When is ibuprofen (nonsteroidal anti-inflammatory drug, NSAID) preferred over paracetamol (acetaminophen)?

From the Guidelines

Ibuprofen is preferred over paracetamol when anti-inflammatory effects are needed, particularly for conditions involving inflammation such as arthritis, sprains, menstrual cramps, and inflammatory pain. The decision to use ibuprofen over paracetamol should be based on the need for anti-inflammatory effects, as ibuprofen has been shown to be more effective in reducing inflammation and providing analgesia in conditions such as knee osteoarthritis 1. According to a study published in the Annals of the Rheumatic Diseases, NSAIDs, including ibuprofen, are more efficacious than paracetamol in the management of knee osteoarthritis, especially in patients with signs of joint inflammation 1.

Key Considerations

• Ibuprofen works by inhibiting cyclooxygenase enzymes (COX-1 and COX-2), which reduces prostaglandin production and provides both analgesic and anti-inflammatory effects, while paracetamol primarily offers pain relief and fever reduction with minimal anti-inflammatory action.
• The typical adult dose of ibuprofen is 200-400mg every 6-8 hours, not exceeding 1200mg daily for over-the-counter use or 3200mg daily when prescribed.
• Ibuprofen should be taken with food to minimize gastrointestinal side effects and avoided in patients with certain conditions, including peptic ulcers, severe kidney disease, heart failure, or those taking anticoagulants.
• A more recent study published in 2017 recommends acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line agents for the treatment of musculoskeletal pain, with the caveat that acetaminophen has fewer side effects than NSAIDs 1.

Special Considerations

• For patients who require NSAIDs for inflammatory conditions, the choice of NSAID should be based on the specific condition being treated, with NSAIDs having short half-lives preferred for acute conditions and those with longer half-lives preferred for chronic conditions 1.
• Selective cyclo-oxygenase-2 (COX-2) inhibitors provide good analgesia with increased safety but at greater expense, and their use should be considered on a case-by-case basis 1.

From the Research

Ibuprofen vs Paracetamol

Ibuprofen is preferred over paracetamol in the following situations:

• In a range of painful conditions, including acute post-operative pain, dysmenorrhoea, osteoarthritis, and rheumatoid arthritis, where ibuprofen has been shown to be consistently superior to paracetamol at conventional doses 2
• In cases where patients have not responded to paracetamol or require more effective pain relief, as ibuprofen has been found to produce more patients with worthwhile pain relief 2
• For patients with rheumatoid arthritis, where nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are usually preferred over paracetamol due to their anti-inflammatory effects 3

Conditions where Ibuprofen may be preferred

Some specific conditions where ibuprofen may be preferred over paracetamol include:

• Acute pain, where ibuprofen has been shown to be more effective than paracetamol in direct and indirect comparisons 2
• Osteoarthritis, where ibuprofen has been found to be superior to paracetamol in terms of pain relief 2
• Migraine, where ibuprofen has been shown to be more effective than paracetamol in indirect comparisons 2

Considerations for choosing between Ibuprofen and Paracetamol

When deciding between ibuprofen and paracetamol, the following factors should be considered:

• The type and severity of the painful condition being treated
• The patient's individual response to each medication
• The potential risks and benefits of each medication, including gastrointestinal, renal, and cardiovascular effects 4, 5