How do I manage a dog with suspected NSAID toxicity including GI and renal complication monitoring?

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Immediate management of suspected NSAID toxicity begins with gastrointestinal decontamination, intravenous fluids (IVF), and gastroprotection, with escalation to intravenous lipid emulsion (ILE) or therapeutic plasma exchange (TPE) in severe cases.12 Gastrointestinal decontamination should be performed as early as possible. Absence of induced emesis is independently associated with greater clinical severity.1 For naproxen specifically, a single dose of activated charcoal with a cathartic should be followed by oral cholestyramine every 6–8 hours for 3 days due to enterohepatic recirculation, and the patient should be monitored for hypernatremia during this period.7 Toxic dose thresholds guide clinical severity expectations. For carprofen, gastrointestinal signs are expected at doses >20 mg/kg, acute kidney injury (AKI) at doses >40 mg/kg, and neurological signs have been documented at doses ≥281 mg/kg.2 Doses up to 160 mg/kg have resulted in minimal complications, primarily gastrointestinal.2 Ibuprofen toxicosis is associated with more severe clinical signs than carprofen.1 Gastrointestinal monitoring should begin at presentation, as GI signs develop rapidly. Approximately 52.5% of dogs treated with TPE for NSAID overdose developed GI signs, and 45.5% of those presented having already developed signs — primarily vomiting and regurgitation — before treatment began.3 GI signs are common across NSAID types and appear earlier than renal injury.3 Renal monitoring requires serial creatinine measurements. Increased time to presentation and higher baseline creatinine at admission are both associated with greater clinical severity.1 Dogs treated with IVF alone had a higher maximal creatinine (median 1.1 mg/dL, range 0.4–8.44 mg/dL) compared with dogs treated with IVF plus ILE (median 0.9 mg/dL, range 0.4–6.2 mg/dL).1 AKI developed in 27.3% of dogs treated with TPE for NSAID overdose.3 Of dogs treated with TPE who had at least one follow-up visit, 91.1% were not azotemic at re