NSAID Overdose – Treatment
Inflammatory, Substance Use, Toxicology
Nonsteroidal anti-inflammatories (NSAIDs) are commonly used for pain management, inflammation, and fevers. Given the widespread availability, overdose is common.
NSAID overdose can cause nephrotoxicity, gastrointestinal toxicity, neurological toxicity, hematological abnormalities, or biochemical abnormalities and needs to be managed appropriately in an ED setting.
Ingestions of less than 100mg/kg are unlikely to result in toxicity whereas ingestions greater than 400mg/kg have a significant risk for toxicity.
Patients with minor overdoses experience mild gastrointestinal symptoms which are self-limiting. There is no antidote for NSAIDs. Treatment in patients who are symptomatic is supportive. Patients who have ingested NSAIDs within 1-2 hours of presentation may be administered activated charcoal in cases of large ingestions or if symptomatic.
- Monitor for a minimum of 4 hours in patients who ingested a standard release preparation.
- Monitor for a minimum of 8 hours in patients who ingested a sustained-release preparation.
- Lab investigations include CBC, INR/PTT, electrolytes, renal function, liver function, and acid-base status
- Consider screening for coingestants.
- Ensure an adequate airway, breathing, and circulation in patients with more severe presentations that include mental status changes or unstable vital signs.
- Patients may require intubation or IV fluids.
- Significant vomiting –IV fluid rehydration.
- Persistent or severe nausea and vomiting – anti-emetics.
- Persistent upper gastrointestinal symptoms that do not settle after a few hours of ingestion – proton pump inhibitor (7-day course).
- Patients with poor renal function or persistent acidosis despite medical management – hemodialysis or hemofiltration.
- Metabolic acidosis that is unresponsive to fluid resuscitation- IV sodium bicarbonate 1 ml/kg 8.4% solution.
- Correct electrolyte abnormalities
- Seizures that do not terminate spontaneously within 1-2 minutes – IV benzodiazepines.
- Diazepam10-20 mg in adults, 0.1-0.3 mg/kg body weight in children.
- Lorazepam4 mg in adults, 0.1 mg/kg in children.
Criteria For Hospital Admission
- Severe symptoms – mental status change, renal dysfunction, severe acidosis.
- Patients who are suicidal.
- Large amounts of sustained-release NSAIDs ingested (>6 g in adults, 400 mg/kg in children).
Criteria For Close Observation And/or Consult
- Assess for suicide risk and co-ingestion in patients with intentional overdoses.
- A longer observation period may be required for NSAIDs with a longer half-life.
Criteria For Safe Discharge Home
- Asymptomatic with normal vital signs – can be after a 4- to 6-hour observation period in children who have ingested less than 100 mg/kg.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Monitor for a minimum of 4 hours in patients who ingested a standard release preparation of NSAIDs.
Monitor for a minimum of 8 hours in patients who ingested a sustained release preparation of NSAIDs.
Activated charcoal can be administered in cases of large ingestions of NSAIDs or if symptomatic, presenting within 1-2 hours of ingestion.
Nonsteroidal Anti-Inflammatory Drugs and Colchicine.
de Olano J, Biary R, Ng PC, Koyfman A, Long B. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020. Accessed January 9, 2022.
Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose.
Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, Chan WL, Smith SW, Olson KR, Gosselin S. 2021; 59(12): 1196-1227. Accessed Jan 17, 2022.
– Clinical Toxicology Journal | Tandf on line
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 25, 2022
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