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Drug Reference

ibuprofen

NSAIDs· Brands: Nurofen, Brufen, Advil, MotrinIVPOTOP

Mechanism of action
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that reversibly inhibits cyclooxygenase (COX) enzymes, specifically COX-1 and COX-2, thereby reducing the synthesis of prostaglandins, which are mediators of inflammation, pain, and fever. It also reduces platelet aggregation by inhibiting thromboxane production.
Pharmacokinetics
Ibuprofen is well absorbed from the gastrointestinal tract, with peak plasma concentrations occurring 1 to 2 hours after oral administration; food delays absorption but does not affect total bioavailability. It is highly protein-bound (99%), widely distributed, and crosses the placental and blood-brain barriers. Metabolism is mainly hepatic via CYP2C9, with a plasma half-life of about 2 hours. Excretion of ibuprofen and its metabolites is predominantly renal, with less than 1% excreted unchanged.
Indications & dosing

Mild to moderate pain

Use lowest effective dose for shortest duration.

  • adult · PO: 200–400 mg every 4-6 hours · Use lowest effective dose for shortest duration.

Dysmenorrhea

Start at first sign of menses.

  • adult · PO: 200–400 mg every 4-6 hours · Start at first sign of menses.

Fever

Not recommended for routine fever prophylaxis.

  • adult · PO: 200–400 mg every 4-6 hours · Not recommended for routine fever prophylaxis.

Osteoarthritis

Use lowest effective dose for shortest duration.

  • adult · PO: 400–800 mg every 6-8 hours · Use lowest effective dose for shortest duration.

Rheumatoid arthritis

Use lowest effective dose for shortest duration.

  • adult · PO: 400–800 mg every 6-8 hours · Use lowest effective dose for shortest duration.

Fever or pain (child)

Max 40 mg/kg/day; use weight-based dosing.

  • pediatric · PO: 5–10 mg/kg every 6-8 hours · Max 40 mg/kg/day; use weight-based dosing.
Contraindications & precautions
  • Active peptic ulcer or gastrointestinal bleeding · Risk of exacerbation, potentially severe bleeding.
  • Severe heart failure (NYHA class III/IV) · NSAIDs can worsen fluid retention and decrease renal function.
  • Severe renal impairment (eGFR <30 mL/min) · Risk of acute kidney injury and further decline of renal function.
  • Third trimester of pregnancy · May cause premature closure of the ductus arteriosus and oligohydramnios.
  • History of bronchospasm, asthma or angioedema precipitated by NSAIDs · Cross-sensitivity can occur, including anaphylactic reactions.
  • Use the lowest effective dose for the shortest duration necessary.
  • Caution in patients with a history of peptic ulcer disease or GI bleeding; consider co-prescription of a proton pump inhibitor.
  • Monitor renal function and blood pressure, especially in the elderly or those with pre-existing cardiovascular disease.
  • Avoid in pregnancy, particularly in the third trimester.
  • Check for potential interactions with anticoagulants, antihypertensives, and other nephrotoxic drugs.
Adverse effects
  • Dyspepsia
  • Nausea
  • Gastrointestinal ulcer or bleedingserious
  • Cardiovascular events, including myocardial infarction and strokeserious
  • Renal impairmentserious
  • Fluid retention and hypertension
  • Anaphylaxisserious
Interactions
  • apixabanmajorAvoid co-prescription where possible. If an NSAID is required, use the lowest effective dose for the shortest duration and consider a gastroprotective agent such as a proton pump inhibitor. If combined, monitor for signs of bleeding (melena, haematemesis, bruising, anaemia) and assess haemoglobin and renal function periodically. For patients with a high bleeding risk, consider alternative analgesics such as paracetamol or a weak opioid.
  • dabigatranmajorAvoid concomitant use where possible. If short-term analgesia is required, consider alternatives such as paracetamol or a non-NSAID analgesic. If ibuprofen is essential, use the lowest effective dose for the shortest duration, closely monitor for signs of bleeding, and regularly assess renal function.
  • prednisolonemajorAvoid co-prescription where alternative analgesic or anti-inflammatory options exist. If unavoidable, prescribe a proton pump inhibitor or misoprostol, use the lowest effective doses for the shortest duration, and monitor for dyspepsia, melaena, or anaemia. Exercise extreme caution in high-risk groups.
  • lisinoprilmajorAvoid routine co-prescription, especially in patients at increased risk. If unavoidable, use the lowest effective dose of ibuprofen for the shortest duration. Monitor blood pressure and serum creatinine, and potassium at baseline and within 1 to 2 weeks after starting or changing therapy. Consider alternative analgesics such as paracetamol or opioids, which have less effect on renal function and blood pressure.
  • spironolactonemajorAvoid concomitant use when possible, especially in patients with renal impairment or risk factors for hyperkalaemia. If co-prescription is necessary, use the lowest effective dose of ibuprofen for the shortest duration. Monitor serum potassium and renal function (creatinine, eGFR) at baseline, within 3 to 5 days of starting therapy, and regularly thereafter. Consider alternative analgesics such as paracetamol. Adjust the spironolactone dose if renal function or potassium changes.
  • aspirinmoderateAvoid concomitant use where possible. If an NSAID is required, consider alternatives such as paracetamol or a non-NSAID analgesic. If combined use is necessary, administer aspirin at least 30 minutes before ibuprofen or at least 8 hours after the last ibuprofen dose, to allow aspirin to irreversibly inhibit platelet COX-1 first. Monitor for signs of gastrointestinal bleeding and renal impairment. The evidence for the specific timing recommendation is moderate, and local formulary or specialist guidance should be consulted.
  • perindoprilmajorAvoid concomitant use where possible. If an NSAID is required, use the lowest effective dose for the shortest duration, and consider paracetamol or alternative analgesia. Monitor blood pressure, serum creatinine, and potassium at baseline and within 1 to 2 weeks after starting or stopping the NSAID, then periodically. Ensure adequate hydration, and exercise caution in elderly patients and those with renal impairment. If hypertension worsens or renal function deteriorates, adjust therapy accordingly.
  • ramiprilmajorAvoid co-prescription in patients at high risk of renal impairment or hypovolaemia. If necessary, use the lowest effective dose of ibuprofen for the shortest duration, monitor renal function and blood pressure at initiation and regularly thereafter, and ensure adequate hydration. Consider alternative analgesics such as paracetamol.
  • warfarinmajorAvoid concurrent use if possible. Prefer paracetamol or a short course of a proton pump inhibitor plus a less gastrotoxic NSAID if an NSAID is essential. If no alternative exists, use the lowest effective dose of ibuprofen for the shortest duration, monitor INR within 3 to 5 days of initiation and regularly thereafter, and watch for signs of bleeding. Prescribe gastroprotection with a proton pump inhibitor.
  • digoxinmajorAvoid co-prescribing digoxin and ibuprofen when possible, especially in patients with renal impairment or heart failure. If the combination is necessary, monitor serum digoxin concentrations, renal function (e.g., creatinine, eGFR), serum potassium, and signs of digoxin toxicity. Consider alternative analgesics such as paracetamol or tramadol. Adjust the digoxin dose based on monitoring.
  • methotrexatemajorAvoid the concomitant use of methotrexate and ibuprofen, especially in patients with renal impairment, elderly patients, or those receiving high-dose methotrexate. If no alternative anti-inflammatory or analgesic agent is available, monitor closely: check renal function, complete blood counts, and methotrexate levels frequently. Consider dose reduction of methotrexate and ensure adequate hydration and urinary alkalinisation where appropriate.
  • lithiummajorAvoid concurrent use where possible, particularly in patients with pre-existing renal impairment or those receiving long-term lithium therapy. If ibuprofen is necessary, use the lowest effective dose for the shortest duration. Monitor serum lithium levels at baseline, then after 3 to 7 days of starting ibuprofen, and periodically thereafter. Monitor renal function (creatinine, eGFR) and signs of toxicity. Adjust lithium dose as needed and recheck levels after any change.
  • clopidogrelmajorAvoid the combination if possible. Consider alternative analgesics such as paracetamol or a selective COX-2 inhibitor, depending on the clinical context. If an NSAID is necessary, use the lowest effective dose for the shortest duration, and consider gastroprotection with a proton pump inhibitor (e.g., omeprazole or pantoprazole). Monitor patients for signs of gastrointestinal bleeding (e.g., melaena, haematemesis) and for reduced antiplatelet efficacy. Advise patients to report any unusual bleeding or bruising. Note that the interaction may be less pronounced with ibuprofen doses taken intermittently or after clopidogrel administration, but the safest approach is to avoid concurrent use.
  • fluoxetinemajorAvoid co-prescription when possible, especially in high-risk patients. If concurrent use is necessary, use the lowest effective dose of ibuprofen for the shortest duration, and consider gastroprotection with a proton pump inhibitor. Monitor patients for signs of GI bleeding, such as black stools, blood in vomit, or dizziness. Advise patients to report any unusual bleeding or abdominal pain.
  • citaloprammoderateWhen citalopram and ibuprofen are co-prescribed, use caution and consider alternative analgesia such as paracetamol if appropriate. If an NSAID is necessary, use the lowest effective dose for the shortest duration, and administer a gastroprotective agent such as a proton pump inhibitor, especially in patients with risk factors. Monitor patients for signs of gastrointestinal bleeding, including black stools, melaena, haematemesis, or unexplained anaemia, and advise them to seek prompt medical attention if these occur.
  • sertralinemajorAvoid concomitant use unless clearly necessary. If the combination is required, consider adding a proton pump inhibitor for gastroprotection, use the lowest effective dose of ibuprofen for the shortest duration, and monitor patients for signs of gastrointestinal bleeding, such as melaena or haemorrhage. Advise patients to report any black stools or unexplained abdominal pain.
  • cyclosporinemajorAvoid concomitant use if possible. If necessary, use the lowest effective dose of ibuprofen for the shortest duration. Monitor serum creatinine, blood urea nitrogen, and cyclosporine trough levels frequently (e.g., every 2-4 weeks) during therapy and for several weeks after discontinuation. Ensure adequate hydration and consider alternative analgesics such as paracetamol for pain relief.
  • rivaroxabanmajorAvoid concurrent use when possible. If combination is necessary, use the lowest effective dose of ibuprofen for the shortest duration. Consider alternative analgesics like paracetamol. Prescribe a proton pump inhibitor for gastroprotection. Monitor patient for signs of bleeding, including haemoglobin, melaena, or unexplained bruising. Advise patient to seek immediate medical attention if bleeding occurs.
  • tacrolimusmajorAvoid co-prescription where possible. Consider alternative analgesia such as paracetamol. If the combination is necessary, ensure adequate patient hydration and closely monitor renal function (serum creatinine, BUN, urine output) at baseline, then at least weekly for the first month or more frequently if renal dysfunction is evident. Also monitor tacrolimus trough levels as renal function changes can affect its clearance; adjust tacrolimus dose as needed. Advise patients to seek medical attention if they note decreased urine output, swelling, or nausea.
  • furosemidemajorAvoid chronic co-administration if possible. If required, monitor renal function, blood pressure, and fluid balance at baseline and periodically thereafter. Use the lowest effective ibuprofen dose for the shortest duration, and consider alternative analgesia such as paracetamol when appropriate. Adjust the furosemide dose as needed to maintain adequate diuresis.
Renal & hepatic adjustment
  • eGFR 0–29: Avoid use in severe renal impairment (eGFR < 30 mL/min/1.73m²); if deemed essential, use the lowest effective dose for the shortest duration and monitor renal function closely. (avoid)
  • eGFR 30–59: Use with caution; consider the lowest effective dose for the shortest duration and monitor renal function regularly.
  • Hepatic impairment (mild): No specific dose adjustment required; use with caution.
  • Hepatic impairment (moderate): Use with caution; consider the lowest effective dose for the shortest duration.
  • Hepatic impairment (severe): Avoid use in severe hepatic impairment due to risk of bleeding and renal impairment. (avoid)
Monitoring, pregnancy & toxicity
  • Renal function (serum creatinine, eGFR) · Baseline and periodically during prolonged therapy; more frequently in patients with renal risk factors.
  • Blood pressure · Baseline and regularly in patients with hypertension or cardiovascular risk.
  • Gastrointestinal symptoms (e.g., dyspepsia, abdominal pain) · Monitor throughout treatment; assess for GI bleeding.
  • Liver function tests · Baseline and periodically in patients with hepatic impairment or on long-term therapy.
  • Full blood count (for anaemia or blood loss) · Baseline and during prolonged therapy if signs of bleeding.
  • Pregnancy: Avoid use in the third trimester due to the risk of premature closure of the ductus arteriosus and possible fetal renal impairment. Use with caution in the first two trimesters, at the lowest effective dose for the shortest duration, only when benefits outweigh risks.
  • Toxicity: Gastrointestinal symptoms: nausea, vomiting, abdominal pain, gastrointestinal bleeding, and ulceration. · Supportive care. Stop the NSAID. Consider activated charcoal if ingestion was recent and the patient is conscious. Monitor for signs of GI bleeding and treat accordingly (e.g., proton pump inhibitors, blood transfusion if needed).
  • Toxicity: Renal impairment: acute kidney injury, especially in overdose or in patients with pre-existing renal disease. · Monitor renal function and urine output. Discontinue the NSAID. Provide supportive care, including fluid management if indicated; haemodialysis may be considered in severe cases.
  • Toxicity: CNS effects: drowsiness, confusion, seizures, and coma in severe overdose. · Supportive care, including airway management and monitoring of vital signs. Treat seizures with benzodiazepines if they occur. Activated charcoal may be useful if within 1–2 hours of ingestion.
  • Toxicity: Metabolic effects: metabolic acidosis and electrolyte disturbances in severe toxicity. · Monitor acid-base status and serum electrolytes. Provide supportive care and correct electrolyte imbalances; consider bicarbonate therapy for severe metabolic acidosis.
Clinical notes
Ibuprofen is used for mild to moderate pain, inflammation, fever, and dysmenorrhoea. It is also used for inflammatory joint diseases such as rheumatoid arthritis and osteoarthritis. It is available as an over-the-counter medicine in many regions; use the lowest effective dose for the shortest duration. Side effects include gastrointestinal irritation and bleeding, renal impairment, fluid retention, and bronchospasm in susceptible individuals. Caution is needed in asthma, dehydration, and concurrent use of anticoagulants or other NSAIDs. Contraindicated in active peptic ulcer disease, severe heart failure, and third trimester pregnancy.

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BNF; local formulary