USE OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) IN COVID-19 PATIENTS

There was an enquiry on the use of Non-steroidal anti-inflammatory drugs (NSAIDs) in COVID-19 patients. The World Health Organization (WHO) has a Release on its website dated April 20, 2020. The Release from the WHO explains the stance of experts on the matter. The WHO notes that Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs, and have a wide range of uses. NSAIDs include nonselective cyclooxygenase (COX) inhibitors (such as ibuprofen, aspirin, diclofenac, and naproxen), as well as selective COX2 inhibitors (such as celecoxib, rofecoxib, and valecoxib). The WHO notes the concerns raised that NSAIDs may be associated with an increased risk of adverse effects when used in patients with acute viral respiratory infections, including COVID-19. The WHO as result conducted a review in order to establish the nature of evidence available in relation to the concern. 

The review aimed to assess the effects of prior and current use of NSAIDs in patients with acute viral respiratory infections on acute severe adverse events such as mortality, the acute respiratory distress syndrome (ARDS), acute organ failure, and opportunistic infections. Furthermore, the review sought to find the effect on acute health care utilization (including hospitalization, intensive care unit (ICU) admission, supplemental oxygen therapy, and mechanical ventilation) as well as on quality of life and long-term survival.

Therefore, a rapid systematic review was carried out on 20 March 2020 on NSAIDs and viral respiratory infections using MEDLINE, EMBASE, and WHO Global Database. The review included studies conducted in humans of any age with viral respiratory infections exposed to systemic NSAIDs of any kind. All studies on COVID-19, the Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) were included irrespective of their sample size.

The WHO review of the evidence available covered a total of 73 studies (28 studies in adults, 46 studies in children, and one study in adults and children). All studies were concerned with acute viral respiratory infections or conditions commonly caused by respiratory viruses, but none specifically addressed COVID-19, SARS, or MERS. The review showed very low certainty evidence on mortality among adults and children. Effects of NSAIDs on the risk for ischaemic and haemorrhagic stroke and myocardial infarction in adults with acute respiratory infections are also unclear. 

Moderate to high certainty evidence showed little or no difference between Ibuprofen and Paracetamol among children with fever with regard to effects on death from all causes, hospitalization for any cause, acute renal failure, and acute gastrointestinal bleeding.Most studies report that no severe adverse events occurred, or that only mild or moderate adverse events were observed. There was no evidence regarding the effects of NSAID use on acute health care utilization, explicit quality of life measures, or long-term survival. 

The WHO notes the limitation of the review in that there no direct evidence from patients with COVID-19, SARS, or MERS was available. Therefore, all evidence included should be considered indirect evidence with respect to the use of NSAIDs prior to or during the management of COVID-19. Only one randomized controlled trial included a sufficiently large number of participants to identify rare severe adverse events. The remaining evidence derives from smaller randomized controlled trials, which are likely to be underpowered for detecting rare severe adverse events, and from case-control and cohort studies with methodological limitations. Studies included not only patients with confirmed viral respiratory infections and known pathogens, but also those with conditions commonly caused by respiratory viruses, such as upper respiratory tract infections and fever in children. It is likely that not all participants had viral respiratory infections. 

NSAIDs are a diverse set of drugs with different risk profiles for different populations and conditions. Not all studies distinguished between different types of NSAIDs. Some of the older studies are likely to have included patients taking specific NSAIDs that are no longer available owing to adverse effect. The WHO concluded that at present there is no evidence of severe adverse events, acute health care utilization, long-term survival, or quality of life in patients with COVID-19, as a result of the use of NSAIDs.

The U.S.A FDA in a Release on March 3, 2020 said it is aware of news reports stating the use of Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, could worsen coronavirus disease (COVID-19). These news reports followed a March 11, 2020 letter in The Lancet medical journal which hypothesized that an enzyme (a molecule that aids a biochemical reaction in the body) is increased by NSAIDs and could aggravate COVID-19 symptoms.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.”For those who wish to use treatment options other than NSAIDs, there are multiple over-the-counter (OTC) and prescription medications approved for pain relief and fever reduction. FDA suggests speaking to your health care professional if you are concerned about taking NSAIDs and rely on these medications to treat chronic diseases.

Meanwhile stay safe, observe all the advised hygiene measures, daily/regularly consume polyphenol-rich cocoa to strengthen your immunity.

DR. EDWARD O. AMPORFUL

CHIEF PHARMACIST

COCOA CLINIC

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