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Nurofen Plus misuse: an emerging cause of perforated gastric ulcer

Martin J Dutch
Med J Aust 2008; 188 (1): 56-57. || doi: 10.5694/j.1326-5377.2008.tb01509.x
Published online: 7 January 2008

Over a 6-month period, two patients presented to a community hospital emergency department with perforated gastric ulcers as the result of recreational misuse of over-the-counter ibuprofen–codeine preparations. Misuse of these medications appears to be an emerging cause of significant morbidity in patients with codeine addiction.

Clinical records
Discussion

Ibuprofen–codeine preparations first entered the Australian over-the-counter (OTC) market in October 2002. The leading product in the market, Nurofen Plus, contains 200 mg ibuprofen and 12.8 mg codeine phosphate in each tablet,1 making it the strongest codeine tablet available in Australia without prescription.

Codeine phosphate is a known drug of misuse. Ibuprofen–codeine products are particularly vulnerable to misuse because of the relatively high amount of codeine contained in each preparation and the absence of toxicity in overdose that is associated with paracetamol preparations.

Several cases of severe hypokalaemia secondary to ibuprofen-induced renal tubule acidosis after Nurofen Plus misuse have been reported in the literature.2-4 One study showed that patients with acute upper gastrointestinal presentations were 5.2 times more likely to have consumed high-dose OTC non-aspirin non-steroidal anti-inflammatory drugs within the previous week, and the increased risk was dose-dependent.5

To our knowledge, the two cases described here are the first reports of perforated gastric ulcers associated with recreational Nurofen Plus misuse.

The database of Australia’s Adverse Drug Reactions Advisory Committee (ADRAC) relies on voluntary reporting, and a drug’s adverse reaction profile becomes better defined as the market gains experience with it. As at July 2007, there had been 26 cases reported to ADRAC of adverse events in patients taking Nurofen Plus (Dr Patrick Purcell, Medical Officer, Adverse Drug Reactions Unit, Therapeutic Goods Administration, personal communication). ADRAC records show that Nurofen Plus was the sole suspected agent associated with two duodenal ulcer perforations. The first case involved a 28-year-old woman who took eight tablets a day “for a period of months” for back pain, and the second involved a 24-year-old woman for which there was no further clinical information. ADRAC has received no reports of perforated gastric ulcers associated with Nurofen Plus, and only one report of this condition in a patient taking an ibuprofen-only preparation.

With only two patients presenting to our community hospital with perforated gastric ulcer in the past 6 months, the presentation is unusual. Misuse of ibuprofen–codeine analgesics, associated with both cases, appears to be a new and important aetiology for this condition.

Vigilant reporting of adverse drug reactions to ADRAC, tighter enforcement of legislative requirements for the dispensing of pharmacy-only medicines, or reformulation of this product (as has occurred with OTC pseudoephedrine products) may help to minimise the health sequelae of ibuprofen–codeine misuse.

  • Martin J Dutch

  • Emergency Department, The Angliss Hospital, Melbourne, VIC.


Correspondence: martin.dutch@mh.org.au

Competing interests:

None identified.

  • 1. New drugs. Ibuprofen/codeine phosphate. Aust Prescriber 2002; 25: 94-99.
  • 2. Lambert AP, Close C. Life-threatening hypokalaemia from abuse of Nurofen Plus. J R Soc Med 2005; 98: 21.
  • 3. Dyer BT, Martin JL, Mitchell JL, et al. Hypokalaemia in ibuprofen and codeine phosphate abuse. Int J Clin Pract 2004; 58: 1061-1062.
  • 4. Chetty R, Baoku Y, Mildner R, et al. Severe hypokalaemia and weakness due to Nurofen misuse. Ann Clin Biochem 2003; 40: 422-423.
  • 5. Lewis JD, Kimmel SE, Localio AR, et al. Risk of serious upper gastrointestinal toxicity with over-the-counter nonaspirin nonsteroidal anti-inflammatory drugs. Gastroenterology 2005; 129: 1865-1874.

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