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Acute Pain | Chronic Pain | General

Ibuprofen in postoperative pain

Clinical bottom line

Ibuprofen is an effective analgesic. A single dose administration of 400 mg had an NNT of 2.5 (2.4 to 2.7) for at least 50% pain relief over 4 to 6 hours compared with placebo in pain of moderate to severe intensity. This is as effective as 10 mg intramuscular morphine.


Ibuprofen is an NSAID with prominent anti-inflammatory, antipyretic and analgesic actions. Analgesic effects are due to both peripheral and central effects. It is a potent inhibitor of cyclo-oxygenase, which results in marked reductions in prostaglandin synthesis.

Systematic reviews

SL Collins, RA Moore, HJ McQuay, PJ Wiffen. Oral ibuprofen and diclofenac in postoperative pain: a quantitative systematic review. European Journal of Pain 1998 2: 285-291.

SL Collins, RA Moore, HJ McQuay, PJ Wiffen, J Edwards. Single dose oral ibuprofen and diclofenac for postoperative pain. The Cochrane Library, Update Software, Oxford 2000.

Updated review prepared summer 2007, with planned publication 2008

Inclusion criteria were full journal publication of trials of ibuprofen in acute postoperative pain; single oral dose; randomised; placebo-controlled; double-blind; moderate to severe baseline pain; adult populations; group size at least 10.

For each trial the mean TOTPAR or SPID values for ibuprofen and placebo groups were converted to the percent of maximum total pain relief based on the categorical pain scales (%maxTOTPAR or %maxSPID). These values were then converted to dichotomous information on the proportion, and then the number of patients, who achieved at least 50%maxTOTPAR. A number-needed-to-treat for at least 50% pain relief and the relative benefit of the treatment were then calculated.

Findings

Ibuprofen 50 mg, 100 mg, 200 mg, 400 mg, 600 mg and 800 mg were significantly superior to placebo (Table 1) and the there was a lower NNT (more effect) with increasing doses. A 400 mg dose (Figure 1) had an NNT of 2.5 (2.4 to 2.7). Data from standard and soluble formulation trials were pooled as there was no difference in the NNTs generated by different formulations at 400 mg.

Table 1: Results for different doses of ibuprofen

Number of
Percent with at least 50% pain relief
Dose
(mg)
Trials
Patients
Ibuprofen
Placebo
Relative benefit
(95% CI)
NNT
(95% CI)
50
3
316
32
11
3.2 (1.9 to 5.1)
4.7 (3.3 to 8.0)
100
6
495
36
9
4.4 (2.7 to 7.2)
3.7 (2.9 to 4.9)
200
34
3248
48
11
4.5 (3.8 to 5.3)
2.7 (2.5 to 2.9)
400
60
5456
55
16
3.7 (3.3 to 4.0)
2.5 (2.4 to 2.7)
600/800
4
165
86
29
3.0 (2.0 to 4.4)
1.7 (1.4 to 2.3)

 

There was a clear dose response with ibuprofen, with higher doses producing lower (better) NNTs. With ibuprofen 200 mg 45% of patients with initial pain of moderate or severe intensity had at least 50% pain relief over 4-6 hours, as did 56% with ibuprofen 400 mg and 79% with ibuprofen 600 mg (Figure 1). Figure 2 shows the same data in terms of the percentage of patients with at least 50% pain relief.

Figure 1: Dose response (NNT) for ibuprofen compared with placebo

Figure 1: Dose response (Percentage with at least 50% pain relief) for ibuprofen compared with placebo

Adverse effects

Single dose oral studies showed no difference in adverse effects between ibuprofen and placebo. Reported adverse effects were mild and transient. Four patients withdrew after ibuprofen and two after placebo, mainly for vomiting soon after the dose was given.

Comment

Ibuprofen is an effective analgesic in postoperative pain, and there is considerable information on over 5,400 patients to support ibuprofen 400 mg.