NSAIDs not linked to increased COVID-19, mortality risk in OA
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There is no increased risk for COVID-19 infection or all-cause mortality among patients with osteoarthritis in primary care who receive NSAIDs, compared with other analgesics, according to data published in Arthritis & Rheumatology.
“Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to help control pain in chronic diseases such as osteoarthritis and are often used in groups at high risk of COVID-19 including older populations,” Joht Singh Chandan, PhD, of the University of Birmingham and the University of Warwick, and colleagues wrote. “However, concerns have been raised regarding the use of NSAIDs in the context of SARS-CoV-2 infection, particularly after the French Health Minister suggested in March that NSAIDs might aggravate the infection.”
“Despite these concerns, NSAIDs have remained an important therapeutic approach to the management of pain, including among older patients,” they added. “However, smaller-scale clinical studies to-date have been unable to adequately investigate whether use of NSAIDs could confer susceptibility to infection by the SARS-CoV-2. Challenges in the design of studies attempting to address this question include selection bias, as well as an inability to account for confounding by indication bias.”
To examine whether NSAID use increases the risk for COVID-19, compared with other common analgesics, Chandan and colleagues conducted a propensity score‐matched cohort study, with active comparators, using data from The Health Improvement Network (THIN). According to the researchers, THIN is a large primary care dataset collected from general practices in the United Kingdom, via electronic medical records. In 2020, the database included approximately 2.1 million active patients from 357 practices.
For their own study, Chandan and colleagues analyzed data from adults diagnosed with OA who completed follow-up from Jan. 30 to July 31. The researchers compared patients who received an NSAID, including topical applications, to those treated with either co‐codamol — paracetamol and codeine — or co‐dydramol — paracetamol and dihydrocodeine. In all, the analysis included 13,202 patients who received NSAIDs and 12,457 treated with comparator drugs. The primary outcome was suspected or confirmed COVID-19. The secondary outcome was all-cause mortality.
According to the researchers, incidence rates during follow-up for suspected or confirmed COVID‐19 were 15.4 per 1,000 person-years among those treated with NSAIDs, and 19.9 for the comparator groups. Adjusted hazard ratios in the unmatched and propensity score matched analyses for primary care consultations with suspected or confirmed COVID‐19 were 0.82 (95% CI, 0.62-1.1) and 0.79 (95% CI, 0.57-1.11), respectively. Meanwhile, for subsequent mortality, the adjusted hazard ratios were 0.97 (95% CI, 0.75-1.27) and 0.85 (95% CI, 0.61-1.2). The findings were unaffected by age or sex.
“Our findings suggest that prescription of NSAIDs (excluding topical preparations) in primary care does not increase susceptibility to COVID-19 or all-cause mortality, including in older patients,” Chandan and colleagues wrote. “These findings are reassuring given the high prevalence of NSAID use in at-risk groups. Further research is needed to investigate whether use of NSAIDs is associated with adverse outcomes from COVID-19 in those with confirmed SARS-CoV-2 infection and whether risks differ by type and dose of NSAID.”
Perspective
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J. Nicholas Manwaring, MSN, APRN, FNP-C
This observational retrospective cohort study by Chandan and colleagues adds to the current body of evidence that seeks to disprove the theoretical fear that regular systemic NSAID use may contribute to COVID-19 susceptibility and possibly contribute to all-cause COVID-19 mortality.
The population sample size for this study (over 24,000 study participants) was an adequate size to allow for appropriate data analysis and interpretation. The data analysis also controlled for age and gender, both of which are variables that are known to contribute to an increased risk for COVID-19 morbidity and mortality. The results of this study support previous findings, which suggest that, regardless of age and gender, there is no increased incidence or all-cause mortality associated with COVID-19 in patients in primary care who are prescribed regular NSAIDs.
However, it is important to note that, because the study was limited to patients with only osteoarthritis, further research may be needed to study COVID-19 susceptibility and mortality as it relates to other disease states where NSAIDs are routinely used. Because the study analysis was limited to outpatient visits, future evaluation of hospitalized COVID-19 patients taking routine NSAIDs could also be beneficial. Additionally, because this study did not select for cause-specific mortality, socioeconomic status, specific dosages or types of NSAIDs used, further analysis in these areas would also be helpful.
NSAIDs are routinely used in rheumatology practice. These patients are often on high-risk medications and also typically possess multiple comorbidities that put them at increased risk for COVID-19 related morbidity and mortality. It is reassuring to know that in spite of so many other known COVID-19 related risks — at least up to this point — the research supports the notion that NSAID use does not contribute to the COVID-19 related risks that have previously been well established.
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