What is the recommended first-line treatment for a patient requiring pain management, considering the use of Paracetamol (PCM) and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Paracetamol vs NSAIDs for Pain Management

Paracetamol (acetaminophen) should be your first-line analgesic for most patients requiring pain management, with NSAIDs reserved as second-line or used in combination for moderate-to-severe pain when contraindications are absent. 1, 2, 3

First-Line: Paracetamol

Start with paracetamol 1000 mg every 6 hours (maximum 4 g/24 hours) as baseline therapy for all pain intensities. 1, 3, 4

Why Paracetamol First?

• Superior safety profile compared to NSAIDs and opioids, with no cardiovascular toxicity, no increased bleeding risk, and no renal toxicity at standard doses 2, 5
• Effective as monotherapy for mild-to-moderate pain and reduces opioid requirements when used in multimodal regimens 1, 6
• Well-tolerated with rare serious adverse effects when used at recommended doses 7, 5, 8
• Preferred in high-risk populations including elderly patients, those with cardiovascular disease, renal impairment, gastrointestinal disorders, asthma, pregnant women, and patients on anticoagulation 2, 5, 8

Critical Dosing Considerations

• Never exceed 4 g daily (reduce to 3 g daily for chronic use, elderly, or liver disease) to avoid hepatotoxicity 3, 5
• No routine dose reduction needed for older adults unless specific contraindications exist 5
• Monitor hepatic function with chronic use, particularly in patients with pre-existing liver disease, malnutrition, or alcohol use disorder 2, 9

Second-Line: Add NSAIDs for Inadequate Relief

If paracetamol alone provides insufficient analgesia after 24-48 hours, add an NSAID (ibuprofen preferred) rather than exceeding paracetamol maximum dose. 1, 3, 4

Combination Therapy for Moderate-to-Severe Pain

• Ibuprofen 400 mg plus paracetamol 1000 mg every 6 hours provides superior analgesia through additive/synergistic mechanisms 1, 4
• Multimodal approach reduces individual drug-related side effects while improving overall pain control 1, 4
• COX-2 selective inhibitors may be considered if gastrointestinal protection is needed, though they don't protect against renal failure or cardiovascular events 1

NSAID Contraindications (Use Paracetamol Alone)

Screen carefully before prescribing NSAIDs:

• Active peptic ulcer disease or history of gastrointestinal bleeding 1, 4
• Severe renal impairment or chronic kidney disease 1, 9
• Heart failure or significant cardiovascular disease 1, 4, 9
• Concurrent anticoagulation therapy 4
• Aspirin-sensitive asthma 7, 8
• Platelet dysfunction or hemophilia 1, 8

When NSAIDs Are Appropriate

NSAIDs are effective for moderate pain when used alone and reduce morphine consumption in multimodal regimens, but require careful patient selection. 1

• Use lowest effective dose for shortest duration to minimize cardiovascular and gastrointestinal risks 1, 9
• Monitor periodically for gastrointestinal bleeding, renal function, blood pressure, and cardiovascular events 1, 9
• Topical NSAIDs recommended for non-low back musculoskeletal injuries to reduce systemic exposure 9

Common Pitfalls to Avoid

• Don't use NSAIDs as first-line in stroke patients due to cardiovascular toxicity and bleeding risk—paracetamol is strongly preferred 2
• Don't combine multiple NSAIDs or use with anticoagulants without careful risk assessment 1, 4
• Don't assume paracetamol is ineffective—it works best when dosed regularly (not "as needed") and combined with other modalities 1
• Don't forget rescue doses—prescribe immediate-release analgesics for breakthrough pain even when baseline therapy is adequate 1

Escalation Strategy

If paracetamol plus NSAIDs remain insufficient:

• Add weak opioids (tramadol 12.5-25 mg every 4-6 hours preferred) for moderate pain 2, 3
• Consider strong opioids (morphine) only for severe pain, with individual titration and laxative prophylaxis 1, 3
• Minimize opioid use through multimodal analgesia incorporating paracetamol and NSAIDs as baseline 1, 2