COVID-19 and NSAIDs: Is There Reason for Concern with Use of Ibuprofen?

NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date

SUMMARY:

Questions have been raised regarding the use of NSAIDs in the setting of COVID-19 infection. Currently, there is no evidence that NSAIDs are associated with adverse outcomes in the setting of COVID-19

• NSAIDs and Respiratory Infections
• Professional Recommendations
• Additional Notes

NSAIDs and Respiratory Infections

• Some studies that have evaluated NSAID use and pneumonia have demonstrated an increased risk for
  • Worsening disease course
  • Longer duration of antibiotic therapy
  • Greater hospital length of stay
• Studies regarding NSAIDs and pneumonia (in general, not specifically COVID-19) were more directed toward long term use Intermittent or short interval use have not been well studied
• Note: To date there is no evidence that ibuprofen or NSAIDs are detrimental in the setting of COVID-19

KEY POINTS:

Professional Recommendations

• FDA

At this time, FDA is not aware of scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms

The agency is investigating this issue further and will communicate publicly when more information is available

However, all prescription NSAID labels warn that “the pharmacological activity of NSAIDs in reducing inflammation, and possibly fever, may diminish the utility of diagnostic signs in detecting infections.”

• US NIH Treatment Guidelines
  • Persons with COVID-19 who are taking NSAIDs for a co-morbid condition should continue therapy as previously directed by their physician 
  • The Panel recommends that there be no difference in the use of antipyretic strategies (e.g., with acetaminophen or NSAIDs) between patients with or without COVID-19 

• NICE (UK)
  • Recommends that patients be advised to take paracetamol (acetaminophen) or ibuprofen in the setting of COVID-19 where antipyretics would help with management
  • Use lowest effective NSAID dose

When patients, carers or healthcare professionals are starting treatment for fever and/or pain in patients (adults or children) with confirmed or suspected COVID-19, all treatment options should be considered and selected based on the greatest benefit compared to potential harms using each medicine’s product information

Additional Notes

• Studies regarding NSAIDs and pneumonia (in general, not specifically COVID-19) were more directed toward long term use
  • Intermittent or short interval use have not been well studied
• Patients should not stop NSAIDs without a discussion with their physicians, especially if NSAIDs used for treatment of chronic illness
  • Patients should continue low-dose aspirin for secondary prevention of cardiovascular disease
  • Anti-inflammatory effects require higher doses (1-4 g per day)
  • Low-dose aspirin for preeclampsia: ACOG recommends that when indicated, low-dose aspirin “should continue to be offered to pregnant and postpartum women” | In the setting of suspected or confirmed COVID-19, “modifications to care may be individualized”
• NSAIDs may be associated with complications, particularly with chronic use and/or underlying health issues
  • Serious complications include: GI ulcers and consequent bleeding | Renal and liver injury

Learn More – Primary Sources:

Risks Related to the Use of Non-Steroidal Anti-Inflammatory Drugs in Community-Acquired Pneumonia in Adult and Pediatric Patients (Voiriot et al, J Clin Med, 2019)

Non-steroidal Anti-inflammatory Drugs May Worsen the Course of Community-Acquired Pneumonia: A Cohort Study (Basille et al. Lung, 2017)

Non-steroidal anti-inflammatory drugs and covid-19 (Little. BMJ, 2020)

Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? (Fang et al. Lancet Resp Med, 2020)

NICE: COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community

FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19

Renin–Angiotensin–Aldosterone System Inhibitors in Patients with Covid-19 (Vaduganathan et al. NEJM 2020)