Is paracetamol (acetaminophen) or steroids, such as prednisone, recommended for managing high fever?

Paracetamol for High Fever: The Recommended First-Line Treatment

Paracetamol (acetaminophen) is the recommended first-line treatment for high fever, while corticosteroids are not routinely recommended for fever management. 1, 2

Primary Recommendation: Paracetamol

Use paracetamol as the first-choice antipyretic for fever control in both adults and children. 2, 3 The evidence strongly supports this approach:

• Dosing for adults: 1000 mg every 4-6 hours (maximum 4 g/day) 2
• Dosing for children: 15 mg/kg per dose every 4-6 hours (maximum 60 mg/kg/day) 3, 4
• Route: Oral administration is preferred for all patients capable of oral intake 2

The rationale is clear: paracetamol has an excellent safety profile with no increased cardiovascular or gastrointestinal complications compared to placebo 2, and it is effective for both fever reduction and associated discomfort 1.

Why NOT Steroids for Routine Fever Management

Corticosteroids are explicitly not recommended for routine fever treatment. 1 The guidelines are unambiguous on this point:

• Adjunctive corticosteroid therapy is not recommended for acute pharyngitis with fever 1
• Corticosteroids should only be considered in very specific contexts (e.g., severe COVID-19 ARDS, or severe streptococcal pharyngitis with 3-4 Centor criteria in adults) 1
• For general fever management, there is no indication for steroid use 1

Clinical Algorithm for Fever Management

Step 1: Assess the need for treatment

• Fever alone does not require treatment 2, 5
• Treat when fever is associated with discomfort or pain 1, 6

Step 2: Administer paracetamol

• Adults: 1000 mg orally every 4-6 hours 2
• Children: 15 mg/kg orally every 4-6 hours 3
• Maximum daily dose: 4 g for adults, 60 mg/kg for children 2, 3

Step 3: Consider ibuprofen as alternative or addition

• If paracetamol is insufficient, ibuprofen (10 mg/kg in children) can be used 4
• Combined use provides 2.5-4.4 additional hours without fever compared to single agents 4
• Caution: Carefully record all dose times to avoid exceeding maximum recommended doses 4

Step 4: Supportive measures

• Maintain adequate hydration (no more than 2 liters per day in adults) 2
• Physical cooling methods (tepid sponging) are not recommended as they cause discomfort 2

Important Caveats and Pitfalls

Avoid these common mistakes:

• Do not use aspirin in children due to Reye's syndrome risk 1, 6
• Do not use paracetamol to prevent febrile seizures - it is ineffective for this purpose 2
• Do not exceed maximum doses: Risk of hepatotoxicity with chronic overdosing >140 mg/kg/day for several days in children 6
• Do not routinely use steroids for fever - they have no role in standard fever management 1

When Steroids Might Be Considered (Rare Exceptions)

Steroids have extremely limited indications related to fever:

• Severe COVID-19 with ARDS on mechanical ventilation 1
• Severe streptococcal pharyngitis in adults with 3-4 Centor criteria (as adjunct to antibiotics, not for fever alone) 1

These are disease-specific indications, not fever management per se.

Safety Profile Comparison

Paracetamol has superior safety compared to alternatives:

• No cardiovascular harm reported 2
• No increased gastrointestinal complications versus placebo 2
• Lower risk of adverse events with repetitive dosing compared to NSAIDs 3
• Safe in all age groups when used at recommended doses 3

Steroids carry significant risks when used inappropriately:

• Immunosuppression
• Metabolic effects
• No proven benefit for routine fever management 1