What is the better medication for a patient with a sore throat, acetaminophen (Tylenol) or ibuprofen (Advil), considering their age, medical history, and potential for bacterial infection like strep throat?

Ibuprofen is Superior for Sore Throat Pain Relief

For acute sore throat, ibuprofen is the better choice over acetaminophen (paracetamol), providing significantly superior pain relief particularly after the first 2 hours of administration. 1, 2

Primary Recommendation

• Ibuprofen (400-600 mg every 6-8 hours, maximum 2.4g daily) should be first-line treatment for sore throat pain in adults without contraindications. 1, 2
• Multiple international guidelines (European Society of Clinical Microbiology and Infectious Diseases, American College of Physicians) specifically recommend ibuprofen as having slightly better efficacy than paracetamol for pharyngitis pain relief. 2
• Direct comparative trials demonstrate ibuprofen 400mg is more effective than acetaminophen 1000mg on all pain rating scales at all time points after 2 hours. 3

Clinical Decision Algorithm

Step 1: Screen for Contraindications to Ibuprofen

Use acetaminophen (1000mg every 6 hours, maximum 4g daily) instead of ibuprofen if patient has:

• Chronic kidney disease or reduced creatinine clearance 1
• History of gastrointestinal bleeding or peptic ulcer disease 1
• Heart failure or significant cardiovascular disease 1
• Cirrhosis (NSAIDs carry renal and bleeding risks) 1
• Age >65 years with multiple comorbidities (consider paracetamol first-line due to superior safety profile) 1

Step 2: Initial Treatment

For patients WITHOUT contraindications:

• Start ibuprofen 400mg every 6-8 hours 1, 2
• Can increase to 600mg every 6 hours if inadequate response, not exceeding 2.4g daily 1

For patients WITH contraindications:

• Start paracetamol 1000mg every 6 hours, maximum 4g/24 hours 1

Step 3: Escalation if Inadequate Response

If single-agent therapy fails after 1-2 doses:

• Add the other medication (combine paracetamol up to 4g daily plus ibuprofen up to 2.4g daily) 1
• This combination approach is supported for breakthrough pain management 1

Step 4: Consider Bacterial Infection

Assess need for antibiotics using clinical scoring (Centor, McIsaac, FeverPAIN): 4

• Score <3 points: No antibiotics indicated, continue symptomatic treatment only 4
• Score 3 points: Consider delayed antibiotic prescription 4
• Score >3 points: Immediate antibiotics can be considered (penicillin first choice for 5-7 days) 4
• Important caveat: Even with high scores suggesting bacterial cause, antibiotics only modestly shorten symptom duration 4

Age-Specific Considerations

Pediatric Patients

For children 6 months to 9 years:

• Both ibuprofen and paracetamol are equally effective with no significant difference in analgesic efficacy or safety 2
• Ibuprofen: 10 mg/kg per dose every 6-8 hours (maximum 40 mg/kg/day) 5
• Paracetamol: 10-15 mg/kg per dose every 4-6 hours (maximum 60 mg/kg/day) 5

For infants under 6 months:

• Paracetamol is the ONLY recommended analgesic (15 mg/kg per dose) 5
• Ibuprofen is contraindicated in this age group 5

Safety Profile Comparison

Ibuprofen carries higher risks of:

• Dose-dependent gastrointestinal bleeding (relative rate 1.11 to 1.49 with higher doses) 1
• Cardiovascular adverse events (risk ratio 1.19 to 1.68) 1
• Renal adverse events (OR of ≥30% decrease in kidney function: 1.40 to 2.19) 1

Paracetamol has:

• Minimal gastrointestinal toxicity at recommended doses 1
• Risk of hepatotoxicity only at doses >4g/24 hours 1
• Superior safety profile for long-term use (studied up to 2 years) 1

Common Pitfalls to Avoid

• Do not use local antibiotics or antiseptics for sore throat—they lack efficacy data and most sore throats are viral. 2, 6
• Do not prescribe antibiotics for low-risk patients (Centor score <3)—this contributes to resistance without meaningful benefit. 4
• Do not exceed maximum daily doses: Paracetamol >4g/24 hours risks hepatotoxicity; ibuprofen >2.4g/24 hours increases adverse events. 1
• Do not use aspirin in children due to Reye's syndrome risk. 7
• Do not assume zinc gluconate helps—it has conflicting efficacy results and increased adverse effects. 8, 2
• Do not recommend herbal treatments or acupuncture—reliable efficacy data are lacking. 8, 2

Gastroprotection Strategy

For high-risk patients requiring ibuprofen:

• Add a proton pump inhibitor for gastroprotection 1
• Use the lowest effective dose for the shortest duration 1