Avian Flu Diary: The NSAIDs & COVID-19 Debate Revisited

#15,109

Four days ago, in The French MOH Warning Over Anti-inflammatory Drugs For COVID-19, we looked at a warning from France's Health Minister on the risk of complications from taking NSAIDs and other anti-inflammatory drugs for COVID-19.

NSAIDs, and other anti-inflammatory drugs (including synthetic corticosteroids), are linked to a wide range of side effects. For NSAIDs, there is a heightened risk of cardiovascular events and bleeding, and in the case of corticosteroids, lowered immunity to infections.

We also looked at a number of research studies over the past dozen years that have suggested some potential negative impacts from taking NSAIDs for viral infections.

In one example, in 2016 French researchers released a study in the Journal of Pediatrics (Nonsteroidal Anti-Inflammatory Drug without Antibiotics for Acute Viral Infection Increases the Empyema Risk in Children: A Matched Case-Control Study), which found an increased risk of Empyema (bacterial lung infection) in children receiving NSAIDS for viral infections.

And just in general, fever is our body's natural way of combating a viral infection. By taking antipyretics of any type, we not only produce a host environment conducive to better viral replication, it can allow someone who is still contagious to feel good enough go to work, or school, and further spread the virus.

While there is still no solid evidence linking the taking of NSAIDs to worse outcomes with COVID-19, over the past couple of days several public health agencies - and at least one medical journal - have come out recommending acetaminophen or paracetamol over NSAIDS for fever reduction and/or body aches with this novel coronavirus.

A few of those statements include:

WHO Now Officially Recommends to Avoid Taking Ibuprofen For COVID-19 Symptoms

AFP 17 MARCH 2020

The World Health Organization recommended Tuesday that people suffering COVID-19 symptoms avoid taking ibuprofen, after French officials warned that anti-inflammatory drugs could worsen effects of the virus.

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The UK's NHS COVID-19 Website - which up until yesterday was recommending either Ibuprofen or paracetamol to treat symptoms, has posted the following notice:

And from the British Medical Journal:

Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1086 (Published 17 March 2020)Cite this as: BMJ 2020;368:m1086

Michael Day

Scientists and senior doctors have backed claims by France’s health minister that people showing symptoms of covid-19 should use paracetamol (acetaminophen) rather than ibuprofen, a drug they said might exacerbate the condition.

The minister, Oliver Veran, tweeted on Saturday 14 March that people with suspected covid-19 should avoid anti-inflammatory drugs. “Taking anti-inflammatory drugs (ibuprofen, cortisone . . .) could be an aggravating factor for the infection. If you have a fever, take paracetamol,” he said.

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There is obviously no such thing as a 100% safe drug, even those we can buy over the counter. For most people, the risks from these drugs - if taken as directed - are acceptable. But those risk are certainly not zero.

In 2015 the FDA Strengthened Warnings Of Cardiovascular Risks With NSAIDs, issuing a communique with the following findings:

The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID. The risk may increase with longer use of the NSAID.

The risk appears greater at higher doses.

It was previously thought that all NSAIDs may have a similar risk. Newer information makes it less clear that the risk for heart attack or stroke is similar for all NSAIDs; however, this newer information is not sufficient for us to determine that the risk of any particular NSAID is definitely higher or lower than that of any other particular NSAID.

NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease. A large number of studies support this finding, with varying estimates of how much the risk is increased, depending on the drugs and the doses studied.

In general, patients with heart disease or risk factors for it have a greater likelihood of heart attack or stroke following NSAID use than patients without these risk factors because they have a higher risk at baseline.

Patients treated with NSAIDs following a first heart attack were more likely to die in the first year after the heart attack compared to patients who were not treated with NSAIDs after their first heart attack.

There is an increased risk of heart failure with NSAID use.

It should be noted that while relative risks of having a heart attack, heart failure, or stroke while taking some of these drugs may double, in terms of absolute risk, the numbers go up far less. If your risk of having a heart attack is 1%, and it goes up by 20% by taking the drug, you are still only at a 1.2% chance of a cardiac event.

Like just about everything else in life, the taking of any medicine involves balancing the risks and the rewards.

In 2015 the FDA recommended that people with heart disease or high blood pressure consult a health care provider before taking NSAIDs, and that everyone try to take the lowest effective dose for the shortest length of time possible.

While acetaminophen & Paracetamol (different names for the same drug) are considered `safer', they are not without risk. Take too much and you can damage your liver - permanently. And since these meds are widely used in hundreds of OTC `cold & flu' medications, it is all too easy to `double dose' yourself without realizing it (see Know Your Dose).