Should ibuprofen be used for COVID-19 symptoms?

Clinical
By
Ann Winkle MPS
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Despite anecdotal reports in the media and the World Health Organization’s (WHO) previous position on the issue, there is currently no peer-reviewed, published scientific evidence to support a direct link between use of the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen and more severe infection with COVID-19.1,2

WHO initially recommended people with COVID-19 avoid taking ibuprofen for symptomatic relief; however, it retracted that advice days later on its official Twitter account.2

As of 18 March, WHO is not aware of any clinical or population-based data on this topic. It is currently consulting with doctors treating patients with COVID-19, and is not aware of any negative effects beyond the usual known adverse effects that limit its use in certain populations.2

In a statement, the TGA said it will continue to monitor the issue.

Where did the issue surrounding ibuprofen and COVID-19 originate?

On 14 March, French Health Minister Olivier Véran advised that anti-inflammatory drugs could aggravate symptoms during the infection. This was partly based on anecdotal reports from a doctor who reported worsening symptoms in four patients with COVID-19 after taking ibuprofen. The minister recommended paracetamol for symptoms rather than anti-inflammatory drugs.3

This concurred with previous advice from the French National Agency for the Safety of Medicines and Health Products not to treat fever or infections with ibuprofen.3

Some United Kingdom experts have endorsed this stance, stating that prolonged illness or complications of respiratory infections, including cardiovascular complications, are more common when NSAIDs are used. A virologist suggested that ibuprofen’s anti-inflammatory properties could ‘dampen down’ the immune system, therefore slowing the recovery process.3

Adverse effects with NSAIDs are well known in certain patient groups (e.g. impaired renal function, heart failure). Conjecture on their effects in COVID-19 infection is not yet supported by strong evidence.1,2

Experts are displaying caution, however. A British epidemiologist said, ‘more research is needed into the effects of specific NSAIDs among people with different underlying health conditions. In the meantime, for treating symptoms such as fever and sore throat, it seems sensible to stick to paracetamol as first choice’.3

A recent study in The Lancet hypothesised that human pathogenic coronaviruses bind to their target cells through angiotensin-converting enzyme-2 receptors, which are boosted by anti-inflammatory drugs such as ibuprofen. That is, ibuprofen could facilitate and worsen COVID-19 infections. This remains a hypothesis.

WHO spokesman Christian Lindmeier said the United Nation’s health agency experts were looking into this to give further guidance.

The complex role that the immune system might play in COVID-19 is underscored by reports that Roche has secured approval from the US Food and Drug Authority (FDA) to begin a Phase 3 clinical trial to test the effectiveness of the anti-inflammation drug Actemra (tocilizumab) to treat patients developing severe complications from COVID-19.4

What does this mean in the Australian context?

Evan Ackerman, immediate past Chair of the Royal Australian College of General Practitioners (RACGP) Expert Committee – Quality Care, and author and advisor on RACGP resources, does not believe patients need to cease long-term ibuprofen use, and strongly encourages them to continue taking their medicine. He contends that evidence linking worsening symptoms in respiratory illnesses and sepsis is very low-level.5

At this stage, however, Dr Ackerman advises patients with COVID-19 to use paracetamol as first-line instead of ibuprofen for symptomatic relief. 

Associate Professor Louis Irving, Director of Respiratory and Sleep Medicine at the Royal Melbourne Hospital, also advocates for a more cautious use of NSAIDs for symptomatic relief of COVID-19.5

Both experts believe more research is needed.5

Information for pharmacists

Pharmacists should refer to relevant Australian clinical guidelines when advising on treatment for pain or fever, and consider the risks and benefits to the individual on a case-by-case basis.1

Advise patients taking ibuprofen or another NSAID for a chronic health problem, not to stop taking it without discussing the issue with their doctor.1

If pharmacists observe any adverse events suggesting a potential link between the use of ibuprofen, or any other medicine, and worse clinical outcomes in COVID-19 patients, they should report it to the TGA.1

Refer to PSA’s dedicated site on current coronavirus information for pharmacists.6

References

  1. Australian Government Department of Health. Therapeutic Goods Administration. No evidence to support claims ibuprofen worsens COVID-19 symptoms. 2020. At: www.tga.gov.au/alert/no-evidence-support-claims-ibuprofen-worsens-covid-19-symptoms
  2. World Health Organization. At: twitter.com/WHO/status/1240409217997189128
  3. Day M. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ. 2020;368:m1086.
  4. Roche. Roche initiates Phase III clinical trial of Actemra/RoActemra in hospitalised patients with severe COVID-19 pneumonia. 2020. At: www.roche.com/media/releases/med-cor-2020-03-19.htm
  5. Lewin E. Ibuprofen and COVID-19: What GPs need to know. RACGP: newsGP. At: www1.racgp.org.au/newsgp/clinical/ibuprofen-and-covid-19-what-gps-need-to-know
  6. Coronavirus disease (COVID-19) information for pharmacists. PSA. At: my.psa.org.au/s/article/Coronavirus-COVID-19