Ibuprofen vs APAP

[vc85]

Our protocols will soon include a choice of Ibuprofen or APAP for fever reduction and pain management

Assuming the agency will carry both which is your choice and why. I know there are hepato-tox issues with APAP. Would that rule it out

 

[Ensihoitaja]

Assuming no alcohol/liver issues, it's really patient's preference. Ibuprofen doesn't do anything for me, I prefer Aleve, personally. You shouldn't be giving enough acetaminophen to cause liver issues (again, barring other factors).

 

[Gurby]

 

[Aprz]

I think Gurby brought up a good point. You can give both and they work well together. I am extremely sensitive to narcotics. I cannot stand things like Percocet, Morphine, Tramadol. Morphine and Tramadol makes me vomit like crazy with no relief in pain. I've also had syncopal episodes when taking Percocet and Tramadol. Zofran and Dramamine does not work to relieve the nausea. I told my parents that if something ever happens to me, just tell them I am allergic to narcotics and only want NSAIDs/Tylenol. Do not give me Morphine or anything like that. I rather be in pain... (famous last words, right?) Anyways, my jam is usually Tylenol/Ibuprofen combo, which for me, works very well to manage my pain in prior situations.

It is my understanding that the liver toxicity of Tylenol is overrated, that you can take it everyday, just as long as you are not taking high doses (>1,000 mg every 6 hours or >3,000 or 4,000 mg per day). The liver problem happens when you take too much, which is easy to do, especially since so many medications come with Tylenol in it without patient's knowing it. I had one patient who took a bunch of Tylenol unintentionally because of back pain because it wasn't working. To put a cherry on top of it, her husband offered to give her Norco (contains Tylenol as well) since the Tylenol wasn't working, so she took a bunch of Norco as well. I think this is why we more commonly see medications containing Tylenol for treatment of chronic pain and arthritis, or at least I do, versus NSAIDs.

While NSAIDs I don't believe are "hard" on your liver, they are harmful to your kidneys even at therapeutic levels (not overdosing the patient). It is my understanding that NSAIDs should not be used for long periods of time for this reason. I don't know what's with Aleve/Naproxen, but it makes me diaphoretic... :/ Ibuprofen doesn't seem to give me any side effect and work well for pain alone or with Tylenol like I said earlier.

From a prehospital perspective, if you are only giving it once and the patient hasn't taken neither, it's not a big deal to give both in my opinion.

The agency I work for allow us to give Tylenol IV, but we do not carry any NSAID.

Tylenol, in our county, is indicated for pain <7/10 OR if the patient is allergic to Morphine for the treatment of pain of any severity. It is contraindicated, in our county, for anyone who has taken =>3,000 mg Tylenol within the past day, alcoholic, liver disease, weigh <50 kg, or taking Isoniazid for tuberculosis. From my experience, we very very very rarely give it, but to be honest, most people usually don't even give Morphine when they should be. I tend to be very easy going with giving Morphine, in my opinion, and so there is usually no reason for me to give Morphine. I've only had the chance to give Tylenol once where the patient was "allergic" to Morphine (actually just gets super nauseous from it), but the patient was afraid of needles and rather be in pain than get an IV from me...

 

[Peak]

The risk of toxicity with standard dosing of acetaminophen is very low, in fact our hepatotogists and transplant surgeons are often okay with us 325 to 650 mg a day even for many of our liver failure patients. I've had psych patients take multiples of their maxium daily dose and still don't come close to a dangerous level when we trend their labs. Certainly there is some risk especially with long term use or those with other liver disease, but it really isn't as bad as it is made out to be.

For the purpose of fever reduction I find ibuprofen to be superior to acetaminophen in my practice, but this is largely anecdotal and I haven't put in the effort into looking into the literature. We do shy away from NSAIDs in dehyrdated patients since the risk of kidney damage is far greater than those who are euvolemic, and naturally those who have preexisting renal disease.

Generally speaking I would start with acetaminophen, the risks are generally lower and the benefit of NSAIDS over APAP in the short duration of EMS/ED care is pretty limited. Also giving ibuprofen may limit our ability to give more appropriate NSAIDs like toradol or indacin for patients who have conditions better treated by those (or other) drugs such as kidney stones or gout.

NSAIDs are also still viewed with hesitation by a lot of surgeons despite the bleeding risk being much lower with one time appropriate dosing than previously thought.

I also wouldn't preclude the use of both, since they have different mechanisms and largely different risk profiles many patients benefit therapeutically from taking both.

 

[Carlos Danger]

The two are not interchangeable. They are different drugs with different mechanisms and precautions and they work best on different types of pain. Both are extremely limited in their utility in the prehospital environment.

Edit:

It is my understanding that the liver toxicity of Tylenol is overrated, that you can take it everyday, just as long as you are not taking high doses (>1,000 mg every 6 hours or >3,000 or 4,000 mg per day).

Actually, the opposite is true. You'll see significant elevations in aminotransferase levels in many people after just a few days taking 4 grams per day. And acetaminophen is associated with liver damage much more often than most people realize, which has actually led to calls on several occasions for it to be made a prescription-only drug. The problem isn't with the recommended doses of acetaminophen, it's with the fact that the drug is found in so many formulations. Sleep medicines, allergy medicines, cold medicines, prescription pain medicines, etc. It's not uncommon for someone to take Goody's powders along with with their Percocet (whether it was prescribed to them or not) and wash it down with some beers and top it off with some NyQuil. You do that for a few days in a row, especially if you are overweight or have other risk factors for hepatic injury, or are also taking NSAIDS or some of the antibiotics or 1000 other drugs that are also hard on your liver, and you have the start of a potentially very serious problem. Then you go to the ED and they give you a gram because of course you didn't admit to everything else you've been taking, and you can see where the problem lies. It takes as little as 7 grams (though usually twice that much) - which is only 14 extra strength Tylenols - to cause hepatotoxicity, and it can take a lot less than that when some of the aforementioned factors are added to the mix. Ibuprofen is less problematic than acetaminophen, but also deserves more respect than it generally gets. None of this means we shouldn't use these drugs, of course, just that we shouldn't be flippant about their presumed safety.

I told my parents that if something ever happens to me, just tell them I am allergic to narcotics and only want NSAIDs/Tylenol.

Of course you can do whatever you want, but it's generally not a good idea to claim to be allergic to things you aren't actually allergic to. Not only does it make it sound as though you lack knowledge about your own health history (no one is "allergic to narcotics", and trust me, there are LOTS of scenarios where you don't only want NSAIDS), but it can cause problems for you in other ways. It's much better to just explain that you've had problems with nausea in the past. It's a common side effect of morphine, and generally easily managed.

 

[Akulahawk]

From what I've seen, they both work well, as Remi says, they're not interchangeable, though they do work well together. That being said, one of the issues I have with giving either in the EMS setting is that unless you have a reasonably long transport time, you're not going to see any significant relief with either, assuming they're being given PO. With Ibuprofen, the one huge issue I have with having EMS give it is it will keep me from being able to give Toradol or any other NSAID for several hours... and where I work, we use Toradol quite frequently for kidney stones - very effective for that! We don't use Indomethacin (Indocin) much where I work though we do have it available.

 

[Peak]

I do think that acetaminophen can have a place in EMS, especially for the treatment of fever or for pain in longer transports.

We are pretty aggressive with fever management for our more complex patients, the last thing our CHD kids or septic patients need is the increased metabolic demand that results from being febrile.

There is a lot of literature that shows using tylenol in pain management decreases LOS and overall costs, even when given IV. I haven't seen much specific to EMS but this is limited due to obvious reasons.

I do think that even in fairly dense urban populations there is utility to IV tylenol. The cost is far less than people think, lexicomp currently states it is about $52 a bottle, although we pay substantially less than that.

I don't think that NSAIDs or acetaminophen are some magical treatment that will end the scourge of narcotics or whatever, but under certain circumstances they definitely have utility.

 

[Akulahawk]

I do think that acetaminophen can have a place in EMS, especially for the treatment of fever or for pain in longer transports.

In the realm of longer transports, I absolutely agree. Of course, part of my bias against having EMS give these meds is that I'm primarily in an urban/suburban area with relatively short transports, maybe 10-15 minutes max for the vast majority of transports. This is also specifically for PO admin of these meds. If we include IV administration, I think IV APAP becomes an interesting option for both pain and fever control even in short duration transports. Same goes for Toradol.

 

[vc85]

No IVs here unfortunately as this will be going in the BLS protocol (similar to Marylands but expanded for both fever and pain)

Our transports are short so PO pain relief is probably not going to be used often. We do have a lot of elderly septic/SIRS though so I can imagine the fever part of the protocol will be used frequently (especially how much the ED gets on the nursing homes for not giving it prior to shipping them out)

 

[Tigger]

I've never understood why much of EMS just doesn't care about temperatures and fever control. I would like to have some tylenol available (we have longer transport times), but we need a real thermometer first I think.

 

[EpiEMS]

I've never understood why much of EMS just doesn't care about temperatures and fever control. I would like to have some tylenol available (we have longer transport times), but we need a real thermometer first I think.

Temperature monitoring ought to be a skill that every transporting unit can perform - cheap and non-invasive

 

[johnrsemt]

We carry both, in liquid form so that we don't need to give them water and so that it works faster. For fever, and lower pain levels.

We also have longer transport times: anywhere from 45 minutes up to 4 hours depending on starting locations

 

[MackTheKnife]

Our protocols will soon include a choice of Ibuprofen or APAP for fever reduction and pain management

Assuming the agency will carry both which is your choice and why. I know there are hepato-tox issues with APAP. Would that rule it out

NSAIDS can have hepatic consequences as well.

 

[rescue1]

I never understood the idea that patients aren't going to see significant relief in the timespan of an EMS transport with PO meds. You're correct that they won't in the twenty minutes you spend with them, but that doesn't mean they won't get pain relief after you drop them off in the ED. Who cares if you aren't around to see the effect?

 

[Akulahawk]

I suspect that the reason this isn't done more frequently is precisely because we aren't around to see the effects. One of the things we're supposed to do when we give pain meds is evaluate the effectiveness of the med... if we're not around, our documentation can appear incomplete to someone that's looking just at pain med given--->where's the pain med reeval...???

I've worked with people that are very much focus in on stuff like that, to the point of not looking (or noticing) that something like turn over of care happens too quickly to re-eval the patient...

 

[Carlos Danger]

I never understood the idea that patients aren't going to see significant relief in the timespan of an EMS transport with PO meds. You're correct that they won't in the twenty minutes you spend with them, but that doesn't mean they won't get pain relief after you drop them off in the ED. Who cares if you aren't around to see the effect?

I'd turn the question around and ask why would you bother giving a drug that isn't very potent and takes an hour to reach peak effect, when you can give more potent drugs that reach peak effect within minutes?

To be honest, in the EMS environment I am just not very concerned about the type of mild discomfort that OTC PO meds are appropriate for. If someone is in more pain than what I would expect a few ibuprofen to adequately manage, then I'll use a drug that I think is likely to get the job done. But if they aren't in enough pain to warrant fentanyl, then I think giving some ibuprofen or aspirin in the hopes that they'll feel a little better 20 minutes after I drop them off but which would then perhaps prevent the administration of better drugs, like celebrex or toradol (or worse yet, they get a double dose of NSAID) isn't a worthy tradeoff.

In many hospitals, a frequent source of med errors is patients getting all kinds of meds in the OR, then getting to the floor and because the anesthesia charting is done on paper or in a system that doesn't communicate well with the rest of the hospital, they get IV toradol or ibuprofen when decadron and celebrex was just given preop a couple hours ago. There's just a lot of opportunity for details to get lost in the shuffle, and the same opportunity exists in the EMS:ED interface.

I'm not saying the risks are great - they aren't - but neither are the benefits. Given the limited ability of these meds to have much impact on the patient's overall satisfaction, I just don't see it as worth doing in most cases.

 

[rescue1]

I'd turn the question around and ask why would you bother giving a drug that isn't very potent and takes an hour to reach peak effect, when you can give more potent drugs that reach peak effect within minutes?

To be honest, in the EMS environment I am just not very concerned about the type of mild discomfort that OTC PO meds are appropriate for. If someone is in more pain than what I would expect a few ibuprofen to adequately manage, then I'll use a drug that I think is likely to get the job done. But if they aren't in enough pain to warrant fentanyl, then I think giving some ibuprofen or aspirin in the hopes that they'll feel a little better 20 minutes after I drop them off but which would then perhaps prevent the administration of better drugs, like celebrex or toradol (or worse yet, they get a double dose of NSAID) isn't a worthy tradeoff.

In many hospitals, a frequent source of med errors is patients getting all kids of meds in the OR, then getting to the floor and because the anesthesia charting is done on paper or in a system that doesn't communicate well with the rest of the hospital, they get IV toradol or ibuprofen when decadron and celebrex was just given preop a couple hours ago. There's just a lot of opportunity for details to get lost in the shuffle, and the same opportunity exists in the EMS:ED interface.

I'm not saying the risks are great - they aren't - but neither are the benefits. Given the limited ability of these meds to have much impact on the patient's overall satisfaction, I just don't see it as worth doing in most cases.

You make a fair point, and I guess I don't really have a great rebuttal to it. The best time to use NSAIDs and acetaminophen is probably when doing event medicine, which I think is not a terrible reason to add them to the scope of practice, given how common that is.

My main complaint was primarily that people use "I won't see the benefits of X medication in the ambulance", which I think is a ridiculous reason to do or not do something. No one says that about giving aspirin to an ACS patient, for example, despite the benefit not even being noticeable for days.

 

[johnrsemt]

We carry both, but just for fevers; ask what the patient has gotten recently and give the other one

 

[VFlutter]

IV Tylenol