University of the
Witwatersrand
Department of Paediatrics
Division of Community
Paediatrics
Assignment A: Is Ibuprofen Better Than Paracetamol
in Reducing Fever?
Ayesha Bibi Khan
Pyrexia Reduction Using Ibuprofen and Paracetamol
Title
Is ibuprofen better than paracetamol at reducing pyrexia?
Scenario
A 10 year old boy presents with a history of dyspnoea and cough of five days duration.
Clinical examination revealed features suggestive of multi-lobar pneumonia, including
collapse and consolidation of the right upper, left upper and left lower lobes. Following
admission he developed a spiking temperature which was treated using paracetamol. His
pyrexia continued for several days. I wondered if using ibuprofen would have been more
beneficial in reducing his pyrexia.
Clinical Question
In children presenting with a significant fever, is ibuprofen better than paracetamol at
controlling pyrexia?
Search Strategy
Cochrane Database of Systematic Reviews and Pubmed:
Search criteria: Ibuprofen +paracetamol +fever
Limits:All child 0-18yrs
English
Abstracts
Human
Search outcome:
Cochrane – One hit which was irrelevant
Pubmed –
41 hits
 10 relevant
 31 irrelevant, relating either to adults, pyrexia control or pharmacologic
and other topics.
Summary of Relevant Papers
Author, date and
country
Patient group
Study type (level of
evidence)
Outcomes
Similar results obtained for degree & rate of
temp ↓ for both groups
Ibuprofen has greater efficacy in terms of
duration of action
Efficacy of high-dose & low-dose ibuprofen is
greater than paracetamol
Drop in temp similar in both groups
At half hour paracetamol greater drop than
ibuprofen
Ibuprofen produced a greater temp decrement &
longer duration of antipyresis than paracetamol
Mefenamic acid>ibuprofen>paracetamol in
degree of antipyresis
Key results
Sheth UK et al 1980
22 children
Not available
Rate of temp ↓
Degree of temp↓
Duration of ↓ in
temp, over 12h
Walson PD et al 1989
USA
127 children aged
2-11yrs
Double-blind randomised
control
Rate of temp ↓,
over 12h
Joshi YM et al 1990
India
175 children aged
4mo-12yrs
Open multi-centric trial
Degree of temp↓
½ hrly for 2h
Kauffmann RE et al
1992 USA
Khubchandani RP et
al 1995 India
37 children aged 212yrs
87 children aged 17yrs
Double-blind randomised
placebo-control study
McIntrye J et al 1996
England
Children in
paediatric ward
aged 2mo-12yrs
Double-blind parallel
group multiple dose study
(level 1b)
Autret E et al 1997
France
Children aged 624mo
Open randomised
% temp ↓
Ibuprofen had greater efficacy than paracetamol
and aspirin.
Vauzelle-Kervroedan
F et al 1997 France
116 children aged
2-8yrs
Double-blind randomised
control (level 1b)
Rate of temp ↓
Degree of temp ↓
Duration of ↓ in
temp, over 6h
Ibuprofen demonstrated greater efficacy than
paracetamol, but this was not statistically
significant.
Wong A et al 2001
Brazil
555 children aged
6mo-6yrs
Modified Double-blind
randomised multi-national
trial (level 1b)
Degree of temp↓
Duration of ↓ in
temp, over 4-6h
Ibuprofen was better than paracetamol at
temperature normalisation
Dipyrone had a longer duration of action than
either ibuprofen or paracetamol
Figueras Nadal C et al
2002 Spain
199 children
Double-blind randomised
controlled trail multicentric
Change in
tympanic temp
over 4h
Ibuprofen showed a greater degree of temp ↓.
Randomised controlled
Degree of temp↓
at 30min & 8h
Degree of temp↓,
over 4h
Mean temp
change efficacy
at 4h
Change in
clinical condition
Study weaknesses
Small numbers
Only tested over
2h
Small numbers
Unblinded
No significant difference between paracetamol
and ibuprofen
Unblinded
Aspirin in
children!
12 children
discontinued use
d/t SE
Commentary
At first glance it seems that an equal number of studies found ibuprofen as efficacious as
paracetamol, and ibuprofen superior to paracetamol. However, on closer inspection and
analysis of the evidence, ibuprofen is clearly superior to paracetamol.
Controlled studies by Walson et al and others show that ibuprofen has greater antipyrexial efficacy than paracetamol. However, this is opposed by the studies by, amongst
others, Sheth et al, which claim paracetamol to be equally efficacious to ibuprofen.
Caution is required when interpreting the Sheth et al study because the numbers studied
are too few to be statistically significant. McIntyre et al did not provide figures of the
number of patients treated, and so one must also approach this study with reserve. Most
studies, it seems, were conducted over a reasonable period of time (4 – 8 hrs); Joshi et al
only conducted their study over two hours. Not withstanding the onset of action of the
drugs, this time frame is insufficient to make a comment on the efficacy of the drugs,
since acute fluctuations in temperature may skew the results in either direction.
The rate of temperature decrease is more impressive, especially in Walson et al and
Wong et al. These studies are well structured (double-blind and randomised control trial),
and have an adequate number of participants to be able to draw reasonable conclusions
from, as well as increasing their reliability.
The duration of action of ibuprofen surpasses that of paracetamol according to Seth et al,
Kauffmann et al and Vauzelle-Kervroeden et al. The evidence is not very convincing as
the former two studies have insufficient numbers to draw conclusions from, and the latter
claims no statistical significance, even though ibuprofen is proven to act longer than
paracetamol. No studies directly oppose these findings.
It can thus be concluded that the efficacy of ibuprofen in terms of degree, rate and
duration of action is superior to that of paracetamol. It should be noted that several
studies show that tolerability was similar with both drugs Regardless, the safety profile of
ibuprofen is less impressive than paracetamol (this is a separate topic and will not be
discussed further here).
Clinical Bottom Line
Ibuprofen is better than paracetamol for reducing fever in children.
References
1. Sheth UK, Gupta K, Paul T et al. Measurement of antipyretic activity of ibuprofen
and paracetamol in children. J Clin Pharmacol. 1980;20:672-5
2. Walson PD, Galletta G, Braden NJ et al. Ibuprofen, acetaminophen, and placebo
treatment of febrile children. Clin Pharm Therapeutics 1989;46:9-17.
3. Joshi YM, Sovani VB, Joshi VV et al. Comparative evaluation of the antipyretic
efficacy of ibuprofen and paracetamol. Indian Pediatr 1990;27:803-6.
4. Kauffman RE, Sawyer LA, Scheinbaum ML. Antipyretic efficacy of ibuprofen vs
acetaminophen. Am J Dis Child 1992;146:622-625.
5. Khubchandani RP, Ghatikar KN, Keny S et al. Choice of antipyretic in children. J
Assoc Physicians India 1995;43:614-16.
6. McIntyre J, Hull D. Comparing efficacy and tolerability of ibuprofen and
paracetamol in fever. Arch Dis Child 1996;74:164-7.
7. Autret E, Reboul-Marty J, Henry-Launois B et al. Evaluation of ibuprofen versus
aspirin and paracetamol on efficacy and comfort in children with fever. Eur J Clin
Pharm 1997;51:367-1.
8. Vauzelle-Kervroedan F, d'Athis P, Pariente-Khayat A et al. Equivalent antipyretic
activity of ibuprofen and paracetamol in febrile children. J Pediatr 1997;131:6837.
9. Wong A, Sibbald A, Ferrero F et al. Antipyretic effects of dipyrone versus
ibuprofen versus acetaminophen in children: results of a multinational,
randomized, modifiable double-blind study. Clin Pediatr (Phila). 2001;40:31324.
10. Figueras NC, Garcia de Miguel MJ, Gomez CA et al. Effectiveness and
tolerability of ibuprofen-arginine versus paracetamol in children with fever of
likely infectious origin. Acta Paediatr. 2002;91:383-90.