Management of Ibuprofen Overdose
Ibuprofen overdose is generally benign and managed with supportive care alone, as serious toxicity is rare and no specific antidote exists. 1
Initial Risk Stratification by Dose
- Ingestions <100-104 mg/kg: Patients are unlikely to develop toxicity and typically remain asymptomatic 2, 1
- Ingestions >100-104 mg/kg: Monitor closely for potential toxic effects, though most patients still experience only mild symptoms 2
- Massive ingestions (>1,000 mg/kg): Rare but can cause severe toxicity including coma, metabolic acidosis, and renal failure 3, 4
Clinical Presentation and Timeline
Most patients who develop toxicity do so within 4 hours of ingestion. 2
Common manifestations (mild, 65-83% asymptomatic):
Severe manifestations (rare, <2% moderate-severe symptoms):
- Central nervous system: Depressed level of consciousness, coma 5, 3, 4
- Metabolic: Severe metabolic acidosis (with or without respiratory alkalosis), lactic acidosis 3, 4, 2
- Renal: Oliguric renal failure, polyuria (paradoxically), elevated creatinine 3, 4, 2
- Cardiovascular: Hemodynamic compromise, tachycardia 3, 2
- Respiratory: Apnea, respiratory failure 5, 2
- Gastrointestinal: Hematemesis, severe GI bleeding 2
Management Algorithm
1. Gastrointestinal Decontamination
- Activated charcoal: Consider if patient presents within 1-2 hours of ingestion and can protect airway 3
- Multi-dose activated charcoal: May be beneficial for sustained-release formulations in massive overdoses 3
- Do NOT induce vomiting 1
2. Supportive Care (Cornerstone of Treatment)
Airway protection and mechanical ventilation if loss of airway reflexes or respiratory failure develops 3, 4
Aggressive fluid resuscitation for hemodynamic compromise and to maintain renal perfusion 3, 4
Correction of metabolic acidosis:
- Intravenous sodium bicarbonate for severe acidosis 3
- Hemodialysis or hemofiltration for refractory acidosis unresponsive to bicarbonate 3
Monitor and support renal function:
3. Adjunctive Therapy
Naloxone trial: Consider in patients with unexplained CNS depression, as case reports suggest potential reversal of altered mental status 5
- This is based on limited evidence but may be attempted given its safety profile 5
4. Laboratory Monitoring
Obtain baseline and serial measurements:
- Serum ibuprofen concentration (therapeutic 5-49 mg/L; levels >700 mg/L associated with severe toxicity) 3, 4
- Complete metabolic panel including renal function 3, 4
- Arterial blood gas for acid-base status 3, 4, 2
- Lactate level 4
5. Observation Period
- Asymptomatic patients with ingestions <100 mg/kg: Observe for 4 hours; if no symptoms develop, medical clearance is appropriate 2, 1
- Symptomatic patients or larger ingestions: Admit for 24-48 hours of supportive care until symptoms resolve 5, 1
- Sustained-release formulations: Prolonged observation and monitoring may be required 3
Critical Pitfalls to Avoid
- Do not assume all overdoses are benign: While most are mild, severe toxicity with coma, acidosis, and renal failure can occur, particularly with massive ingestions 3, 4, 2
- Do not miss sustained-release formulations: These require prolonged monitoring and may benefit from multi-dose activated charcoal 3
- Do not delay supportive care: There is no specific antidote; aggressive supportive management is life-saving in severe cases 3, 4
- Do not overlook polyuria as a sign of toxicity: Paradoxical polyuria can occur alongside metabolic acidosis in massive overdoses 4
Prognosis
With aggressive supportive care, survival is expected even in massive overdoses with serum levels exceeding previously fatal concentrations. 4 Fatalities are extremely rare (only 7-9 reported cases) and typically involve complicating factors such as sustained-release formulations or delayed presentation 3, 1