The last few days proved to be a manic time not only in all supermarkets but also pharmacies. The situation is surreal. Pharmacy teams have been under enormous pressure from the workload. People also buy an excessive amount of over the counter medications due to coronavirus (covid-19) pandemic. A few days ago, a French Health Minister Olivier Véran and a qualified doctor Tweeted: “Taking anti-inflammatory drugs (ibuprofen, cortisone) could be an aggravating factor for the infection. If you have a fever, take paracetamol”. With paracetamol going in and out of stock, many patients are left in ‘limbo’. Every day, I am asked several times, ‘Can I take ibuprofen for management of coronavirus symptoms’? Patients who use other non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen for the management of different long-term conditions, ask whether it is ‘safe’ to continue taking their medication. In this post, I will talk about:
- Use of NSAIDs in the management of coronavirus symptoms (how NSAIDs work).
- A possible explanation for the aggravating effect of NSAIDs on coronavirus infected patients.
- The hypothesis behind the increased risk of coronavirus infection in patients taking ibuprofen and other NSAIDs.
- WHO advice on taking ibuprofen for the management of coronavirus infection.
- NHS statement on coronavirus to clinical staff.
Ibuprofen and coronavirus: the role of NSAIDs
Ibuprofen is the most used over the counter NSAID available in the UK, whereas naproxen is one of the most prescribed drugs in the UK and most prescribed NSAID. Ibuprofen is the weakest anti-inflammatory drug from the NSAIDs class with a lower risk of side effects. Ibuprofen and other NSAIDS can be taken to:
- Help with management of the pain
- Reduce fever
- Reduce the inflammation due to injury or in the management of long-term inflammatory conditions such as osteoarthritis, rheumatoid arthritis, and other acute conditions such as gout and dysmenorrhoea.
I previously explained how NSAIDs reduce pain and inflammation. In summary, NSAIDs stop the production of chemicals (enzymes) called cyclo-oxygenase COX-1 and COX-2. COX 1 and COX 2 enzymes are responsible for the synthesis of prostaglandins, which are produced in response to injury or infection (BMJ, 2013).
With fever being one of the main symptoms of COVID infection, it makes sense to use NSAIDs in the management of this condition. Many patients choose to use both paracetamol and ibuprofen in the management of fever as both drugs have distinctive mechanisms of action, which allow for more effective treatment.
Can ibuprofen aggravate coronavirus infection?
Although French Health minister did not explain the reasoning behind the avoidance of ibuprofen in the management of coronavirus symptoms, the BMJ published a more detailed follow-up, suggesting that this observation came from a doctor who treated young coronavirus patients. According to BMJ, this particular doctor reported 4 cases of young patients with no underlying conditions who developed severe symptoms after using NSAIDs at the beginning of the infection (BMJ, 2020). Most stories on coronavirus and ibuprofen quote Ian Jones, a professor of virology at the University of Reading. He said that ibuprofen, through its anti-inflammatory actions, could negatively affect the immune system and consequently slows down the recovery process. In his comment, Professor Jones also suggested that there are similarities between the COVID-19 and SARS I virus, which potently can contribute to the development of pneumonia (lung inflammation). No other evidence exists to support the aggravating effect of NSAIDs.
Ibuprofen & coronavirus: hypothesis on the increased risk of infection
The Lancet published an interesting paper, putting forward a suggestion (hypothesis) on the increased risk of catching of coronavirus due to treatment with certain drugs, such as ibuprofen. What is the link between ibuprofen and the increased risk of coronavirus infection?
According to the paper, some drugs increase the number of ACE-2 receptors on the surface of specific cells in the body. Generally, receptors are a binding site, to which a drug or other molecule or a virus can bind/attach (key and lock idea).
The COVID-19 virus attaches to the ACE-2 receptor of the epithelial cells located in the lungs, intestines, kidney, and blood vessels (Wan et al, 2019). Diabetic patients who take a drug called ACE inhibitor or angiotensin II receptor blocker have an increased number of ACE receptors present. The same increase is seen in patients with high blood pressure who are treated with ACE inhibitors or angiotensin II receptor blockers (Li et al, 2017). Ramipril, an ACE inhibitor, is one of the most popular prescribed drugs in the UK and the most common medication prescribed in the management of high blood pressure. It is suggested that :
- An increased number of ACE receptors facilitate infection with coronavirus.
- Diabetic patients or patients with high blood pressure who are treated with ACE inhibitor or angiotensin II blocker have an increased risk of developing a severe case of covid-19.
Coronavirus advice: Can you take ibuprofen for the management of coronavirus symptoms?
World Health Organisation (WHO) statement on ibuprofen and coronavirus use
Since the announcement, the World Health Organisation issued a statement:
“At present, based on currently available information, WHO does not recommend against the use of ibuprofen.”
WHO added that consultation takes place concerning coronavirus and ibuprofen use with doctors involving in the treatment of COVID-19 cases. So far, no reports, which suggest the negative effect of ibuprofen in the management of coronavirus symptoms exist.
Coronavirus and ibuprofen: NHS statement to healthcare staff
On 17/03/20, Professor Stephen Powis (NHS medical director) issued an alert to all NHS clinical staff regarding all anti-inflammatory medications and concerns in their use during coronavirus infection. This alert explains that the statement from the French Health Minister is based on provisional information, which has not been published and seen by UK authorities. Additionally, it is said no evidence exists on the negative impact of NSAIDs use in the management of coronavirus (COVID-19) infection. Lastly, Professor Stephen Powis explains that there is no evidence which suggests that taking NSAIDs such as ibuprofen or naproxen increases the chances of acquiring a coronavirus.
The National Institute for Health and Care Excellence (NICE) and The Medicines and Healthcare products Regulatory Agency (MHRA) are asked by NHS to review (any) evidence.
A suggestion is made to use paracetamol instead of ibuprofen in patients with a confirmed case of coronavirus (covid-19).
Patients who take NSAIDs for any other medical reason should not stop taking them.
Should I stop taking NSAIDs?
In a panic, patients who manage their long term conditions with ibuprofen or other non-steroidal anti-inflammatory drugs, such as naproxen, question the ‘safety’ of the treatment, taking into account current outbreak of coronavirus. Should they stop taking NSAIDs?
- Do not stop taking your medication without consulting a doctor
- There is no evidence to suggest NSAIDS make coronavirus infection worse
Little evidence exists to support the hypothesis that ibuprofen or other NSAIDS worsen coronavirus infection. Patients with confirmed covid-19 infection should use paracetamol in preference to ibuprofen. Patients who take NSAIDs every day for the management of long term conditions should not stop taking their medication and consult their GP if in doubt.
BMJ (2013; 346:f3195). Non-steroidal anti-inflammatory drugs (NSAIDs). Available at: https://www.bmj.com/content/346/bmj.f3195 Accessed on 14/01/2020
BMJ (2020). Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. Available at: https://www.bmj.com/content/bmj/368/bmj.m1086.full.pdf Accessed on 20/03/2020
Li XC, Zhang J, Zhuo JL. The vasoprotective axes of the renin-angiotensin system: Physiological relevance and therapeutic implications in cardiovascular, hypertensive and kidney diseases. Pharmacol Res. 2017;125(Pt A):21–38. doi:10.1016/j.phrs.2017.06.005 Available at: https://doi.org/10.1016/j.phrs.2017.06.005 Accessed on 20/03/2020
Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor Recognition by the Novel Coronavirus from Wuhan: an Analysis Based on Decade-Long Structural Studies of SARS Coronavirus. J Virol. 2020;94(7):e00127-20. Published 2020 Mar 17. doi:10.1128/JVI.00127-20 Available at: https://doi.org/10.1128/jvi.00127-20 Accessed on 20/03.2020