Questions about NSAIDs and COVID-19 remain, but acetaminophen appears safe

There is no strong evidence to date to support or discourage the use of NSAIDs in patients with COVID-19, according to a presentation during the virtual PAINWeek meeting.

Confusion about NSAID use in COVID-19 arose in March after a paper published in The Lancet Respiratory Medicine stated that certain NSAIDs, particularly ibuprofen, can upregulate ACE2 receptors, the viral entry point for SARS-CoV-2. Some have argued that this could increase the risk for contracting and developing severe COVID-19, Joseph V. Pergolizzi Jr., MD, cofounder and chief operating officer of NEMA Research, Inc. in Naples, Florida, said during the presentation.

Shortly after The Lancet paper was released, the Minister of Health in France tweeted that NSAIDs can worsen COVID-19 infection. However, other experts said there is no evidence to confirm this theory.

Pergolizzi said the anti-inflammatory effects of NSAIDs would seem beneficial for patients with COVID-19, a disease that involves an “inflammatory cascade,” which can lead to cytokine storm. However, in addition to potentially upregulating ACE2 receptors, these drugs are associated with other risks. For example, Pergolizzi said NSAIDs may slow viral elimination, increase the risk for secondary infection and mask early symptoms of COVID-19.

Pergolizzi and colleagues conducted a literature review of new reports, case studies, clinical trials and commentaries to better understand whether NSAIDs increase the risk for COVID-19 and worsen disease severity.

Based on the review, Pergolizzi said there is no evidence that occasional use of oral, over-the-counter NSAIDs exacerbates infection in patients with suspected or mild COVID-19. He added that “it appears acetaminophen, or paracetamol, is safe” for patients with COVID-19. Still, no medical societies or organizations advocate for its use.

The researchers said “there is no reason” for patients who are currently taking NSAIDs for chronic pain to stop treatment because of COVID-19-related concerns. But as with other analgesics, NSAIDs should be taken “at the lowest effective doses for the shortest periods of time,” they added.

“As always with COVID-19 scientists and physicians, we’re working hard to understand the viral infection, so we don’t have all the answers,” Pergolizzi said. “It’s important that we continuously read the literature and look for evidence-based medicine before we make rash decisions when it comes to our patients.”

References:

• Fang L, et al. Lancet Respir Med. 2020;doi:10.1016/S2213-2600(20)30116-8.
• Pergolizzi J, et al. Abstract 34. Presented at: PAINWeek: Sept. 11-13, 2020. (virtual meeting).