This is an update of the summary presented on December 17th, 2013. Based on our readers’ comments and questions, we have sought answers from the author. Due to their importance, we chose to present those in an updated post.
Dr. Edmund Bailey
What would be the recommended dosing and schedule for combining the two medications? And what would be the maximum dosing guideline? If rescue medications are required, what would be recommended and how would that be modified, if a patient has a codeine allergy?
Based on this review, the ideal doses are 400mg ibuprofen and 1000mg paracetamol, both may be taken four times a day (every 6-8 hours). The maximum daily dose for ibuprofen is 2400mg and 4000mg for paracetamol. Based on clinical experience, it is advisable to alternate both drugs for maximal effect as they have different modes of action. Codeine allergy is rare, although more commonly, patients will have an intolerance to codeine as it is an opioid analgesic with side effects, including constipation which is a major problem for some. Tramadol may be used instead of codeine in those who are struggling.
Other Cochrane reviews are available on other analgesics used in the post-operative pain model, with specific sections on post-operative wisdom tooth pain.
Did the article mention the dosage of both Ibo.and parac. in the new drug Nuromol??
The dose is 200mg/500mg ibuprofen/paracetamol per tablet, although two tablets can be taken at a time doubling the dose.
The summary is based on the Cochrane systematic review: Ibuprofen versus paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth
Context
- Both paracetamol and ibuprofen are commonly used analgesics for the relief of pain following the surgical removal of lower wisdom teeth (third molars).
- In 2010, a novel analgesic (marketed as Nuromol) containing both paracetamol and ibuprofen in the same tablet was launched in the United Kingdom. This drug has shown promising results to date and there is a need to compare the combined drug with the single drugs using this model.
- In this review, the optimal doses of both paracetamol and ibuprofen are investigated via comparison of both and via comparison with the novel combined drug. The side effect profile of the study drugs was taken into consideration.
- This review will help oral surgeons to decide on which analgesic to prescribe following wisdom tooth removal.
Purpose of the Review
- To compare the beneficial and harmful effects of paracetamol, ibuprofen and the novel combination of both in a single tablet for pain relief following the surgical removal of lower wisdom teeth, at different doses and administered post-operatively.
Conclusions
- There is high quality evidence that ibuprofen is superior to paracetamol at doses of 200 mg to 512 mg and 600 mg to 1000 mg respectively based on pain relief and use of rescue medication data collected at six hours postoperatively.
- The majority of this evidence (five out of six trials) compared ibuprofen 400 mg with paracetamol 1000 mg, these are the most frequently prescribed doses in clinical practice.
- The novel combination drug is showing encouraging results based on the outcomes from two trials when compared to the single drugs.
Main Results
- Seven studies were included, they were all parallel-group studies, two studies were assessed as at low risk of bias and three at high risk of bias; two were considered to have unclear bias in their methodology. A total of 2241 participants were enrolled in these trials.
- Ibuprofen was found to be a superior analgesic to paracetamol at several doses with high quality evidence suggesting that ibuprofen 400 mg is superior to 1000 mg paracetamol based on pain relief (estimated from TOTPAR data) and the use of rescue medication meta-analyses.
- The risk ratio for at least 50% pain relief (based on TOTPAR) at six hours was 1.47 (95% confidence interval (CI) 1.28 to 1.69; five trials) favouring 400 mg ibuprofen over 1000 mg paracetamol, and the risk ratio for not using rescue medication (also favouring ibuprofen) was 1.50 (95% CI 1.25 to 1.79; four trials).
- The combined drug showed promising results, with a risk ratio for at least 50% of the maximum pain relief over six hours of 1.77 (95% CI 1.32 to 2.39) (paracetamol 1000 mg and ibuprofen 400 mg) (one trial; moderate quality evidence), and risk ratio not using rescue medication 1.60 (95% CI 1.36 to 1.88) (two trials; moderate quality evidence).
- The information available regarding adverse events from the studies (including nausea, vomiting, headaches and dizziness) indicated that they were comparable between the treatment groups. However, we could not formally analyse the data as it was not possible to work out how many adverse events there were in total.
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When my patients ask me, “What will it be, doc. Acetaminophen or Ibuprofen?”, I order them a cocktail of 2 regular strength Tylenols (325mg x 2) and 2 regular strength Advils (200mg x 2) to be taken together every 4 hours (5 times a day) 8am, 12 noon, 4pm, 8pm and midnight by the clock. Don’t wait for the pain to come and then react. This comes close to the daily maximum of each drug. This works out to 3,250mg of Acetaminophen (max. dose 4000mg in 24h) and 2000mg of Ibuprofen (max. dose of 2400mg in 24h). I strictly warn to not exceed these doses, for the sake of the liver and kidneys. If I anticipate that more pain relief is needed after a surgical procedure, then I may modify the cocktail by substituting two Tylenol 3’s for the two regular strength Tylenols.