A Man Took 1176 Ibuprofen Tablets In A Month.
This Is What Happened To His Kidneys.
SB is a 34 year old man, presenting to the emergency room with dizziness, muscle aches,
and fatigue.
He tells the admitting nurse that over the last few days, when he would use the bathroom,
he’d glance back into the toilet, and it would look like asphalt.
SB loved running, but sometimes his body would just hurt.
Must be getting too old, he thought.
One day, while he was running he felt like his shin splints had returned.
It hurt to put any pressure on his legs.
Ibuprofen was always his go to when he thought he was sick or in pain.
It’s over the counter.
People take aspirin every day and it’s basically the same medicine, it even comes in 1000 tablet
packs.
Clearly, you’re supposed to finish the whole pack of medicine for a full course, otherwise
why would they sell it like this? he thought, as he followed the label and took 6 tablets
every 24 hours with an extra one just for good measure.
At first, he would spread out the doses like the bottle said, but eventually, that was
too cumbersome, so he’d take all 7 tablets at once.
And nothing bad happened.
He felt great.
He wasn’t sure if his legs actually hurt anymore, but gotta finish that whole course,
he thought.
One night, SB had forgotten he had taken 7 ibuprofen in the morning.
He had also forgotten he took another 7 at lunch time.
And he forgotten he had taken 7 at dinner, as he put another 7 tablets into his mouth,
for a total of 28 in a single day.
As he swallowed, he felt that THESE tablets didn’t go all the way down.
It felt like they were somehow stuck in his chest.
This isn’t something to worry about, it’ll all take care of itself, he thought, as he
went to bed.
But a few hours later at 3am, SB jumped awake.
Just under his chest was a terrible feeling, like a sharp object had plunged in and started twisting.
He wasn’t sure if it was heartburn, but as the night continued, it did start to go
away.
When he woke up, he wasn't sure if he was alright, but Ibuprofen is a pain reliever
and he had pain during the night, so the answer here was to take more.
"How does ibuprofen know where the pain is?"
he thought, as he went on like this for several days, consuming all 1000 tablets, and then
he bought more.
But then SB noticed that he had difficulty swallowing.
It felt like something was in his chest but he didn't know what.
He noticed that his stools were darker than normal, almost looking like asphalt.
His stomach would start to hurt like it did that night.
He'd burp, and it’d hurt and taste like blood.
One morning, SB felt especially weak.
He thought it was kind of weird how every time he went to urinate, the volume was so
much less than the amount of liquid he drank.
He felt like he had the flu, but he checked and he didn't have a fever.
As he stumbled into the bathroom, he looked in the mirror.
He knew he was supposed to be looking at himself, but something didn’t look right.
And as he burped, what came up was blood, as he calls for 911 and he’s brought to
the emergency room where we are now.
At examination, there were several clues to tell the medical team what was happening,
because they had no idea of SB’s ibuprofen excess.
He didn't tell them about it because he didn't think it was a problem.
SB’s skin was pale and he had tachycardia.
Tachy- meaning fast and cardia referring to heart rate.
His heart rate was fast, but he also had orthostatic hypotension.
Ortho from Ancient Greek referring to straight or upright.
Static also from Ancient Greek meaning fixed in place but in this context referring to
standing.
Hypo meaning low and tension referring to blood pressure.
His blood pressure would suddenly decrease when he stood up.
But why was this happening?
SB told them about his hematemesis.
That his stools looked like asphalt.
Both of these suggest that blood somehow got in to his GI tract and was digested.
His hemodynamic instability appears to be consistent with blood loss-- his tachycardia
was his heart beating faster to compensate for less blood volume.
And when he stood up, there just wasn’t enough blood volume to keep his pressure normal.
Clearly, SB has been suffering from blood loss due to a GI bleed, but why was this happening?
This brings us to a concept called dissolution.
When you take a tablet or capsule by mouth, it has to get into the stomach so it can dissolve
and absorb into the bloodstream.
Do you remember that SB took some tablets and felt like they didn't go down all the
way?
Well, sometimes, solid medicines taken by mouth go into the esophagus, and they just
stay there.
Most of the time this shouldn’t be a problem.
The smooth muscle will get it down by a movement called peristalsis and tablets and capsules
usually slide down when wet.
Labels will often say take with a whole glass of water so you can wash it down, or that
you should take the medicine with food, something that will push it into the stomach, but SB
didn’t do that.
He went right to bed, and laid down.
The tablets that he swallowed that night stuck against his esophageal mucosa and made contact
for some time.
But that’s only the start of his problems.
Ibuprofen is a Non-steroidal anti-inflammatory medicine.
Some times, the "steroid" name confuses people because it makes us think of ANABOLIC steroids
in bodybuilding and sports.
Much more commonly in medicine, we use corticosteroids as an anti-inflammatory.
Inflammation is the immune system response to physical injury and infection to protect
the body, but sometimes inflammation goes too far.
It causes swelling when you don’t want swelling.
It causes fever, when you don’t want fever like for young children where high body temperatures
can impact their brain.
And inflammation can cause pain, so anti-inflammatory medicines stop all these from happening.
Corticosteroids are based off of cortisol, which is a hormone naturally produced in our
bodies to limit inflammation.
Whenever you see a mention of hormones, know that they are chemical messengers in the body
and that they’re subject to natural feedback mechanisms in order to limit their function
and maintain balance in the body.
Hormone feedback can be exceptionally difficult to manage, but ibuprofen is non-steroidal.
It works in an entirely different way, which is a benefit at therapeutic doses.
But SB didn't take a therapeutic dose, he repeatedly took a toxic one over a month and
this starts to explain all of his problems.
Doctors send a camera down his throat to take a look at his GI tract, and they find ulcers
in his esophagus and his stomach.
These look like the canker sores in your mouth you sometimes get, except for SB, doctors
noticed that his ulcers were bleeding.
They found the source of his blood loss, but why is this happening?
This brings us back to the name "non-steroidal anti inflammatory medicine."
Steroids work very generally in humans, sending signals right to the immune system.
But NSAIDS like ibuprofen, work very specifically.
Inside almost every cell in the body is the enzyme cyclo-oxygenase.
When you get tissue damage like a cut, cyclo-oxygenase makes a chemical called prostaglandin, and
that draws the immune system in.
Ibuprofen stops cyclooxygenase from working, so prostaglandin isn’t produced, and the
immune system doesn’t react.
This should be ok, except prostaglandin does more than just draw the immune system in.
In the GI tract, it helps inhibit stomach acid secretion.
It stimulates mucus production, and helps with blood flow in the inner lining.
This explains why SB has ulcers, and why they’re bleeding, because not only was ibuprofen physically
stuck to the inner lining of his esophagus during that one night, he had also been taking
huge amounts of ibuprofen for so many days that there were no prostaglandins, and other
ulcers formed, and worsened, and started to bleed.
While the doctors had the camera down SB’s throat, they were able to stop the bleed by
cauterizing the ulcers, that’s applying temperature to seal the wounds so that they
wouldn’t bleed anymore.
But this wasn’t his only problem.
When he presented to the emergency room, SB told the medical team that he was noticeably
urinating a lot less than normal.
When he was admitted, a blood test found that his kidneys weren’t functioning properly,
and when his ulcers were cauterized, another blood test finds that his kidneys have completely
shut down.
But this shouldn’t be surprising, bringing us back to prostaglandins.
We already established that prostaglandins promote inflammation and pain.
We also know that prostaglandins help secrete the protective layer in the GI tract.
In the kidneys, prostaglandins open up blood vessels flowing in.
Because prostaglandins aren’t made anymore for SB due to his mass ingestion of ibuprofen,
blood cant get in to be filtered.
Blood also can’t get in to supply oxygen.
As SB’s kidneys become starved of oxygen, parts of both start to necrose.
And this had been going on for at least a few days before he presented to the emergency
room because of the sheer amount of ibuprofen that he was taking daily.
Do you remember SB thought that his ibuprofen was just like taking daily aspirin?
Well, he was right in that they’re both NSAIDS.
But, daily aspirin is 25% of a full dose of aspirin, whereas SB was taking overdose amounts
of ibuprofen every day.
The dose makes the poison, but there’s also the element of time.
Ibuprofen tablets take about 2 hours to go from the stomach into the blood.
This brings us to an idea called half life.
When medicine is circulating in the body, some of it makes its way into the liver, where
it’s broken down or metabolized.
Half life is the amount of time it takes for the drug level in blood to be cut in half,
and for ibuprofen, it’s 2 hours.
Because he took 7 tablets 4 times every day, the ibuprofen levels in his blood remained
abnormally high for a very long time.
It caused injury to the point of bleeding inside his stomach and his esophagus.
The blood loss caused his heart to become unstable.
It constricted blood vessels going in to his kidneys, preventing them from functioning
and causing parts of them to start to die.
This almost never happens at regular doses.
Over the counter medicines can be dangerous when misused like this.
It doesn’t help that some of these medicines are sold in large bulk packaging, occasionally
being misinterpreted by people as designed for a single course of medicine.
The label on the package will always tell you how to take it.
When used properly, NSAIDS are effective antiinflammatories.
Ibuprofen is generally more effective as an analgesic, an meaning without and -algesia
referring to pain, compared to aspirin.
Blood clotting is a kind of inflammation and platelets are a kind of blood cell that are
responsible for clotting, and they also have cyclooxygenase.
Aspirin is better at working with clots than ibuprofen because it irreversibly stops platelet
cyclooxygenase, unlike ibuprofen which is reversible, so not as effective.
The GI side effects of NSAIDS are so well known that you find things like enteric coated
aspirin, which helps limit contact with stomach and esophageal mucosa, and also liquid gel
caps, which don’t need time for dissolution in the stomach, they can dump a liquid bolus,
quickly absorbed.
And generally these medicines aren’t as common for fever because of their known GI
and kidney side effects, for fever, you usually take acetaminophen [paracetamol], which can
still be misused, but has a high therapeutic index.
This brings us to another concept called drug resistance.
Sometimes you’re told if you take ibuprofen for headache too often, it will eventually
just not work for you anymore.
That’s not true.
It’s not an antibiotic where you’re pitting drug therapy against a live organism and the
organism evolves to evade the medicine.
It’s also not a habit forming medicine based off of this plant, which can create a dependency
based on the body adapting to it.
If you’re taking NSAID for pain spread out through a couple times a month, theres no
rebound feedback mechanism, or adaptation in the body that will limit its efficacy.
I had to explain that to my own parents, because they used to scare me out of taking headache
medicine when I was a kid.
And the topic of NSAIDS can go on forever.
In the context of cyclooxygenase, theres multiple isoforms of it, and we’ve found
medicines that inhibit only COX-2 instead of COX-1 for pain, and interestingly enough
one of them is named “celecoxib,” “selective COX inhibitor,” and it’s analgesic without
prominent GI side effects bringing us back to SB.
In the hospital, the medical team infused water through his body to rehydrate him and
to get flow back through his kidneys.
His bleeding ulcers were fixed, and the waste that was floating around in his blood because
his kidneys had shut down was managed.
Without knowing his baseline kidney function before he took all the ibuprofen, it’s not
known by how much exactly his kidney function decreased, or how permanent any damage done
might be.
But when the time arrived, massive urination preceded him being discharged from the hospital,
as he was able to make a recovery.
This case was referred to me from a Chinese question and answer website, asking if ibuprofen
really does come in 1000 tablet packs in the United States.
Every situation described in this video is one that I have seen myself, relating to NSAID
misuse, which unfortunately is common.
There’s other situations I didn't describe here, like patients taking multiple prescription
NSAIDs because they saw different primary care, and no one knows that the patient is
doubling up or tripling up their care.
So please do your best to be aware of what medicines you’re taking, how much you’re
taking, and how often you’re taking them and please try to stick with the instructions
that are on the package label.
Thanks so much for watching.
Take care of yourself and be well.