Nonsteroidal Anti-inflammatory Drug (NSAID) Toxicity in Emergency Room
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Abstract
Nonsteroidal anti-inflammatory medicines, collectively referred to as NSAIDs in academic context, exhibit chemical diversity while concurrently manifesting comparable therapeutic and harmful effects. All pharmaceutical substances under this particular category function by diminishing inflammation, alleviating pain, and reducing fever by means of inhibiting enzymes responsible for the creation of endoperoxides, often referred to as cyclooxygenase (COX) enzymes. The two cyclooxygenase isozymes, COX-1 and COX-2, are responsible for the conversion of arachidonic acid into its endoperoxide metabolites. These metabolites include prostacyclin, prostaglandins, and thromboxane, each exhibiting a wide range of biological activities such as inflammation, regulation of smooth muscle tone, and promotion of thrombosis. The COX-1 enzyme is consistently produced and is recognized as the main provider of prostanoids required for maintaining physiological balance, such as safeguarding the stomach epithelium. In contrast, the COX-2 enzyme is capable of being induced, leading to a substantial increase in the synthesis of prostanoids in circumstances characterized by stress and inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) may induce toxicity via the same pharmacological mechanisms that contribute to their therapeutic efficacy. This review aims to discuss NSAIDs toxicity in details, its symptoms, and possible management in the emergency room.
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References
Morita I. Distinct functions of COX-1 and COX-2. Prostaglandins Other Lipid Mediat. 2002 Aug;68-69:165-75.
Saad J. Nonsteroidal Anti-Inflammatory Drugs Toxicity. StatPearls - NCBI Bookshelf. Published July 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK526006/
Phillips WJ, Currier BL. Analgesic pharmacology: II. Specific analgesics. J Am Acad Orthop Surg. 2004 Jul-Aug;12(4):221-33.
Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006 Aug;108(2):428-41.
Shekelle PG, Newberry SJ, FitzGerald JD, Motala A, O'Hanlon CE, Tariq A, Okunogbe A, Han D, Shanman R. Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Jan 03;166(1):37-51.
Oyler DR, Parli SE, Bernard AC, Chang PK, Procter LD, Harned ME. Nonopioid management of acute pain associated with trauma: Focus on pharmacologic options. J Trauma Acute Care Surg. 2015 Sep;79(3):475-83.
Zacher J, Altman R, Bellamy N, Brühlmann P, Da Silva J, Huskisson E, Taylor RS. Topical diclofenac and its role in pain and inflammation: an evidence-based review. Curr Med Res Opin. 2008 Apr;24(4):925-50.
van den Bekerom MPJ, Sjer A, Somford MP, Bulstra GH, Struijs PAA, Kerkhoffs GMMJ. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events. Knee Surg Sports Traumatol Arthrosc. 2015 Aug;23(8):2390-2399.
May JJ, Lovell G, Hopkins WG. Effectiveness of 1% diclofenac gel in the treatment of wrist extensor tenosynovitis in long distance kayakers. J Sci Med Sport. 2007 Feb;10(1):59-65.
Barkin RL. Topical Nonsteroidal Anti-Inflammatory Drugs: The Importance of Drug, Delivery, and Therapeutic Outcome. Am J Ther. 2015 Sep-Oct;22(5):388-407.
Davis JS, Lee HY, Kim J, Advani SM, Peng HL, Banfield E, Hawk ET, Chang S, Frazier-Wood AC. Use of non-steroidal anti-inflammatory drugs in US adults: changes over time and by demographic. Open Heart. 2017;4(1):e000550.
Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, Farrar K, Park BK, Breckenridge AM. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ. 2004 Jul 03;329(7456):15-9.
Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report [published correction appears in Clin Toxicol (Phila). 2014 Dec;52(10):1284]. Clin Toxicol (Phila). 2010;48(10):979-1178. doi:10.3109/15563650.2010.543906
NPIS Annual Report 2009/2010 and Five Year Review. Available at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1284474775986. Accessed April 25, 2011.
Rothenberg RJ, Holcomb JP. Guidelines for Monitoring of NSAIDS: Who Listened? J Clin Rheumatol. 2000 Oct;6(5):258-65
Hunter LJ, Wood DM, Dargan PI. The patterns of toxicity and management of acute nonsteroidal anti-inflammatory drug (NSAID) overdose. Open Access Emerg Med. 2011;3:39-48.
Johnson JM. Over-the-counter overdoses: A review of ibuprofen, acetaminophen, and aspirin toxicity in adults. Adv Emerg Nurs J. 2008;30(4):369-378.
Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS. Goldfrank’s Toxicologic Emergencies. 8th ed. New York: McGraw Hill; 2006.
Mannix R, Ewald MB. Toxicity of Over-the-Counter and Oral Hypoglycemic Agents. Elsevier eBooks. doi:10.1016/b978-032303004-5.50183-6.
Hörl WH. Nonsteroidal Anti-Inflammatory Drugs and the Kidney. Pharmaceuticals (Basel). 2010;3(7):2291-2321. Published 2010 Jul 21. doi:10.3390/ph3072291
Brubaker RH, Vashisht R, Meseeha M. High anion gap metabolic acidosis. In: StatPearls [Internet]. StatPearls Publishing; 2023.
Wiegand TJ. Nonsteroidal Anti-inflammatory Drug (NSAID) Toxicity Clinical Presentation: History, Physical Examination. https://emedicine.medscape.com/article/816117-clinical#?form=fpf
Sostres C, Gargallo CJ, Arroyo MT, Lanas A. Adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2010 Apr;24(2):121-32.
Varga Z, Sabzwari SRA, Vargova V. Cardiovascular Risk of Nonsteroidal Anti-Inflammatory Drugs: An Under-Recognized Public Health Issue. Cureus. 2017 Apr 08;9(4):e1144.
Wongrakpanich S, Wongrakpanich A, Melhado K, Rangaswami J. A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in The Elderly. Aging Dis. 2018 Feb;9(1):143-150.
Moore N, Pollack C, Butkerait P. Adverse drug reactions and drug-drug interactions with over-the-counter NSAIDs. Ther Clin Risk Manag. 2015;11:1061-75.
Levy ZD. Exam 4 Questions. Absolute Neurocritical Care Review. 2017;143-188. Published 2017 Sep 5. doi:10.1007/978-3-319-64632-9_4
Zyoud SH, Al-Jabi SW, Bali YI, Al-Sayed AM, Sweileh WM, Awang R. Availability of treatment resources for the management of acute toxic exposures and poisonings in emergency departments among various types of hospitals in Palestine: a cross-sectional study. Scand J Trauma Resusc Emerg Med. 2014;22:13. Published 2014 Feb 21. doi:10.1186/1757-7241-22-13
Höjer J, Troutman WG, Hoppu K, et al. Position paper update: ipecac syrup for gastrointestinal decontamination. Clin Toxicol (Phila). 2013;51(3):134-139. doi:10.3109/15563650.2013.770153
Nogi K, Shiraishi A, Yamamoto R, et al. Intermittent Hemodialysis for Managing Metabolic Acidosis During Resuscitation of Septic Shock: A Descriptive Study. Crit Care Explor. 2019;1(12):e0065. Published 2019 Dec 10. doi:10.1097/CCE.0000000000000065
Marciniak KE, Thomas IH, Brogan TV, Roberts JS, Czaja A, Mazor SS. Massive ibuprofen overdose requiring extracorporeal membrane oxygenation for cardiovascular support. Pediatr Crit Care Med. 2007;8(2):180-182. doi:10.1097/01.PCC.0000257036.26436.42
Rostom A, Muir K, Dube C, Lanas A, Jolicoeur E, Tugwell P. Prevention of NSAID-related upper gastrointestinal toxicity: a meta-analysis of traditional NSAIDs with gastroprotection and COX-2 inhibitors. Drug Healthc Patient Saf. 2009;1:47-71. doi:10.2147/dhps.s4334
Sohail R, Mathew M, Patel KK, et al. Effects of Non-steroidal Anti-inflammatory Drugs (NSAIDs) and Gastroprotective NSAIDs on the Gastrointestinal Tract: A Narrative Review. Cureus. 2023;15(4):e37080. Published 2023 Apr 3. doi:10.7759/cureus.37080