An article by Thomas Drake and others published in The Lancet Rheumatology May 7, 2021 explores this issue.
Early in the pandemic, it was suggested that pre-existing use of non-steroidal anti-inflammatory drugs, NSAIDs, would lead to an increased disease severity in patients with COVID-19. This was an important consideration as non-steroidal anti-inflammatories are an important analgesic and are widely available to the general public without prescription.
The author’s aimed to characterise the safety of NSAIDs and identify whether pre-existing NSAID use was associated with an increased severity of COVID-19.
The concerns based on unpublished data led to advise against the use of NSAIDs. However, given the widespread general use of NSAIDs, this debate spurred multiple studies to refute or confirm a possible association.
The mechanism through which NSAIDs could theoretically be of harm in patients with COVID-19 is by up regulation of the angiotensin converting enzyme 2, ACE2 receptors in the lungs, arteries, heart, kidneys and intestines. These are used by SARS-CoV-2 as an entry point into cells. Additionally, NSAIDs might delay diagnosis of COVID-19 by masking inflammation and fever.
After several initial studies, the WHO and the European Medicines Agency, the EMA and the US Food and Drug Administration, FDA, did not advocate against Ibuprofen use for COVID-19 but they continue to recommend careful monitoring given the theoretical risks.
This study analysed the association between NSAID exposure and severe COVID-19 outcomes, including mortality, critical care admission, need for invasive ventilation, need for oxygen, and acute kidney injury.
None of these outcomes were significantly associated with NSAID exposure in the two weeks prior to hospital admission. The distribution of previous NSAID use was similar in those who died compared with those who survived, indicating that the association of NSAID use with non-mortality outcomes, including critical care admission and treatments, were not affected by excess mortality in any exposure group.
Sub analysing, the type of NSAID use also did not indicate any increased risk for mortality in patients taking Ibuprofen compared with those not taking any NSAIDs. The study also did not provide any insight into whether comparative drugs such as paracetamol were better, equal, or worse in terms of COVID-19 outcomes.
The study enrolled 78,674 patients across 255 healthcare facilities in England, Scotland and Wales and at hospital admission there were no significant differences in severity of symptoms observed between those taking NSAIDs and those not.
The conclusion was that NSAID use with COVID-19 appeared to confer no increased risk of poor outcome. This study therefore supported the clinical statements from the WHO, EMA and FDA of the lack of harmful effects of NSAID use in COVID-19. Therefore, based on this current knowledge, patients should not need to refrain or discontinue from taking NSAIDs if they have COVID-19 infection.
The London General Practice provides full services for all COVID-19 related issues. As the leading London doctors’ clinic, it offers rapid COVID-19 testing, test to release COVID-19 testing, and all regulatory and mandatory COVID-19 testing such as the day two and day eight COVID-19 testing and test for release day five COVID-19 testing.
Dr Paul Ettlinger
Founder, The London General Practice