Can Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) be given to patients with dengue?

NSAIDs Should NOT Be Given in Dengue

NSAIDs (except aspirin at antiplatelet doses) are contraindicated in dengue fever and must be avoided due to increased bleeding risk from thrombocytopenia and platelet dysfunction inherent to the disease. 1, 2

Primary Recommendation

• Acetaminophen (paracetamol) is the only recommended antipyretic and analgesic for dengue patients 1
• All NSAIDs—including ibuprofen, naproxen, diclofenac, and aspirin—should be stopped immediately when dengue infection is suspected to minimize bleeding risk 2

Why NSAIDs Are Contraindicated

Bleeding Risk Mechanisms

• Dengue causes thrombocytopenia (platelet counts can drop to 19-86 x 10⁹/L) and leucopenia, which are distinguishing features of dengue hemorrhagic fever (DHF) 1, 2
• NSAIDs inhibit platelet function through COX inhibition, compounding the already impaired hemostasis from dengue-induced thrombocytopenia 2
• Dengue patients have a 55-fold increased risk of nonvariceal upper GI bleeding within 30 days of infection (adjusted HR 55.40; 95% CI: 32.17-95.42) 3
• The combination of NSAID-induced platelet dysfunction plus dengue-related thrombocytopenia creates a dangerous synergistic bleeding risk 1, 2

Clinical Manifestations Requiring Caution

• Dengue hemorrhagic fever presents with hemorrhagic manifestations, thrombocytopenia, and hemoconcentration 1
• Patients may develop hemorrhagic skin lesions during hospitalization even with initially mild presentations 2
• Laboratory findings include rising hematocrit, thrombocytopenia, and transformed lymphocytes on peripheral smear 1

Emerging Evidence Controversy

Recent Research Challenging Traditional Guidelines

While traditional consensus guidelines contraindicate NSAIDs, two recent studies suggest low-dose ibuprofen may have comparable safety to acetaminophen in non-severe dengue:

• A 2025 retrospective study of 262 hospitalized dengue patients found no significant differences in platelet reduction, bleeding events, severe thrombocytopenia, or progression to severe dengue between low-dose ibuprofen (cumulative dose 0.6g) and acetaminophen groups 4
• A 2019 review argued that postoperative bleeding data with ibuprofen at OTC doses (≤1200 mg/day) shows zero to minimal bleeding risk, and that acetaminophen's hepatotoxicity risk may be concerning given dengue's frequent hepatic complications 5

Critical Limitations of These Studies

• Both studies involved non-severe dengue only—patients without severe dengue at admission 4
• The ibuprofen doses were very low (0.6g cumulative) compared to typical NSAID dosing 4
• These are retrospective observational studies, not randomized controlled trials 5, 4
• No RCTs have evaluated NSAID safety in dengue 5

Definitive Clinical Recommendation

Despite emerging research, NSAIDs should remain contraindicated in dengue based on:

1. Biological plausibility: The mechanism of NSAID-induced platelet dysfunction combined with dengue thrombocytopenia creates clear bleeding risk 1, 2
2. Established bleeding risk: The 55-fold increased GI bleeding risk within 30 days of dengue infection makes any additional antiplatelet effect unacceptable 3
3. Lack of high-quality evidence: No RCTs support NSAID safety, and observational studies are limited to non-severe cases with very low doses 5, 4
4. Safe alternative exists: Acetaminophen provides adequate symptomatic relief without antiplatelet effects 1

Practical Management Algorithm

For fever control in suspected or confirmed dengue:

• Use acetaminophen only for antipyresis and analgesia 1
• Immediately discontinue any NSAIDs, aspirin, or antiplatelet agents 2
• Monitor platelet count, hematocrit, and vital signs closely 1
• Watch for warning signs: severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy, liver enlargement 1

Common pitfall to avoid:

• Do not assume "mild" dengue is safe for NSAIDs—patients can progress rapidly to DHF/DSS with hemorrhagic complications even after initially benign presentations 2

Post-recovery consideration:

• After recovery, the medium-term (31-365 days) and long-term (>365 days) bleeding risks return to baseline, so antithrombotic medications can be safely resumed if indicated 3