What alternative medication can be given to a patient with an allergy to paracetamol (acetaminophen) for pain and fever management?

Alternative Medications for Paracetamol Allergy

For patients with paracetamol allergy, NSAIDs—specifically ibuprofen at 1.2 g daily—should be the first-line alternative for pain and fever management, as it carries the lowest gastrointestinal risk among all NSAIDs while providing effective analgesia and antipyresis. 1, 2

Primary Alternative: Ibuprofen

• Ibuprofen 400 mg three times daily (1.2 g/day total) is the recommended first-choice NSAID due to its superior safety profile compared to other NSAIDs, particularly regarding gastrointestinal complications 3, 1, 2

• Ibuprofen demonstrates effective antipyretic action comparable to or superior to paracetamol, with the advantage of less frequent dosing (every 6-8 hours versus every 4 hours) and longer duration of action 4

• For acute pain management, ibuprofen is superior to codeine-paracetamol combinations with a number needed to treat of 2.7 versus 4.4 2

Secondary Alternatives if Ibuprofen Fails

• If ibuprofen at 1.2 g daily provides inadequate relief, increase the dose to 2.4 g daily (though this higher dose carries intermediate gastrointestinal risk similar to diclofenac and naproxen) 3

• Diclofenac or naproxen may be considered if ibuprofen fails at maximum doses, recognizing these carry higher gastrointestinal risk than ibuprofen 3

• Mefenamic acid 6 mg/kg/dose is an effective alternative NSAID with comparable antipyretic efficacy to high-dose paracetamol 5

For Patients Who Cannot Tolerate NSAIDs

• Opioid analgesics (codeine, tramadol) with or without other non-paracetamol agents are useful alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 3

• Codeine alone demonstrates better pain relief than placebo (effect size 0.78) but causes more adverse events including gastrointestinal upset, constipation, and dizziness 3

• Tramadol may be considered as an alternative oral analgesic, though evidence in specific pain conditions varies 3

Critical Safety Considerations

Gastrointestinal Risk Hierarchy

• The gastrointestinal risk hierarchy is: Ibuprofen < Diclofenac/Naproxen < Other NSAIDs 1, 2

• For patients with increased gastrointestinal risk, co-prescribe proton pump inhibitors with NSAIDs to reduce bleeding risk 3, 1

• Misoprostol and proton pump inhibitors reduce the risk of NSAID-induced duodenal ulcers and other serious upper gastrointestinal injury 3

Cardiovascular and Renal Precautions

• NSAIDs should be avoided entirely in patients with severe chronic kidney disease, heart failure, or history of gastrointestinal bleeding 6, 2

• Monitor blood pressure, renal function (BUN, creatinine), liver function, and CBC every 3 months during chronic NSAID use 2

• Discontinue NSAIDs if BUN or creatinine doubles, hypertension develops or worsens, or liver enzymes increase >3× upper limit of normal 2

Antiplatelet Interactions

• Ibuprofen interferes with aspirin's antiplatelet effect—patients on low-dose aspirin should take ibuprofen ≥30 minutes after aspirin or ≥8 hours before aspirin 2

• For patients requiring anticoagulation or antiplatelet therapy, NSAIDs must be used with extreme caution and gastroprotection 1

Special Populations

Elderly Patients

• Use the lowest effective NSAID dose for the shortest duration in patients ≥60 years 2

• NSAIDs should be used with extreme caution and gastroprotection if required in elderly patients 1

Pediatric Patients

• Ibuprofen is at least as effective as paracetamol for analgesia and more effective as an antipyretic in children 4

• The safety profile of ibuprofen is comparable to paracetamol when used appropriately with correct dosing regimens 4

Route of Administration

• The oral route should be the first choice for analgesic administration 3

• Topical NSAIDs can provide significant pain reduction with fewer systemic side effects than oral NSAIDs, though evidence for their role remains limited 3, 6

Common Pitfalls to Avoid

• Do not prescribe NSAIDs on an "as required" basis for chronic pain—analgesics for chronic pain should be prescribed on a regular schedule 3

• Review NSAID requirements regularly (at least every 6 months) and encourage limited "as required" use when appropriate 3

• Never assume all NSAIDs have equivalent safety profiles—ibuprofen at standard doses (1.2 g daily) is significantly safer than other NSAIDs regarding gastrointestinal complications 3, 1

• Do not overlook the need for rescue doses of medication for breakthrough pain episodes in addition to regular basal therapy 3