When to use acetaminophen (Tylenol) over ibuprofen over ketorolac?

From the Guidelines

Tylenol (acetaminophen) should be used as the first-line agent for the treatment of musculoskeletal pain due to its fewer side effects compared to NSAIDs, including ibuprofen and ketorolac, as recommended by the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV 1. When deciding between Tylenol, ibuprofen, and ketorolac, it is essential to consider the specific condition being treated and individual patient factors.

• Use Tylenol for mild pain and fever when anti-inflammatory effects aren't needed, especially in patients with kidney problems, bleeding risks, or stomach ulcers, at doses of 325-650mg every 4-6 hours (maximum 3000mg daily, or lower dosing for patients with liver disease) 1.
• Choose ibuprofen for conditions with inflammation like arthritis or menstrual cramps at 200-400mg every 4-6 hours (maximum 1200mg daily for OTC use), but avoid in patients with kidney disease, heart failure, or stomach ulcers.
• Reserve ketorolac for short-term management of moderate to severe acute pain in hospital settings, typically given as 10mg every 4-6 hours (maximum 40mg daily) for no more than 5 days due to its potent effects and higher risk profile. These medications work differently: Tylenol blocks pain signals in the brain without reducing inflammation, ibuprofen reduces inflammation by blocking prostaglandin production, and ketorolac provides stronger anti-inflammatory effects but with greater side effect risks.
• Always consider a patient's medical history, other medications, and the specific pain condition when selecting the appropriate option, as recommended by the clinical practice guideline 1.

From the Research

Comparison of Tylenol, Ibuprofen, and Ketorolac

• Tylenol (acetaminophen) is generally well tolerated and a suitable first-choice analgesic for many adults with mild to moderate acute pain, including those with liver, kidney, or cardiovascular disease, gastrointestinal disorders, asthma, or who are older 2.
• Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is effective for acute pain, but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 3.
• Ketorolac is another NSAID that has been compared to ibuprofen and diclofenac for acute, nonradicular low back pain, with results suggesting that ketorolac may result in better pain relief and less stomach irritation than ibuprofen 4.

Specific Considerations

• For patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder, lower doses of acetaminophen should be used 3.
• For patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease, NSAIDs such as ibuprofen and ketorolac should be used with caution 3.
• For patients with acute musculoskeletal pain refractory to ibuprofen, oxycodone/acetaminophen may result in slightly greater pain relief than acetaminophen alone, but with more medication-related adverse events 5.

General Guidelines

• Acetaminophen and NSAIDs are first-line treatment options for most patients with acute mild to moderate pain 3.
• Combination therapy using a small amount of opioid together with a nonopioid pain reliever may be effective and reduce opioid consumption 6.
• The short-term use of opioids under close clinical supervision may be appropriate for severe acute pain, but nonopioid therapy may be preferred 6.