By John Gever, Executive Editor, MedPage Today
Is ibuprofen dangerous for patients with COVID-19? That has been a major topic of discussion this week, but without a clear answer.
It began last Saturday, when France's health minister, Olivier Véran, tweeted that NSAIDs, including ibuprofen, "could be an aggravating factor" in coronavirus infection and that "paracetamol" (acetaminophen in the US) should be used to treat fever.
Later in the day, an official statement from the Ministry of Health regarding the management of COVID-19 included the following:
"Serious adverse events have been reported related to the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19, suspected or confirmed cases. We remind you that the treatment of poorly tolerated fever or pain in the context of COVID-19 or any other respiratory viral infection is based on paracetamol , without exceeding a dose of 60 mg/kg/day and 3 g/day. NSAIDs should be avoided."
"On the contrary, patients receiving corticosteroids or other immunosuppressants for a chronic condition should not interrupt their treatment unless advised otherwise by the doctor who is treating them for that condition."
Neither Véran nor the ministry followed up with details about the adverse event reports. The state news service Agence France-Presse further muddied the waters on Tuesday with an article citing a brief Lancet article published on March 11 as the justification, but that article made no mention of NSAIDs or adverse event reports. Rather, it speculated that patients with type 2 diabetes and hypertension might be at increased risk from COVID-19 and raised the theoretical possibility that certain antihypertensive medications could increase patients' susceptibility to infection.
The World Health Organization also weighed in on Tuesday, with a spokesperson telling reporters that COVID-19 patients treating themselves should use acetaminophen instead of ibuprofen. But he, too, had no details on the actual basis for the recommendation. The agency's professionals are "investigating this to provide further guidance," he said.
Independent experts expressed bewilderment over the warnings. CNN quoted two people on Tuesday who said they were unaware of any evidence specifically linking ibuprofen to worse outcomes. However, another cited the Lancet article as indirectly suggesting a “hypothetical risk” that NSAIDs could promote viral entry into host cells, as “shown in animal models, but not in patients.” And that is a far cry from the “serious adverse events” that the French health ministry said were reported.
In fact, the European Medicines Agency entered the fray on Wednesday, seeking to allay concerns about NSAIDs.
"There is currently no scientific evidence to establish a link between ibuprofen and the worsening of COVID-19," according to a statement published on the agency's website . "EMA is monitoring the situation closely and will review any new information that becomes available on this topic in the context of the pandemic."
The statement acknowledged some evidence that ibuprofen and ketoprofen can worsen chickenpox (varicella) and certain bacterial infections. But to treat the symptoms of COVID-19, “patients and healthcare professionals should consider all available treatment options, including paracetamol and NSAIDs. Each medicine has its own benefits and risks, which are reflected in its product information and should be considered alongside EU national treatment guidelines, most of which recommend paracetamol as the first-line treatment for fever or pain.”
"According to EU national treatment guidelines, patients and healthcare professionals can continue to use NSAIDs (such as ibuprofen) according to the approved product information. Current advice includes using these medicines at the lowest effective dose for the shortest possible period."
Meanwhile, other doctors argued that mild to moderate fevers don't require any treatment. "Fever is not an illness," said Jane Orient, MD, executive director of the American Association of Physicians and Surgeons, in a press release . "Very high fevers (e.g., 105 degrees) can cause brain damage, and children can have seizures. But don't take Tylenol or ibuprofen at the first sign of a fever."