NSAIDs Toxicity


Classes of Nonsteroidal Agents Available in the U.S.
Class & Agent Half-Life with Therapeutic Doses of Standard PO Tablets or Capsules*(hrs)
Nonselective NSAIDs
Salicylates  
Aspirin 3
Diflunisal 8-12
Salsalate 16
Acetic acids  
Diclofenac 2
Indomethacin 4-5
Ketorolac 5
Meclofenamate 1–2 (15)
Mefenamic acid 2
Nabumetone <1 (22-26)
Sulindac 8 (16)
Tolmetin 5
Propionic acids  
Fenoprofen 3
Flurbiprofen 6-8
Ibuprofen 2
Ketoprofen 2-4
Naproxen 12-17
Oxaprozin 16-45 (38-57)
Pyrazolones  
Phenylbutazone 72
Oxicams  
Piroxicam 50
Partially selective COX-2 inhibitors
Etodolac 6-8
Meloxicam 20-24
Selective COX-2 inhibitors
Celecoxib 11
Rofecoxib 17
Valdecoxib 8-11


 

MECHANISM/TOXICITY

SYMPTOMS/EXAM


NSAID Toxicity with Therapeutic Doses:
Organ System Clinical Toxicity
Central nervous system Headache, cognitive difficulties, behavioral changes, acute psychosis, aseptic meningitis
Pulmonary Hypersensitivity pneumonitis, bronchospasm, pulmonary edema
GI Dyspepsia,* gastritis, gastric and duodenal erosions, mucosal bleeding,* gastric and duodenal perforation
Cardiac Increased risk of myocardial infarction, increased risk of sudden death following a myocardial infarction
Hepatic Spectrum of hepatic injury, from asymptomatic elevation in serum transaminases to fulminant liver failure
Renal Sodium and water retention,* hyperkalemia, mild azotemia,* renal failure
Hematologic Increased risk of bleeding secondary to platelet inhibition, bone marrow suppression, aplastic anemia, agranulocytosis, thrombocytopenia, renal cell aplasia, hemolytic anemia
Dermatologic Maculopapular rashes, toxic epidermal necrolysis, photosensitivity reactions
Reproductive system Slow uterine contractions, stimulate premature closure of ductus arteriosus, fetal intracranial hemorrhage, necrotizing enterocolitis, oligohydramnios, and renal dysfunction

 
NSAID Toxicity after an Acute Overdose:
Initial symptoms within 4 h after ingestion Abdominal pain, nausea, vomiting
Central nervous system Headache, nystagmus, diplopia, altered mental status, coma, muscle twitching, and seizures (mefenamic acid)
Cardiovascular Hypotension, shock, bradydysrhythmia
Electrolyte Hyperkalemia, hypocalcemia, hypomagnesemia
GI and hepatic Continued abdominal pain, nausea, vomiting, hepatic injury, pancreatitis (rare)
Renal Renal insufficiency

 

DIAGNOSIS

TREATMENT

 

DISOPSITION AND FOLLOW-UP