Case three-continued>>

موضوع: Case three-continued>> الجمعة يناير 16, 2009 8:01 pm

Three days later, the resident was performing rapid clinical evaluation
for the inpatient cases.

Nada's condition was improving, with gradual resolution of the edema..

Pleural effusion became minimal, but there was still shifting dullness.

Body weight dropped to 22kg, and total 24 urinary protein dropped to
2g/day.

He decided to continue the same treatment plan.

He was about to leave the room when noticed a strange thing.

He noticed a pack of Brufen syrup on the table beside Nada.

On asking the mother, she told him that she gave Nada a teaspoonful

of Brufen Syrup three times daily; she added that she did that following

the advice of her neighbor who told her that this drug is beneficial for Nada.

The resident got angry, and told her that this drug can be very harmful to

Nada's condition!!

Questions:

Could you explain the resident's point of view?

the active ingredient of Brufen is iboprofen which is an NSAID
this probably be harmful because of its effect on the stomach which is alrealdy at risk due to steroids. it may cause GI bleeding
also diuretics potentiate the nephrotoxicity od iboprofen

the following are the drug interactions with brufen:
Antihypertensives: Reduced antihypertensive effect.

Diuretics: Reduced diuretic effect. Diuretics can increase the risk of nephrotoxicity of NSAIDs.

Cardiac glycosides: NSAIDs may exacerbate cardiac failure, reduce GFR and increase plasma cardiac glycoside levels.

Lithium: Decreased elimination of lithium.

Methotrexate: Decreased elimination of methotrexate.

Cyclosporin: Increased risk of nephrotoxicity with NSAIDs.

Mifepristone: NSAIDs should not be used for 8-12 days after mifepristone administration as NSAIDs can reduce the effects of mifepristone.

Other analgesics: Avoid concomitant use of two or more NSAIDs.

Corticosteroids: Increased risk of gastrointestinal bleeding.

Anticoagulants: Enhanced anticoagulant effect.

Quinolone antibiotics: Animal data indicate that NSAIDs can increase the risk of convulsions associated with quinolone antibiotics. Patients taking NSAIDs and quinolones may have an increased risk of developing convulsions.

Brufen syrup

The active ingredient is Ibuprofen, a NSAID.

It is a product of Abbott Laboratories, which was founded in 1888.

It is headquartered in Illinois,USA.

Brufen is one of the most popular NSAID in the Egyptian market.

It is a available as tablets 200, 400 , 600 ,800mg.

It is also available as syrup, 100mg/5ml.

Dose:

Adults: The recommended dosage of Brufen is up to 1200 mg daily

in divided doses, according to the condition.

But in Acute gout: 2400 mg daily either as 800 mg 8 hourly or 600 mg 6 hourly until the acute symptoms have been relieved.

Children:The usual dose is 5 mg/kg of bodyweight every 4 - 6 hours. DO NOT EXCEED 20 mg/kg of bodyweight per day.

Indications: Analgesic,antipyretic,anti-inflammatory.

The images will be available soon, but the net is very slow now.

Nice Dr Amani. BUT read the following carefully please.....

The most important of these interactions in our patient's condition are:

One-The interaction between Furosemide and Ibuprofen:
As you mentioned, Ibuprofen can reduce the diuretic effect of furosemide.
But more importantly ,remember that this patient is hypovolemic due to:
One-Shift of fluid from the intracellular to the extracellular space.
Two-Diuretic-induced hypovolemia.

This hypovolemia affects renal perfusion, and the locally synthesized prostaglandins
(specially PGE) act to vasodilate the afferent arterioles in an attemp to mainatain
adequate renal perfusion and hence adequate Glomerular filtration rate-GFR.

With the administration of Ibuprofen, the cyclo-oxygenase enzyme is blocked, with
diminished formation of these beneficial prostaglandins,so renal perfusion is
adversely affected.

Two-The interaction between corticosteroids and Ibuprofen.
There is increased risk of GIT adverse effects.

Now remeber this rule, NSAIDs are used with caution in any patient with
renal insufficiency.

Now, based on the above expalnation, can you explain why NSAIDs can
precipitate Heart failure in compensated patients?

as I understood , renal insuffeciency causes accumulation of fluid in the body which increases a fluid overload on the heart and as a result increases the work of the heart, right? with a preexisting heart disease compensatory mechanisms cannot help such a problem

Excellent,so we conclude that NSAIDs should be used with caution in renal and

cardiac insufficiency.

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