University of Texas Health Science Center at Houston Houston, Texas, United States
Background/Case Studies: Numerous case studies describe the use of apheresis procedures in the treatment of various drug overdoses, poisonings, and toxin removal. Based on the American Society for Apheresis (ASFA) guidelines, it is a category III indication of therapeutic plasma exchange (TPE). Massive overdose of ibuprofen is an uncommon occurrence, despite its widespread use in the management of reducing pain and inflammation. Ibuprofen also has characteristics that make it amenable to successful removal with TPE, including high protein binding and low volume of distribution. Herein, we describe a unique case report highlighting the potential role of plasma exchange in the management of severe ibuprofen overdose.
Study
Design/Methods: A 17-year-old male with a medical history of anxiety and depression presented with intentional ingestion of 500 tablets of 200 mg ibuprofen. Prior to arrival, he received activated charcoal and was intubated due to hypotension and risk of respiratory failure/airway compromise due to altered mental status at an outside hospital. On presentation, he had a blood pressure of 111/53, heart rate of 116 beats per minute, temperature of 35.8°C, and a respiratory rate of 26 breaths per minute. He was admitted to the pediatric intensive care unit for monitoring and management to prevent further decompensation. Continuous renal replacement therapy (CRRT) was initiated for severe metabolic acidosis and acute renal failure. A trial of TPE was attempted, and one plasma volume was exchanged for a single procedure using fresh frozen plasma as the replacement fluid.
Results/Findings: Serum ibuprofen level decreased from 860 mcg/mL to 470 mcg/mL. He developed gastrointestinal hemorrhage requiring resuscitation and vasopressors, with subsequent interventional radiology embolization of the left gastric artery and gastroepiploic artery 24 hours after presentation. The next day, the patient’s hemodynamic status improved. CRRT and vasopressors were discontinued 48 hours after initial presentation. He was extubated 5 days after the initial presentation. Table 1 summarizes his clinical improvement, including his coagulation profile, liver function tests, and renal function tests pre- and post-therapeutic plasma exchange procedure. Conclusions: Therapeutic plasma exchange has proven to be effective and safe in reducing plasma levels of protein-bound medications like ibuprofen. It can also be a lifesaving management option, especially in the setting of massive drug overdose with severe clinical presentation. Very early initiation of the treatment (within the first 24-48 hours of exposure) is recommended, and the number of procedures depends on the observed improvement of the clinical picture.
