Take ibuprofen or diclofenac with water, not food
By Dr Geraldine Moses Nov 24
Do you advise patients to take ibuprofen with food? Many health professionals do, but unfortunately this advice is now considered out of step with the latest evidence and it’s time we all caught up!
The dogma has always been that non-steroidal anti-inflammatory drugs (NSAIDs) are best taken with food or milk to reduce the risk of adverse gastrointestinal effects. The reason behind this advice has been a belief that NSAIDs are irritating to the stomach lining and food somehow provides a protective barrier in the stomach and thus making NSAIDs safer. Unfortunately, Rainsford and Bjarnason conducted a literature review looking for evidence to support the assumption that taking oral NSAIDs with food improves their safety, and found it was non-existent.(1) Moore et al (2) followed this up with a similar but more extensive summary of the literature in 2015, looking at all NSAIDs and came to a similar conclusion, that not only is there no evidence that taking NSAIDs with food improves their safety or tolerability in humans, but also there is no evidence that taking NSAIDs on an empty stomach increases the risk of adverse effects. (2)
Moore et al also investigated the effect of food on the pharmacokinetics of NSAIDs, particularly ibuprofen and diclofenac, and showed that food slows down their absorption, such that the peak plasma concentrations (Tmax) occurs up to 2 hours later and the peak plasma concentration (Cmax) is reduced by 20-30%. (1, 2) Eventually, the same amount of drug is absorbed overall, but the peak analgesic onset is reduced and delayed. (1, 2)
This is a problem since the perceived efficacy of single-dose analgesics depends on high, early plasma concentrations. This has been shown in dental pain models (third molar extraction) where more rapid absorption of ibuprofen with an earlier and higher Cmax gives earlier onset of analgesia resulting in better overall and longer lasting analgesia. [4,5]
Rapid onset of analgesia also conveys an element of safety, in that meeting patient expectations for pain relief reduces the risk of premature repeat dosing. Patients often expect that over-the-counter analgesics such as NSAIDs work very quickly but when this is not the case, perhaps due to taking the drug with food, the patient may ingest another dose much sooner. Furthermore the patient may be tempted to double the dose next time in the belief that this leads to greater chance of rapid onset analgesia. In either case, the risk of adverse events is increased. (2)
Back in 2015, regulatory agencies approved labelling changes of ibuprofen and diclofenac containing products such as Nurofen and Voltaren to just say in their instructions “Take with water” and nothing about food. At the same time, the Australian Medicines Handbook changed their instructions regarding diclofenac and ibuprofen to say for them to be taken with water. (3) For some reason they still advise for naproxen to be taken with or after food.
Finally, readers are reminded that it is so much easier to take medicines without regard to meals. Over the years I have seen people turn themselves inside-out trying to take their ibuprofen or diclofenac with food, sometimes forcing food down or delaying the dose unnecessarily until the next meal. I’ve also seen sick babies and children unnecessarily force-fed so the parent could give a dose of ibuprofen “with food”, which unsurprisingly the child often threw right back up! Plenty of people swear that taking ibuprofen with food reduces its gastric irritation, but it is now clear that this technique probably works by reducing how much drug is absorbed. I’d suggest just taking a lower dose in the first place.
So in the interests of practising evidence-based medicine and maximising pain relief for our patients, let’s advise them to take ibuprofen without food or milk. Just take it with water.
References:
1. Rainsford KD, Bjarnason I. NSAIDs: take with food or after fasting? J Pharm Pharmacol 2012; 64: 65–9.
2. Moore RA, Derry S, Wiffen PJ, Straube S. Effects of food on pharmacokinetics of immediate release oral formulations of aspirin, dipyrone, paracetamol and NSAIDs – a systematic review. Br J Clin Pharmacol Sep 2015; 80(3): 381-388.
3. Pigram M. Food for thought on ibuprofen. http://www.pharmacynews.com.au/News/Latest-news/Food-for-thought-on-ibuprofen. Published 01/09/15.
4. Moore RA, Derry S, Straube S, Ireson-Paine J, Wiffen PJ.Faster, higher, stronger? Evidence for formulation and efficacy for ibuprofen in acute pain. Pain 2014; 155: 14–21.
5. Moore RA, Derry S, Straube S, Ireson-Paine J, Wiffen PJ. Validating speed of onset as a key component of good analgesic response in acute pain. Eur J Pain 2015 Feb;19(2):187-92
