A 28-year-old man from Bangalore is on day 3 of dengue fever with fever (39.5°C), myalgia, and headache. He has no contraindications to NSAIDs. Which is the drug of choice for fever and pain management in this patient?

Explanation

## Antipyretic and Analgesic Management in Dengue Fever ### The NSAID Controversy in Dengue Despite the patient having "no contraindications to NSAIDs," **NSAIDs are NOT recommended in dengue** due to: 1. **Increased bleeding risk** — NSAIDs inhibit platelet aggregation and increase gastric bleeding risk 2. **Worsening plasma leakage** — NSAIDs may exacerbate vascular permeability 3. **Renal impairment** — NSAIDs reduce renal perfusion in volume-depleted dengue patients 4. **Hepatotoxicity** — NSAIDs may worsen dengue-associated liver injury ### Why Paracetamol is First-Line **Key Point:** Paracetamol is the **drug of choice** for fever and pain management in dengue. It is safe, effective, and does not increase bleeding or plasma leakage. **High-Yield:** The WHO, CDC, and Indian guidelines (Park, ICMR) all recommend **paracetamol (acetaminophen) as the antipyretic of choice in dengue**. Maximum dose: 3–4 g/day in divided doses (max 1 g per dose). ### Mechanism of Paracetamol Safety in Dengue - **No antiplatelet effect** — does not inhibit platelet function - **No NSAID-like effects** — does not increase GI bleeding or plasma leakage - **Hepatic metabolism** — safe at therapeutic doses even with mild dengue-associated transaminitis - **Antipyretic efficacy** — effective at lowering fever and reducing pain ### Comparative Table: Antipyretics in Dengue | Drug | Mechanism | Safety in Dengue | Recommendation | |------|-----------|------------------|----------------| | **Paracetamol** | COX inhibitor (CNS-selective) | Safe; no antiplatelet effect | **First-line** | | **Ibuprofen** | NSAID; inhibits COX-1/2 | **Avoid** — increases bleeding risk | Contraindicated | | **Aspirin** | NSAID + antiplatelet | **Avoid** — high bleeding risk | **Contraindicated** | | **Indomethacin** | NSAID; potent COX inhibitor | **Avoid** — increases plasma leakage | Contraindicated | **Warning:** Even though the stem says "no contraindications to NSAIDs," **dengue itself is a contraindication to NSAIDs**. This is a common exam trap. ### Clinical Pearl Patients with dengue often have thrombocytopenia by day 3–5. NSAIDs in this setting significantly increase the risk of spontaneous bleeding (epistaxis, haematemesis, haematuria). Paracetamol avoids this risk entirely. **Mnemonic — Dengue Fever Drugs to AVOID: AINS** - **A**spirin - **I**buprofen - **N**abumetone - **S**alicylates (all NSAIDs) Use **Paracetamol** instead.