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WARNINGS

Cardiovascular Effects

Cardiovascular Thrombotic Events

Clinical trials of several COX – 2 selective and nonselective NSAIDs of up to three years duration have

shown an increased risk of serious cardiovascular (CV) thrombotic events, myocardial infarction, and stroke,

which can be fatal. All NSAIDs, both COX – 2 selective and nonselective, may have a similar risk.

Patients with a known CV disease or risk factors for CV disease may be at greater risk. To minimize the

potential risk for an adverse CV event in patients treated with an NSAID, the lowest effective dose should be used for the shortest

duration possible. Physicians and patients should remain alert for the

development of such events, even in the absence of previous CV symptoms. Patients should be

informed about the signs and/or symptoms of serious CV events and the steps to take if they occur.

There is not consistent evidence that concurrent use of aspirin mitigates the increased risk of serious

CV thrombotic events associated with NSAID use. The concurrent use of aspirin and an NSAID does

increase the risk of serious GI events (see WARNINGS, GASTROINTESTINAL EFFECTS -RISK OF

ULCERATION, BLEEDING AND PERFORATION).

Two large, controlled clinical trials of a COX-2 selective NSAID for the treatment of pain in the first

10  – 14 days following CABG surgery found an increased incidence of myocardial infarction and stroke (see

CONTRAINDICATIONS).

Hypertension

NSAIDs including ibuprofen tablets, can lead to onset of new hypertension or worsening of

pre-existing hypertension, either of which may contribute to the increased incidence of CV events. Patients

taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs.

NSAIDs, including ibuprofen tablets, should be used with caution in patients with hypertension. Blood

pressure (BP) should be monitored closely during the initiation of NSAID treatment and throughout the course

of therapy.

Congestive Heart Failure and Edema.

Fluid retention and edema have been observed in some patients taking NSAIDs. Ibuprofen tablets

should be used with caution in patients with fluid rentention or heart failure.

Gastrointestinal Effects – Risk of Ulceration, Bleeding and Perforation

NSAIDs, including ibuprofen tablets, can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of

the stomach, small intestine, or large intestine, which can be fatal. These serious adverse events can occur at any time, with or without warning symptoms, in

patients treated with NSAIDs. Only one in five patients, who develop a serious upper GI adverse event on NSAID therapy, is symptomatic. Upper GI ulcers,

gross bleeding, or perforation caused by NSAIDs occur in approximately 1 % of patients treated for 3 – 6 months, and in about 2 – 4 % of patients treated for one

year. These trends continue with longer duration of use, increasing the likelihood of developing a serious GI event at some time during the course of

therapy. However, even short – term therapy is not without risk. NSAIDs should be prescribed with extreme caution in those with a prior history of ulcer

disease or gastrointestinal bleeding. Patients with a prior history of peptic ulcer disease and / or gastrointestinal bleeding who use NSAIDs have a greater

than 10 – fold increased risk for developing a GI bleed compared to patients treated with neither of these risk factors. Other factors that increase the risk of

GI bleeding in patients treated with NSAIDs include concomitant use of oral corticosteroids or anticoagulants, longer duration of NSAID therapy,

smoking, use of alcohol, older age, and poor general health status. Most spontaneous reports of fatal GI events are in elderly or debilitated

patients and therefore, special care should be taken in treating this population.

To minimize the potential risk for an adverse GI event in patients treated with an NSAID, the lowest effective dose should be used for the shortest

possible duration. Patients and physicians should remain alert for signs and symptoms of GI ulcerations and bleeding during NSAID therapy and

promptly initiate additional evaluation and treatment is a serious GI event is suspected. This should include discontinuation of the NSAID until a

serious GI adverse event is ruled out. For high – risk patients, alternate therapies that do not involve NSAIDs should be considered.

Renal Effects

Long – term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients

in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion. In these patients, administration of a NSAID

may cause a dose – dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decomposition.

Patients at greatest risk of this reaction are those with impaired renal function, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors,

and the elderly. Discontinuation of NSAID therapy is usually followed by recovery to the pretreatment state.

Advanced Renal Disease

No information is available from controlled clinical studies regarding the use of ibuprofen tablets in patients with advanced renal disease. Therefore,

treatment with ibuprofen tablets is not recommended in those patients with advanced renal disease. If ibuprofen tablet therapy must be initiated,

close monitoring of the patients renal function is advisable.

Anaphylactoid Reactions

As with other NSAIDs, anaphylactoid reactions may occur in patients without known prior exposure to ibuprofen tablets. Ibuprofen tablets should not

be given to patients with the aspirin triad. This symptom complex typically occurs in asthmatic patients who experience rhinitis with or without nasal

polyps, or who exhibit severe, potentially fatal bronchospasm after taking aspirin or other NSAIDs (see CONTRAINDICATIONS and PRECAUTIONS,

Preexisting Asthma). Emergency help should be sought in cases where an anaphylactoid reaction occurs.

Skin Reactions

NSAIDs, including ibuprofen tablets, can cause serious skin adverse events such as exfoliative dermatitis. Stevens – Johnson Syndrome (SJS), and

toxic epidermal necrolysis (TEN), which can be fatal. These serious events may occur without warning. Patients should be informed about the signs

and symptoms of serious skin manifestations and use of the drug should be discontinued at the first appearance of skin rash or any other

sign of hypersensitivity.

Pregnancy

In late pregnancy, as with other NSAIDs, ibuprofen tablets should be avoided because it may cause premature closure of the ductus arteriosus.