Ibuprofen Contraindications and Precautions
- coronary artery bypass graft surgery (CABG)
- NSAID hypersensitivity
- salicylate hypersensitivity
- acute bronchospasm
- acute myocardial infarction
- alcoholism
- anemia
- angina
- anticoagulant therapy
- asthma
- bone marrow suppression
- breast-feeding
- cardiac arrhythmias
- cardiac disease
- cerebrovascular disease
- chemotherapy
- coagulopathy
- coronary artery disease
- corticosteroid therapy
- dental disease
- dental work
- diabetes mellitus
- edema
- elderly
- GI bleeding
- GI disease
- heart failure
- hematological disease
- hemophilia
- hepatic disease
- hypertension
- immunosuppression
- intramuscular injections
- jaundice
- labor
- myocardial infarction
- nasal polyps
- neutropenia
- peptic ulcer disease
- peripheral vascular disease
- pregnancy
- renal disease
- renal failure
- renal impairment
- rheumatoid arthritis
- stroke
- surgery
- systemic lupus erythematosus (SLE)
- tachycardia
- thrombocytopenia
- tobacco smoking
- ulcerative colitis
- urticaria
- varicella
Ibuprofen Contraindications and Precautions
Cautious use of ibuprofen is recommended in patients with asthma. Of 100 children 6 - 18 years of age with mild or moderate persistent asthma, 2% experienced a drop in forced expiratory volume in 1 second (FEV1) of more than 20% and 4% experienced a FEV1 decrease of greater than 15% within 1 hour of ibuprofen ingestion. None of these children had exposure to ibuprofen prior to the study, and none experienced a decline in lung function after placebo. Ibuprofen is contraindicated in patients with salicylate hypersensitivity or NSAID hypersensitivity who have experienced asthma, urticaria, or other allergic reactions after taking aspirin or other NSAIDs. Severe, rarely fatal, anaphylactoid reactions to ibuprofen have been reported in such patients. Ibuprofen should not be used in patients with aspirin-sensitive asthma or the aspirin triad because of the approximate 5% cross-sensitivity that occurs between aspirin and NSAIDs. The triad typically occurs in patients with asthma who experience rhinitis with or without nasal polyps, or who experience severe, potentially fatal acute bronchospasm after taking aspirin or other NSAIDs. The use of NSAIDs, including ibuprofen, may cause serious and potentially fatal skin reactions including exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Patients should be instructed to discontinue the medication and contact their health care provider if erythema, rash, blisters, or related skin reactions develop.
Chronic use of ibuprofen can result in gastritis, ulceration with or without perforation, and/or GI bleeding, which can occur at any time, often without preceding symptoms. Therefore, ibuprofen is relatively contraindicated in patients with a history of or active GI disease including peptic ulcer disease and ulcerative colitis. Patients with a prior history of peptic ulcer disease or GI bleeding who use NSAIDs have a greater than 10-fold increased risk for developing a GI bleed compared to patients with neither of these risk factors. It is recommended not to initiate therapy with maximum doses in these patients due to the likely increased frequency of adverse reactions. Patients at increased risk for NSAID-induced GI bleeding include those receiving concurrent myelosuppressive chemotherapy, corticosteroid therapy, or anticoagulant therapy, tobacco smoking patients, the elderly, and patients with alcoholism. Patients should not self-medicate with ibuprofen if they consume 3 or more alcoholic beverages per day. All patients receiving prolonged treatment should be routinely monitored for potential GI ulceration and bleeding (see Adverse Reactions). Consider therapies besides NSAIDs for high risk patients.
Ibuprofen should be used with caution in patients with hepatic disease. Severe hepatic reactions have occurred during treatment with ibuprofen, and patients with hepatic impairment are at an increased risk for developing these complications. The half-life of ibuprofen is prolonged in patients with severe cirrhosis; however, specific dosage adjustment guidelines are not available. Ibuprofen should be discontinued if elevated hepatic enzymes persist or worsen, or if signs or symptoms of hepatic disease, such as jaundice, develop (see Adverse Reactions).
Due to the role of prostaglandins in renal function and hemodynamics, patients with renal disease should be closely observed during therapy with ibuprofen due to an increased risk for adverse reactions during treatment. Conditions such as congestive heart failure or hypertension can be exacerbated with ibuprofen. Dosage adjustment may be necessary. Meta-analysis have demonstrated that the effect of NSAIDs on blood pressure is the greatest in hypertensive individuals receiving antihypertensive medication. In addition, normotensive patients receiving antihypertensive therapy had higher increases in blood pressure than subjects with uncontrolled hypertension or normotensive subjects receiving no hypertensive therapy. Patients with renal impairment, renal failure, hepatic disease, diabetes mellitus, systemic lupus erythematosus (SLE), or congestive heart failure, rheumatoid arthritis, edema, extracellular volume depletion (i.e., hypovolemia or dehydration), sepsis; those taking diuretics or nephrotoxic drugs; and the elderly are at the highest risk for complications related to suboptimal renal perfusion.
Ibuprofen, like all NSAIDs, may exacerbate hypertension and congestive heart failure (see Adverse Reactions) and may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. The risk may increase with duration of use, and patients with cardiovascular disease or risk factors for cardiovascular disease (e.g., high blood pressure) may be at greater risk. Caution is recommended when administering ibuprofen to patients with cardiac disease, cardiomyopathy, cardiac arrhythmias (e.g., tachycardia), significant coronary artery disease (including acute myocardial infarction, angina, or history of myocardial infarction), peripheral vascular disease, cerebrovascular disease (e.g., stroke, transient ischemic attack), hypertension, pre-existing renal disease, fluid retention, or edema. Use the lowest effective dose for the shortest duration possible to minimize the potential risk for an adverse cardiovascular event.
Ibuprofen should be used cautiously in patients with preexisting hematological disease (e.g., coagulopathy or hemophilia) or thrombocytopenia due to the effect of the drug on platelet function and vascular response to bleeding. Ibuprofen should also be used with caution in patients undergoing surgery when a high degree of hemostasis is required. NSAIDs should be used with caution in patients with immunosuppression or neutropenia. NSAIDs may mask the signs of infection such as fever or pain in patients with bone marrow suppression.
Anemia may be exacerbated with the use of oral NSAIDs. This may be due to fluid retention, GI blood loss, or an incompletely described effect upon erythrogenesis. Patients who have initial hemoglobin values of 10 g/dl or less and who are to receive long-term NSAID therapy should have hemoglobin values determined periodically.
Intramuscular injections should be administered cautiously to patients receiving ibuprofen. IM injections may cause bleeding, bruising, or hematomas due to platelet effects secondary to ibuprofen therapy.
Use of ibuprofen may cause increased bleeding in patients with dental disease. Patients should inform their dentist they are taking ibuprofen prior to any dental work due to a potential increased risk of bleeding. Patients should be instructed on proper oral hygiene.
Ibuprofen is classified as a FDA pregnancy risk category B drug: no studies have linked ibuprofen use during pregnancy and congenital defects. Although ibuprofen has not been shown in studies to cause fetal harm early on in pregnancy, use of ibuprofen should be avoided unless the potential therapeutic benefits justify its use during pregnancy. Ibuprofen is classified as a FDA pregnancy risk category D drug if used during the third trimester, due to the potential for prostaglandin synthetase inhibitors to cause in utero constriction of the fetal ductus arteriosus. Of 40 babies born with persistent pulmonary hypertension of the newborn (PPHN), 87.5% had the presence of an NSAID in their meconium versus 24.6% of 61 children born without PPHN; the presence of only 4 NSAIDs was examined. In addition to meconium aspiration, asphyxia, respiratory distress syndrome, and group B streptococcal pneumonia, ductus arteriosus constriction by an NSAID appears to be another predisposing factor for PPHN development, as a patent ductus arteriosus was absent in 18 of the 40 infants. Prostaglandin synthetase inhibitors also have the potential to prolong pregnancy and inhibit labor if taken during the third trimester.
Ibuprofen use has been associated with necrotizing fasciitis in children following varicella virus infection. In a retrospective, case-controlled study, children who had received ibuprofen prior to hospitalization were more likely to have complicated infections that included renal sufficiency, streptococcal toxic shock syndrome, higher temperatures and longer duration of symptoms than the control group. Although this study did not prove a causal relationship, prescribers should be aware of a potential increase risk for necrotizing fasciitis when ibuprofen is given during primary varicella infections.
Ibuprofen is considered to be generally compatible with breast-feeding. In studies using a 1 mcg/ml assay, ibuprofen was not detected in the milk of lactating mothers.
Ibuprofen is contraindicated for the treatment of peri-operative pain in the setting of coronary artery bypass graft surgery (CABG). An increased incidence of myocardial infarction and stroke was found through analysis of data regarding the use of a COX-2 selective NSAID for the treatment of pain in the first 10 - 14 days after CABG surgery. This warning is not currently applicable to non-prescription strength products (e.g., Advil®); however the precaution has been added voluntarily by some manufacturers.
[ Last revised: 2/24/2006 9:14:00 PM ]
References
. Zerr DM, Alexander ER, Duchin JS, et al. A case-control study of necrotizing fasciitis during primary varicella. Pediatrics 1999;103:783 - 90.
. Frishman WH. Effects of nonsteroidal anti-inflammatory drug therapy on blood pressure and peripheral edema. Am J Cardiol 2002;89(suppl):18D - 25D.
. Alano MA, Ngougmna E, Ostrea EM, et al. Analysis of nonsteroidal antiinflammatory drugs in meconium and its relation to persistent pulmonary hypertension of the newborn. Pediatrics 2001;107:519 - 23.
. Debley JS, Carter ER, Gibson RL, et al. The prevalence of ibuprofen-sensitive asthma in children: a randomized controlled bronchoprovocation challenge study. J Pediatr 2005;147:233 - 38.
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