Case 13 – Over the Counter

Case #13: Over the Counter
Author: Michael Gottlieb, MD
Peer Reviewer: Jenny Lu, MD

A 71 year old female with a past medical history of hypertension, peptic ulcer disease, osteoarthritis, and chronic low back pain presented to the ED with abdominal pain for the past day. The abdominal pain began early yesterday morning and was epigastric, sudden-onset, constant, sharp, 10/10, non-radiating and not improved/worsened/associated with any other factors. Review of systems also revealed increased bilateral knee and back pain for which she had been self-treating with a two or three over-the-counter (OTC) pain reliever pills every hour for the past two days. Physical exam is significant for abdominal tenderness worst in the epigastrium without rebound tenderness or guarding. Rectal exam revealed occult blood.

Vitals: Temp: 98.2, HR: 98, RR: 12, BP: 132/94, O2 sat: 97% on RA

What is the most likely etiology of this patient’s presentation?
Although there are multiple potential etiologies for this woman’s abdominal pain, her history of peptic ulcer disease (PUD) in conjunction with frequent use of OTC pain medications (most likely NSAIDs or aspirin) point to gastritis or PUD exacerbation. Both aspirin and NSAIDs are common causes of dyspepsia, gastritis, and gastric bleeding. In her case, she was determined to have taken 3 pills of Ibuprofen 200 mg every two hours for two days (significantly above the maximum recommended prescription dosing of 3200 mg per day).
What other clinical symptoms might you expect to see with this patient?
CNS: Headache, Cognitive and behavioral changes, Aseptic meningitis
CV: Increased risk of MI and post-MI sudden cardiac death (COX inhibition)
Pulmonary: Hypersensitivity pneumonitis, Bronchospasm, Pulmonary edema (NOTE: Avoid NSAIDs in asthmatics)
GI: Dyspepsia, Gastritis, Gastric and duodenal erosions, Mucosal bleeding, Gastric and duodenal perforations, Transaminitis, Hepatic injury
GU: Hyperkalemia, Acute kidney injury, Fluid and electrolyte retention, Pregnancy loss (associated with spontaneous abortions in 1st and 2nd trimesters and premature PDA closure in the 3rd trimester) (NOTE: Avoid in HF patients)
Hematology: Increased bleeding, Pancytopenia, Hemolytic anemia
Dermatology: Rashes, Photosensitivity, Toxic Epidermal Necrolysis
What is the initial management for this patient?
With NSAID overdose, treatment is predominately supportive. Don’t forget to consider concomitant acetaminophen toxicity. Also consider Multi-dose Activated Charcoal (MDAC) for massive ingestions.
What are some common drug interactions with NSAIDs?
Aminoglycosides: Increased risk of aminoglycoside toxicity
Anticoagulants: Increased risk of bleeding
Anti-hypertensives: Reduced anti-hypertensive efficacy
Digoxin: Increased risk of digoxin toxicity
Lithium: Increased risk of lithium toxicity
Sulfonylureas: Increased hyperglycemic effects
What is the disposition for these patients?
Symptomatic patients should be admitted to the appropriate inpatient area. Otherwise, most patients can be discharged with follow-up if they remain asymptomatic after 6 hours


Farkouh ME, Greenberg BP. An evidence-based review of the cardiovascular risks of nonsteroidal anti-inflammatory drugs. Am J Cardiol. 2009 May 1;103(9):1227-37.

Hall AH, Smolinske SC, Conrad FL, et al. Ibuprofen overdose: 126 cases. Ann Emerg Med. 1986 Nov;15(11):1308-13.

Kearney PM, Baigent C, Godwin J, et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ. 2006 Jun 3;332(7553):1302-8.

Kleinknecht D. Interstitial nephritis, the nephrotic syndrome, and chronic renal failure secondary to nonsteroidal anti-inflammatory drugs. Semin Nephrol. 1995 May;15(3):228-35.

Leuppi JD, Schnyder P, Hartmann K, et al. Drug-induced bronchospasm: analysis of 187 spontaneously reported cases. Respiration 2001; 68(4):345-51.

Moore RA, Derry S, Phillips CJ, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs), cyxlooxygenase-2 selective inhibitors (coxibs) and gastrointestinal harm: review of clinical trials and clinical practice. BMC Musculoskelet Disord. 2006 Oct 20;7:79.

Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994 Nov 10;331(19):1272-85.

Roujeau JC, Kelly JP, Naldi L, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995 Dec 14;333(24):1600-7.

Return to Case List