Can ibuprofen (nonsteroidal anti-inflammatory drug) cause diarrhea, especially in patients with a history of gastrointestinal disorders such as irritable bowel syndrome or inflammatory bowel disease?

Does Ibuprofen Cause Diarrhoea?

Yes, ibuprofen can cause diarrhoea, though it occurs relatively infrequently and is dose- and duration-dependent, with the risk increasing substantially at higher anti-inflammatory doses (≥2400 mg/day) and with prolonged use.

Mechanism and Incidence

• NSAIDs, including ibuprofen, are recognized as a cause of drug-induced diarrhoea through multiple mechanisms including secretory effects, shortened transit time, and exudative enteropathy 1
• Ibuprofen is specifically listed among drugs that can cause diarrhoea in clinical practice guidelines for managing diarrhoea in cancer patients 2
• At over-the-counter doses (up to 1200 mg daily for up to 7 days), diarrhoea was reported as one of the principal gastrointestinal adverse events, though the overall incidence was comparable to paracetamol 3

Dose-Duration Relationship

The risk of gastrointestinal complications, including diarrhoea, with ibuprofen is strongly dose- and duration-dependent 4:

• At OTC doses (≤1200 mg/day), gastrointestinal adverse events including diarrhoea occur at rates similar to placebo or paracetamol 5, 4
• At full anti-inflammatory doses (2400 mg/day), the risk of GI complications becomes comparable to other NSAIDs 2, 6
• Short-term use (<14 days) shows dose-dependent damage, while serious outcomes are exceedingly rare 5

Clinical Context and Risk Factors

Patients with pre-existing gastrointestinal disorders are at higher risk:

• Those with a history of non-ulcer GI disease experienced significantly more GI adverse events (including diarrhoea) than those without such history, though ibuprofen still had the lowest incidence among NSAIDs studied 3
• In IBS patients, NSAIDs should be avoided or used cautiously as they can exacerbate symptoms 2
• Women experience GI adverse events more frequently than men (15.5% vs 12.8%) 3

Comparative Safety Profile

• Among commonly used NSAIDs, ibuprofen consistently ranks at the lower end of gastrointestinal toxicity, particularly at standard analgesic doses 2, 6, 4
• The low risk profile is largely attributable to the relatively low doses prescribed in routine clinical practice 6
• Ibuprofen causes significantly fewer GI adverse events than aspirin (11.5% vs 18.5%) and similar rates to paracetamol (13.1%) at OTC doses 3

Practical Management Approach

When prescribing ibuprofen, minimize GI risk by:

• Using the lowest effective dose for the shortest duration necessary 2, 6
• For simple analgesia (headache, toothache), limit to OTC doses (≤1200 mg/day) where diarrhoea risk is minimal 2, 4
• For inflammatory conditions requiring higher doses, consider that GI complications including diarrhoea become more likely 2, 6
• If diarrhoea develops, adjust or discontinue the medication as recommended in palliative care guidelines 2

Important Caveats

• The time between drug initiation and diarrhoea onset can be variable, sometimes occurring after prolonged use 1
• NSAIDs can cause enteropathy affecting the entire GI tract, not just upper GI complications, with 70% of patients developing some degree of NSAID-enteropathy 5
• In patients with IBS-D or inflammatory bowel disease, ibuprofen should be used with extreme caution or avoided, as it may worsen diarrhoea 2