Why Paracetamol is Given for Fever
Paracetamol (acetaminophen) is recommended for fever management primarily to relieve discomfort and associated symptoms like headache and body aches, not to reduce body temperature itself, as fever reduction alone does not improve clinical outcomes. 1
Primary Rationale for Use
The key indication is symptom relief, not temperature normalization. The NICE COVID-19 guidelines explicitly state: "Do not use antipyretics with the sole aim of reducing body temperature" 1. Instead, paracetamol should be given when patients have fever and other symptoms that antipyretics would help treat, such as:
The drug should be continued only while these symptoms persist, not for the duration of fever itself 1.
Safety Profile Supporting First-Line Use
Paracetamol has an exemplary safety record at therapeutic doses, making it the preferred antipyretic across all age groups. 2
- In therapeutic doses (4 g/day for adults, 60 mg/kg/day for children), paracetamol relieves fever with minimal risk of complications 3
- It has a tolerability profile similar to placebo when used short-term 4
- Unlike NSAIDs, paracetamol avoids platelet impairment, gastrointestinal toxicity, and nephrotoxicity 5
- It is safe for use in children of all ages, unlike NSAIDs which have age restrictions 4
Preferred Over NSAIDs in Many Populations
Until more evidence emerges, paracetamol is preferred to NSAIDs for patients with acute febrile illnesses. 1
The NICE guidelines specifically recommend paracetamol over NSAIDs for COVID-19 patients with fever 1. This preference extends to other vulnerable populations:
- Children with viral illnesses: Paracetamol became the mainstay pediatric antipyretic after aspirin was linked to Reye's syndrome in the 1980s 2
- Patients with liver disease: Paracetamol at reduced doses (2-3 g/day) is safer than NSAIDs, which cause additional hepatic, renal, and gastrointestinal complications 5
- Elderly patients and those with cardiovascular, renal, or bleeding disorders: Paracetamol avoids the cardiovascular and renal risks associated with NSAIDs 2
Important Clinical Caveats
Fever itself is a beneficial biological response and does not require treatment in most cases. 6
- Public concern about childhood fever and febrile convulsions is largely unwarranted 6
- Paracetamol shows no important advantage over placebo in preventing febrile convulsions 6
- The drug is probably over-prescribed for fever management, with its value more perceived than real 6
Hydration is equally important. Patients should be advised to drink fluids regularly to avoid dehydration (no more than 2 liters per day) 1.
Dosing for Efficacy
To maximize efficacy, appropriate dosing is paramount. Older studies using subtherapeutic doses of ≤10 mg/kg showed paracetamol to be less effective than NSAIDs 4. However, when used at 15 mg/kg in children, paracetamol is significantly more effective than placebo and at least as effective as NSAIDs for fever management 4.
When NOT to Use Paracetamol
Avoid paracetamol in acute liver failure caused by paracetamol overdose itself (though N-acetylcysteine should still be administered) 7. For patients with chronic liver disease, paracetamol remains safe at reduced doses of 2-3 g/day maximum 7, 5.