In this episode, I’ll discuss the analgesic ceiling dose of ibuprofen in ED patients.
NSAIDs (including ibuprofen) have a ceiling dose beyond which, no additional analgesic effect is seen. I must have missed that part of the lecture in pharmacy school because I don’t remember encountering this concept in practice until I heard a talk from ED physician Larry Raney that is archived on freeemergencytalks.net about the rational use of NSAIDs.
Back in episode 473, I talked about the evidence behind the discrepancy between the labeled dose and the analgesic ceiling dose of IV ketorolac. There is similar data on the ceiling dose of ibuprofen as well.
In Annals of Emergency Medicine, a group of authors compared the analgesic efficacy of oral ibuprofen at 3 different doses for adult ED patients with acute pain.
225 patients were split evenly between groups. the primary outcome was the difference in pain scores between the 3 groups at 60 minutes.
About three-quarters of the patients had musculoskeletal pain such as that from a sprain, strain, or fracture. The next most frequent causes of pain were abscesses, lacerations, dental pain, and headache.
All patients were given liquid ibuprofen – the first group received a single dose of oral ibuprofen at 400 mg; the second group, at 600 mg; and the third group,
at 800 mg.
The authors observed no clinically meaningful differences in the mean numeric rating scale pain scores between the 3 dose groups at 60 minutes. The need for rescue analgesia was also not different between groups, with 4 patients in the 400 mg and 800 mg group needed a rescue analgesic at 60 minutes, as well as 1 patient in the 600 mg group.
The study was adequately powered to show differences in analgesia, but there were not enough patients to show a difference in adverse effects between the 3 groups such as GI discomfort.
Based on this study, 400 mg appears to be the ceiling dose of analgesic effect for ibuprofen when given to ED patients with common causes for pain. The authors hope that with their research and “proper patient and provider education supported by the evidence, the myth of better pain relief with “prescription-only” dosages will be debunked.”
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