It’s widely accepted in the medical community that acetaminophen is safer than ibuprofen. Cardiologists hate ibuprofen. It’s just that the average patient for the average use-case will find ibuprofen more effective than acetaminophen for pain control.
The risk is cumulative and dose-dependent. There’s some evidence for lifetime dose of ibuprofen being associated with chronic kidney disease (CKD). The less the better, generally speaking. Though there are some conditions like pericarditis where high-dose ibuprofen for weeks is indicated (a condition in which acetaminophen is not standard of care).
If you are using Ibuprofen for pain control, most of your analgesic bang-for-your-buck will be at 400mg. There’s diminishing analgesia returns as you go above this to 800mg (unless you are at the ends of the spectrum of adult weight).
Anyway, just my five cents. Thanks for getting the word out there. We also should really be banning the Costco size bottles of ibuprofen. I think it encourages casual overuse. But alas.
Yes, the main issue is efficacy. Ibuprofen is anti-inflammatory; acetaminophen is not. In any case where pain is caused by inflammation, you get a stronger effect because it prevents the inflammation, i.e. dental pain and arthritis.
In menstrual pain, ibuprofen prevents pain partially by blocking the action of prostaglandins which stimulate the uterine muscles to contract, which is what causes the pain to begin with.
Basically some of the undesirable side effects of ibuprofen in some cases are actually desirable, depending on the kind of pain. I use ibuprofen for menstrual and dental pain, acetaminophen for everything else.
I was wrong all along too. I’ve been terrified of acetaminophen for years because I knew about how easy it was to overdose and was afraid I’d forget when I’d taken the last dose one day.
Ibuprofen has been my go to analgesic because of that. Oh well live and learn I guess.
This tracks with my experience with doctors as well! I’d always assumed Ibuprofen was safer for some reason, and then when I was dealing with some chronic back pain issues last year, multiple doctors independently recommended prioritizing Tylenol over ibuprofen for pain relief if possible.
>Ibuprofen inhibits the body’s production of the Cyclooxygenase (COX) enzyme.
This is incorrect, ibuprofen inhibits COX activity, not production of the enzyme itself. (Another way of phrasing this is that ibuprofen inhibits prostaglandin production.)
Interestingly, prostaglandin signaling is involved in ovulation. So don't take ibuprofen if you're trying to get pregnant. (But in case you're wondering, COX inhibitors aren't reliable enough at blocking ovulation to use in emergency contraception: https://pmc.ncbi.nlm.nih.gov/articles/PMC4040982/ )
Unfortunately, I believe you are correct that this is incorrect! Thank you for the correction.
(I note to anyone causally reading this that this is a purely "local" issue. That sentence should be "ibuprofen inhibits the COX enzymes", but everything that comes after is still true.)
Ok what about for sprains, strains, and other musculoskeletal issues? I always thought ibuprofen was good for these because it specifically reduces inflammation.
This is interesting - no one tells you consider tradeoffs in taking an OTC drug. The FDA just tells you if it's safe and efficacious, and for what / with what risks, but it doesn't tell you when to take it. A doctor could tell you what to do in a specific situation, but we (mostly) don't have a doctor following us around all the time. You could ask AI, which may be better than guessing, but you'd have to build the habit to actually ask, instead of just reaching for you have. There's a sort of "everyday medical judgment" gap that no one is really filling. It would be nice to have an instruction manual for basic health, like a chart you can put up inside the medicine cabinet, that specifically guides decision making in common situations. Like the food pyramid, but for drugs.
I also immediately wondered why you wouldn't just take NAC along with acetaminophen, so thanks for footnote 6! I'm not sure the concern about side effects of NAC are well-founded though. Supplementing with glycine and NAC (both glutathione precursors) has some evidence for being beneficial even absent acetaminophen overdose: https://www.bcm.edu/news/glynac-supplementation-reverses-aging-hallmarks-in-aging-humans
Believe it or not, the first version of this used "paracetamol" everywhere, and "acetaminophen" only appeared in parentheses in the first sentence. It looks like when we made the change to "acetaminophen", we forgot to switch the parenthetical.
I had some serious inflammation in my noggin and was on the powerful steroidal anti-inflammatory Dexamethasone for a long time (several months). Wonderful stuff but I was still getting some headaches. My doctors told me to use acetaminophen rather than any NSAIDs (aspirin, ibuprofen), so as not to double up. On reflection given how bad my heartburn was on Dex, I definitely would not have wanted to risk making it any worse.
As a result acetaminophen is my default painkiller at this point.
When I was getting vaccinated one time the pharmacist recommended that if I got a headache etc. I should take Acetaminophen so as not to risk suppressing immune reaction.
It’s widely accepted in the medical community that acetaminophen is safer than ibuprofen. Cardiologists hate ibuprofen. It’s just that the average patient for the average use-case will find ibuprofen more effective than acetaminophen for pain control.
The risk is cumulative and dose-dependent. There’s some evidence for lifetime dose of ibuprofen being associated with chronic kidney disease (CKD). The less the better, generally speaking. Though there are some conditions like pericarditis where high-dose ibuprofen for weeks is indicated (a condition in which acetaminophen is not standard of care).
If you are using Ibuprofen for pain control, most of your analgesic bang-for-your-buck will be at 400mg. There’s diminishing analgesia returns as you go above this to 800mg (unless you are at the ends of the spectrum of adult weight).
Anyway, just my five cents. Thanks for getting the word out there. We also should really be banning the Costco size bottles of ibuprofen. I think it encourages casual overuse. But alas.
Yes, the main issue is efficacy. Ibuprofen is anti-inflammatory; acetaminophen is not. In any case where pain is caused by inflammation, you get a stronger effect because it prevents the inflammation, i.e. dental pain and arthritis.
In menstrual pain, ibuprofen prevents pain partially by blocking the action of prostaglandins which stimulate the uterine muscles to contract, which is what causes the pain to begin with.
Basically some of the undesirable side effects of ibuprofen in some cases are actually desirable, depending on the kind of pain. I use ibuprofen for menstrual and dental pain, acetaminophen for everything else.
I was wrong all along too. I’ve been terrified of acetaminophen for years because I knew about how easy it was to overdose and was afraid I’d forget when I’d taken the last dose one day.
Ibuprofen has been my go to analgesic because of that. Oh well live and learn I guess.
Interesting. For me personally 800 mg of ibuprofen feels more than twice as effective as 400 mg.
This tracks with my experience with doctors as well! I’d always assumed Ibuprofen was safer for some reason, and then when I was dealing with some chronic back pain issues last year, multiple doctors independently recommended prioritizing Tylenol over ibuprofen for pain relief if possible.
>Ibuprofen inhibits the body’s production of the Cyclooxygenase (COX) enzyme.
This is incorrect, ibuprofen inhibits COX activity, not production of the enzyme itself. (Another way of phrasing this is that ibuprofen inhibits prostaglandin production.)
Interestingly, prostaglandin signaling is involved in ovulation. So don't take ibuprofen if you're trying to get pregnant. (But in case you're wondering, COX inhibitors aren't reliable enough at blocking ovulation to use in emergency contraception: https://pmc.ncbi.nlm.nih.gov/articles/PMC4040982/ )
Unfortunately, I believe you are correct that this is incorrect! Thank you for the correction.
(I note to anyone causally reading this that this is a purely "local" issue. That sentence should be "ibuprofen inhibits the COX enzymes", but everything that comes after is still true.)
Ok what about for sprains, strains, and other musculoskeletal issues? I always thought ibuprofen was good for these because it specifically reduces inflammation.
It may be good for pain relief, but inflammation is part of the healing process. It may delay recovery.
An interesting addition is etoricoxib which I think is approved mostly anywhere other than the US.
it carries a different mixture of these risks, which I think makes it ideal for some usage patterns.
This is interesting - no one tells you consider tradeoffs in taking an OTC drug. The FDA just tells you if it's safe and efficacious, and for what / with what risks, but it doesn't tell you when to take it. A doctor could tell you what to do in a specific situation, but we (mostly) don't have a doctor following us around all the time. You could ask AI, which may be better than guessing, but you'd have to build the habit to actually ask, instead of just reaching for you have. There's a sort of "everyday medical judgment" gap that no one is really filling. It would be nice to have an instruction manual for basic health, like a chart you can put up inside the medicine cabinet, that specifically guides decision making in common situations. Like the food pyramid, but for drugs.
I also immediately wondered why you wouldn't just take NAC along with acetaminophen, so thanks for footnote 6! I'm not sure the concern about side effects of NAC are well-founded though. Supplementing with glycine and NAC (both glutathione precursors) has some evidence for being beneficial even absent acetaminophen overdose: https://www.bcm.edu/news/glynac-supplementation-reverses-aging-hallmarks-in-aging-humans
But what about naproxen? It's my favorite and seems to work best for me! Tell us more about naproxen! 😄
My not-that informed and not-medical advice understanding is that among NSAIDs at analgesic doses the big three risks go roughly like this:
CVD risk: aspirin < naproxen < ibuprofen
GI risk: ibuprofen < naproxen < aspirin
kidney risk: aspirin ≈ naproxen ≈ ibuprofen
Not medical advice!
Thank you, Doctor Dyno 🫡
Ya dude it’s very obvious which one is worse…
(It is not at all obvious. Great writeup — thank you.)
If you’re mentioning the UK in a footnote, maybe worth also listing “paracetamol” near the top of the article as the local name for acetaminophen.
Believe it or not, the first version of this used "paracetamol" everywhere, and "acetaminophen" only appeared in parentheses in the first sentence. It looks like when we made the change to "acetaminophen", we forgot to switch the parenthetical.
I had some serious inflammation in my noggin and was on the powerful steroidal anti-inflammatory Dexamethasone for a long time (several months). Wonderful stuff but I was still getting some headaches. My doctors told me to use acetaminophen rather than any NSAIDs (aspirin, ibuprofen), so as not to double up. On reflection given how bad my heartburn was on Dex, I definitely would not have wanted to risk making it any worse.
As a result acetaminophen is my default painkiller at this point.
When I was getting vaccinated one time the pharmacist recommended that if I got a headache etc. I should take Acetaminophen so as not to risk suppressing immune reaction.