocytopenia, but improved rapidly with supportive care. Renal function remained normal and no gastrointestinal bleeding occurred.

CONCLUSIONS

Massive ingestion of ibuprofen may result in a variable picture with some elements of significant toxicity, but supportive care usually results in survival without sequelae.