Despite popular belief that you have to take ibuprofen with food, you can take low-dosages of ibuprofen (up to 1200mg/day in split doses for 1 to 7 days) on an empty stomach and this will give you faster pain relief than taking it with food. Food increases the time it takes for ibuprofen to be absorbed, although it won't affect how much is absorbed. There is actually no evidence that taking ibuprofen with food prevents gastric irritation – ibuprofen at OTC doses has a low incidence of gastric irritation anyway. The risk of gastric irritation has more to do with other risk factors that may be present, such as:

• Older age (>65 years)
• Use of other medications that also increase gastric irritation, such as aspirin, SSRI antidepressants (eg, citalopram, fluoxetine), anticoagulants (such as warfarin or dabigatran), or prednisone
• Alcohol use
• Higher dosages of ibuprofen (more than 1200mg/day), including prescription dosages (this increases the risk 2 to 3 fold)
• Duration of ibuprofen use
• Helicobacter pylori infection
• History of smoking
• Previous history of gastric ulcers, bleeding ulcers, or GERD
• Recent surgery
• Serious other medical conditions, such as chronic inflammatory bowel disease, liver or kidney disease, cancer, or diabetes.

The risk of gastrointestinal bleeding and irritation is reduced by using a COX-2 selective NSAID, such as celecoxib, or by taking ibuprofen with a mucosal protective agent such as misoprostol or omeprazole.

Why do different sources advise taking ibuprofen with food?

This advice stems from a desire to protect people from gastrointestinal adverse events, such as dyspepsia, or more serious events such as gastrointestinal bleeding. Although research has shown aspirin to be associated with higher rates of adverse events and gastric irritation there is no evidence that taking occasional, intermittent doses of OTC NSAIDs, such as ibuprofen, produce higher event rates. In addition, there is no convincing evidence that taking NSAIDs with food prevents side effects.

The primary way NSAIDs irritate the gastric mucosa is via inhibition of COX-1-dependent prostaglandins, which protect the stomach lining from injury from stomach acid, although some also have a direct irritant effect. Superficial irritation to the gastric lining is more common than ulceration and it is estimated that 1%–2% of people who take NSAIDs daily experience a significant gastrointestinal event per year.

How can I reduce the risk of GI adverse events with ibuprofen or other NSAIDs?

For older patients requiring NSAID pain who have no contraindications for NSAID use, reducing the risk of NSAID-induced GI complications can be achieved by:

• Considering COX-2 inhibitors such as celecoxib. Celecoxib with omeprazole offers the lowest risk for GI events
• Using the lowest effective dose for the shortest possible time
• Targeting modifiable risk factors (such as alcohol use, smoking, concurrent GI irritating medications)
• Adding gastro-protective agents
• Testing for (and treating if necessary) Helicobacter pylori infection.

Acetaminophen carries the lowest risk for GI adverse events so should be considered for people at high risk. Other alternatives with less risk are topical NSAIDs, although they still carry some risk. Encourage the use of other non-pharmacological treatments like heat packs, massage, exercise, or physiotherapy.

People with heart disease, kidney problems, high blood pressure, or other chronic medical conditions, should ask their doctor about using ibuprofen before taking it.