The Use of NSAIDs in COVID-19 Patients: Q&A with Bryan D. Hayes, PharmD
In This Article
- Several major health authorities have addressed the use of non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, for patients with COVID-19
- Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP, says that NSAIDs may be used in these patients with the standard health considerations
- While acetaminophen and NSAIDs may be considered for COVID-19 patients, the health advisories surrounding the virus could still change as ongoing research evolves
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On March 17, the French Health Minister Olivier Veran tweeted that taking non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, could worsen the clinical course of patients infected with COVID-19. Clinicians and researchers are still learning about COVID-19 and determining treatment options. Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP, senior attending pharmacist in Emergency Medicine and Toxicology at Massachusetts General Hospital, clarifies the risks and benefits of drugs like ibuprofen for use in patients with COVID-19.
Q: Is there evidence that currently supports the French Health Minister's claim?
Hayes: This was based, at least in part, on a recent article in The Lancet hypothesizing that NSAIDs could increase, or upregulate, angiotensin-converting enzyme 2 (ACE2). We know that severe acute respiratory syndrome coronaviruses, such as SARS-CoV and SARS-CoV2 (i.e., COVID-19) bind to their target through ACE2. ACE2 is present in epithelial cells throughout the body including the lungs. Importantly, The Lancet piece was a correspondence, not a research study. And, it was specifically directed at patients with diabetes and hypertension, both conditions in which there is an increase in ACE2 expression.
On March 18, the World Health Organization (WHO) tweeted, in a double-negative fashion, that they "do not recommend against the use of ibuprofen." The European Medicines Agency (equivalent to the FDA in the U.S.), published a statement the same day stating: "There is currently no scientific evidence establishing a link between ibuprofen and worsening of COVID-19."
As of the time of this writing, ibuprofen and other NSAIDs may be used in patients with COVID-19. However, some hospitals including Mass General are being extra cautious and recommending that frontline providers assess and document recent NSAID use and avoid prescribing NSAIDs while patients are admitted.
Q: These types of drugs are more closely regulated in France than they are in the U.S. If you are showing symptoms (fever, cough), is there any risk to taking things like ibuprofen, etc.?
Hayes: The risks with taking ibuprofen are the same in COVID-19 patients as they are in non-COVID-19 patients. NSAIDs have boxed warnings linked to serious cardiovascular thrombotic events and gastrointestinal (GI) bleeding, ulceration and perforation. Patient factors affecting cardiovascular risk include the presence of prior cardiovascular disease, history of systemic inflammatory disorder, older age, male gender, hypertension, hyperlipidemia, diabetes and smoking. NSAID factors affecting cardiovascular risk include duration, frequency, dose of therapy and maybe the degree of selectivity for inhibition of cyclooxygenase (COX)-2 relative to COX-1. For GI bleeding, patient risk factors include prior history of a GI ulcer/hemorrhage; age >60; high NSAID dose; concurrent use of glucocorticoids, antiplatelet agents, anticoagulants and selective serotonin reuptake inhibitors (SSRI).
The bottom line is that in any condition, NSAIDs should be taken at the lowest effective dose for the shortest duration possible for the given indication. Naproxen or ibuprofen may be the best oral options. In patients with significant cardiovascular disease, alternatives to NSAIDs should be considered.
Q: Do we have a specific recommendation for medical professionals speaking to their patients who are showing symptoms? Is acetaminophen really the best option?
Hayes: At this time, both acetaminophen (otherwise known as paracetamol in other parts of the world) and NSAIDs such as ibuprofen may be considered for patients showing symptoms of COVID-19. Because they work through different mechanisms, they both can be taken together or in an alternating fashion.
Q: Is there anything else you'd like health care providers to be aware of when considering what to prescribe patients who may have contracted COVID-19?
Hayes: Remember that acetaminophen dosing should not exceed 4,000 mg in a 24 hour period including from other sources such as hydrocodone/acetaminophen. The other point to keep in mind is that this information could change as the research evolves.
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