Nonsteroidal antiinflammatory drug (NSAID) poisoning
- Mark Su, MD, MPH
Mark Su, MD, MPH
- Clinical Associate Professor of Emergency Medicine
- New York University School of Medicine
- Arun Nagdev, MD
Arun Nagdev, MD
- Medicine Director, Emergency Ultrasound
- Highland General Hospital
- Assistant Clinical Professor
- University of California, San Francisco
- Section Editor
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Millions of people worldwide take nonsteroidal antiinflammatory drugs (NSAIDs) on a regular basis to treat pain and inflammation. Patients with an acute overdose of NSAIDs often present to emergency departments and represent a sizable percentage of cases reported to regional poison centers . As aging populations have increasingly come to rely on NSAIDs, chronic toxicity and acute poisonings have become more commonplace. Given the relative frequency of toxic NSAID exposures, emergency and primary care clinicians need to understand the diagnosis and management of this poisoning.
Acute NSAID poisoning is reviewed here. A summary table to facilitate emergent management is provided (table 1). A general approach to suspected drug intoxication and discussions of chronic NSAID toxicity are provided elsewhere. (See "General approach to drug poisoning in adults" and "Nonselective NSAIDs: Overview of adverse effects".)
NSAIDs are competitive inhibitors of the enzyme cyclooxygenase (COX) (figure 1). NSAIDs prevent COX-mediated production of prostaglandins and thromboxanes but not leukotrienes and other eicosanoids. (See "NSAIDs: Pharmacology and mechanism of action".)
There are two COX isoforms, COX-1 and COX-2. The constitutive enzyme, COX-1, is expressed in most tissues and enables regulation of basal cellular homeostasis (platelet function, gastric mucosal integrity, and regulation of renal blood flow). The activity of the inducible COX-2 isoenzyme increases in inflammatory and pain states .
Numerous animal and human studies have demonstrated the role of COX-1 in inflammation [3,4]. In general, all NSAIDs inhibit both isoforms, with most adverse reactions believed to be attributable to COX-1 inhibition. The development of newer COX-2 selective NSAIDs arose from the desire to maintain therapeutic antiinflammatory function, while decreasing the rates of adverse drug effects, most notably gastrointestinal and renal toxicity. (See "Nonselective NSAIDs: Overview of adverse effects".)
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- HISTORY AND PHYSICAL EXAMINATION
- CLINICAL ASPECTS OF ACUTE TOXICITY
- Acid base abnormalities
- Acute renal failure
- Cardiovascular toxicity
- Central nervous system toxicity
- Hematological toxicity
- Allergic reactions
- LABORATORY EVALUATION
- General diagnostic testing
- Testing for NSAID toxicity
- DIFFERENTIAL DIAGNOSIS
- MANAGEMENT OF ACUTE TOXICITY
- Airway, breathing, circulation
- Gastrointestinal decontamination
- Other supportive measures
- Extracorporeal removal
- Patient disposition
- CHRONIC TOXICITY
- ADDITIONAL RESOURCES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS