IN BRIEF
Management of Ibuprofen Overdose
Safety Profile: Fifteen Years of Clinic
Experience with Ibuprofen. Royer GL,
Seckman CE, Welshman IR. Am J Med.
1984;77:25–34
Ibuprofen Overdose in Adults. Hall AH,
Smolinske SC, Stove B, et al. J Clin
Toxicol. 1992;30:23–37
Ibuprofen Overdose: 126 Cases. Hall AH,
Smolinske SC, Conrad FL, et al. Ann
Emerg Med. 1986;15:1308 –1313
Acute Renal Insufficiency in Ibuprofen
Overdose. Kim J, Gazarian M, Verjee Z,
Johnson D. Pediatr Emerg Care. 1995;11:
107–108
Safety Profile: Fifteen Years of Clinical
Experience with Ibuprofen. Royer GL,
Seckman CE, Welshman IR. Am J Med.
1984;77:25–34
Ibuprofen has become one of the
most popular and widely used non-
steroidal anti-inflammatory drugs
(NSAIDs) since its introduction in
the United States in 1974. This
propionic acid derivative inhibits
prostaglandin synthesis and pos-
sesses both analgesic and antipyretic
properties. NSAIDs usually are
absorbed rapidly after oral adminis-
tration. Renal excretion usually is
the primary route of elimination.
Common side effects from NSAID
use usually are due to potent inhibi-
tion of prostaglandin synthesis.
These side effects include gastroin-
testinal (GI) irritation with dyspep-
sia, increased occult GI blood loss,
GI bleeding, and possible peptic
ulceration. All of these symptoms
can be alleviated with the adminis-
tration of nonabsorbable antacids
and food. Elevation of transaminase
levels as well as alkaline phospha-
tase also can occur.
Acute poisoning with NSAIDs
does not result in significant mor-
bidity and mortality, although seri-
ous toxicity (including reports of a
few deaths) has been documented.
Because ibuprofen has been increas-
ingly available over the counter, the
risk of overdose may be increased.
Overdose with ibuprofen usually
results in only mild symptoms, but
large overdoses (>400 mg/kg) are
Pediatrics in Review Vol. 18 No. 3 March 1997
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associated with more significant
complications.
Clinical findings associated with
major ibuprofen overdose include GI
symptoms such as anorexia, nausea,
vomiting, and epigastric pain. Neu-
rologic changes are seen as well and
include confusion, disorientation,
dizziness, drowsiness, seizures,
apnea, and stupor progressing to
coma. Examination may reveal
hyper- or hypothermia, abnormal
respirations ranging from hyperven-
tilation to respiratory depression,
hypotension, sinus tachycardia or
bradycardia, and abnormal neuro-
logic and neuromuscular activity
with ataxia, nystagmus, and seizure
activity. Subsequently, renal dys-
function with oliguria or anuria may
supervene, and clinical evidence of
bleeding due to hypoprothrombin-
emia and thrombocytopenia may
occur later. An elevated anion gap
metabolic acidosis can be seen fol-
lowing large ingestions.
Because there is a statistically
significant correlation between the
milligram-per-kilogram amount
ingested (by history) and the devel-
opment of symptoms in pediatric
patients, attention should be paid to
the exact quantity of ingestion of
ibuprofen and the approximate time
of ingestion. Initial laboratory stud-
ies should include a venous blood
gas, electrolyte levels, blood urea
nitrogen (BUN), creatinine, liver
function studies, and an ibuprofen
concentration obtained approxi-
mately 4 hours postingestion.
Ibuprofen levels should be plotted
on the ibuprofen nomogram, which
may aid in predicting which initially
asymptomatic patients are at risk of
becoming symptomatic later. Chil-
dren who have a history of ingesting
less than 100 mg/kg may be
observed at home. Those who
ingested 100 to 200 mg/kg should
have emesis induced at home and be
referred to a medical facility if
symptoms occur. Ingestions of 200
to 400 mg/kg require immediate
referral to a health care facility for
gastric emptying with administration
of activated charcoal and observa-
tion for at least 4 hours. Ingestions
of more than 400 mg/kg carry the
greatest risk for developing serious
symptoms and should be treated in
the hospital as an emergency.
Treatment of acute poisoning
with ibuprofen is the same as that
for all NSAID compounds. Respira-
tory depression may require ventila-
tory support, fluids and vasopressors
may be indicated for hypotension,
and hydration status should be mon-
itored closely. Gastric emptying
should be performed by emesis in a
conscious patient or by lavage in a
semiconscious patient who has a
protected airway. Effective gastric
emptying must be achieved within
several hours of ingestion because
peak drug levels occur within 2 to
3 hours. Because seizures can occur
in children ingesting ibuprofen,
inducing emesis should be consid-
ered carefully.
Activated charcoal at a dose of
1 g/kg also may be administered to
decrease absorption, along with a
cathartic. Close attention should be
paid to BUN and creatinine values
as well as to urine output. Seizures
usually are managed with lorazepam
or barbiturates. Alkaline diuresis
has not been reported to be a useful
procedure in ibuprofen overdose.
The remainder of therapy in
ibuprofen overdose is directed
toward specific clinical signs and
symptoms and generally is support-
ive. Ibuprofen overdose generally is
benign, but serious symptoms lead-
ing to death may develop.
Tina C. Zecca, DO
Chief Resident, Pediatrics
CHNJ and NJMS
Newark, NJ
107
 Management of Ibuprofen Overdose
Tina C. Zecca
Pediatrics in Review 1997;18;107
DOI: 10.1542/pir.18-3-107

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 Management of Ibuprofen Overdose
Tina C. Zecca
Pediatrics in Review 1997;18;107
DOI: 10.1542/pir.18-3-107

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/18/3/107

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
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Illinois, 60143. Copyright © 1997 by the American Academy of Pediatrics. All rights reserved.
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