What is more effective for fever management, acetaminophen (paracetamol) or ibuprofen?

From the Guidelines

Paracetamol (acetaminophen) is generally recommended as the first choice for fever management, especially for children and those with certain health conditions, due to its safety profile and effectiveness in reducing fever without affecting inflammation. For adults, the standard paracetamol dose is 500-1000mg every 4-6 hours (maximum 4000mg daily), while ibuprofen is typically 200-400mg every 6-8 hours (maximum 1200mg daily) 1.

Key Considerations

• Paracetamol works primarily in the brain to reset the body's temperature regulation without affecting inflammation, making it suitable for most people including pregnant women and those with stomach issues.
• Ibuprofen reduces fever by blocking prostaglandins throughout the body and has anti-inflammatory properties, which can provide additional benefit for fever accompanied by inflammation or pain.
• However, ibuprofen should be avoided by those with kidney problems, heart conditions, stomach ulcers, or asthma.

Important Guidance

• For persistent fevers, you can alternate between both medications (ensuring proper dosing intervals) after consulting a healthcare provider.
• Take paracetamol with or without food, while ibuprofen should be taken with food to minimize stomach irritation.
• If fever persists beyond three days or exceeds 103°F (39.4°C), seek medical attention.

Evidence-Based Recommendation

The most recent and highest quality study, published in 2020, recommends paracetamol as the preferred choice for fever management in patients with COVID-19, until more evidence is available 1. Although an older study from 2005 suggests that ibuprofen is superior to paracetamol for reducing fever in certain cases 1, the more recent guideline from 2020 takes precedence in guiding clinical practice. Another study from 2012 provides guidance on the management of acute sore throat, recommending either ibuprofen or paracetamol for relief of symptoms, but this is not directly applicable to the question of fever management in general 1.

From the Research

Fever Management Comparison

The effectiveness of acetaminophen (paracetamol) and ibuprofen for fever management can be compared based on several studies:

• A study from 2015 2 found that paracetamol is significantly more effective than placebo and at least as effective as non-steroidal anti-inflammatory drugs (NSAIDs) when used at a dose of 15 mg/kg for fever and pain management in children.
• Another study from 2013 3 showed that ibuprofen has the advantage of less frequent dosing and a longer duration of action, making it a suitable alternative to paracetamol, and that it is at least as effective as paracetamol as an analgesic and more effective as an antipyretic.
• A 2023 study 4 found that paracetamol 1,000 mg represents the first choice for the treatment of fever in the emergency department, followed by paracetamol/ibuprofen 500/150 mg, and that the combination of paracetamol and ibuprofen was more effective in patients with bacterial fever one hour after administration.
• The PITCH randomised controlled trial from 2009 5 established that the use of both paracetamol and ibuprofen together was superior to using either medicine alone for additional time without fever in the first 4 hours and 24 hours, and that ibuprofen was superior to paracetamol alone for additional time without fever in the first 4 hours.
• A literature review from 2010 6 found that ibuprofen was marginally more effective at reducing fever, but noted that the maximum dose of paracetamol was not administered in the studies examined, highlighting the need for more methodologically sound research using equivalent doses of both drugs.

Key Findings

Key findings from the studies include:

• Paracetamol is effective for fever management in children when used at a dose of 15 mg/kg 2.
• Ibuprofen has a longer duration of action and is at least as effective as paracetamol as an analgesic and more effective as an antipyretic 3.
• The combination of paracetamol and ibuprofen may be more effective for fever management in certain cases, such as bacterial fever 4.
• Using both paracetamol and ibuprofen together can be superior to using either medicine alone for additional time without fever 5.
• More research is needed to determine the optimal dosing and combination of paracetamol and ibuprofen for fever management 6.