A questionable report from France’s Health Ministry stirred some controversies on Saturday that are still ongoing. According to France’s Health Minister Olivier Veran, many of the popular anti-inflammatory painkillers such as ibuprofen might be aggravating the effects of COVID-19. Veran, a neurologist himself tweeted that “taking anti-inflammatory drugs (ibuprofen, cortisone…) could be an aggravating factor of the infection. If you have a fever, take paracetamol. If you are already on anti-inflammatory drugs or in doubt, ask your doctor for advice.”
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His statement was widely criticized by experts as currently there is no scientific data backing it up. Something that does support Veran’s statement, however, was a report by the French government stating that there are “grave adverse effects” to using non-steroid anti-inflammatory drugs (NSAID) such as ibuprofen as they have “been identified with patients affected by Covid-19, in potential or confirmed cases.”
Acetaminophen Instead of NSAIDs
The ministry’s report also included a recommendation in favor of paracetamol (known in the U.S. as acetaminophen) instead of NSAIDs – “We repeat that the treatment of a fever or of pain linked to Covid-19 or to any other respiratory viral disease should be paracetamol,”
Amid the controversy around Veran’s tweet, a lot more questions were raised and answered. Muge Cevik, a University of St. Andrews Infection and Global Health Division researcher stated that he was “Deeply concerned about this [Veran’s] bold statement. There’s no scientific evidence I am aware of that ibuprofen [causes worse] outcomes in #COVID19.”
Dr. Yvonne Maldonado, professor of pediatrics and infectious disease epidemiologist at Stanford University in California also chipped in saying that “I don’t think we’ve had any firm evidence to suggest that [ibuprofen aggravating Covid-19] is a concern at this point,”
Nevertheless, Veran does have the support of some experts who mention that many countries’ general guidelines about anti-inflammatory painkillers include caution anyway, regardless of the presence of coronaviruses in the patients.
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Rupert Beale, a group leader in Cell Biology of Infection at the UK’s Francis Crick Institute, told the UK’s Science Media Centre that “There is a good reason to avoid ibuprofen as it may exacerbate acute kidney injury brought on by any severe illness, including severe Covid-19 disease. There isn’t yet any widely accepted additional reason to avoid it for Covid-19,”
Dr. Yogen Kanthi, assistant professor of cardiology at the University of Michigan also supports the idea that COVID-19 might be affected by NSAIDs when it comes to its ability to bind to human cells. Kanthi himself studies inflammations and claims that “There is data from basic science studies that have shown that Covid-19 itself binds to a protein at the surface of cells called ACE2. There is a hypothetical risk that giving NSAIDs like ibuprofen could increase levels of ACE2 shown in animal models, but not in patients.”
Cortisone is another drug Veran alluded to in his statement but most experts claim that there’s not enough evidence in that case as well. “The data is quite unclear,” said Kanthi.
There are risks, a lot of experts admit, as anti-inflammatory drugs might be suppressing the immune response of the body that’s necessary to fight off the disease. However, most experts, including Dr. Yvonne Maldonado maintain that I don’t think there’s any evidence so far to suggest that.”
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More research is on the way and we will hopefully have conclusive answers soon. If you do want to err on the side of cautiousness, then most professionals agree that paracetamol (or acetaminophen) is “generally preferred” as a substitute for ibuprofen.
NSAIDs such as ibuprofen are commonly used to treat fever – one of the main symptoms of COVID-19.
“Most deaths from Covid-19 have been among older people and those with underlying health conditions such as cardiovascular disease. We already know that NSAIDs should be prescribed with caution for people who have underlying health conditions,” said Charlotte Warren-Gash, an Associate Professor of Epidemiology, London School of Hygiene and Tropical Medicine.
The UK’s National Health Service (NHS) is typically not as hard on NSAIDs such as ibuprofen as France. France’s rules are more strict than those of most countries regarding the sale of painkillers as both paracetamol and ibuprofen, as well as many other products, have been moved “behind the counter” as of this year.
The UK’s National Institute for Health and Care Excellence, on the other hand, recommends ibuprofen for anti-inflammatory purposes but advises that the lowest possible doses should be used if the patient has underlying conditions such as cardiovascular or kidney problems.
Nevertheless, England’s Public Health Agency is still not following France’s lead and doesn’t advise COVID-19 patients against the use of NSAIDs such as ibuprofen.
“For COVID-19, research is needed into the effects of specific NSAIDs among people with different underlying health conditions, which takes into account the severity of infection,” Warren-Gash said. “In the meantime, for treating symptoms such as fever and sore throat, it seems sensible to stick to paracetamol as first choice.”
Tom Wingfield, a consultant physician at the Liverpool School of Tropical Medicine also supports the notion that paracetamol should “generally be preferred” over ibuprofen in most situations simply because of the fewer risks of side effects it presents.
“It is not clear from the French Minister’s comments whether the advice given is generic ‘good practice’ guidance or specifically related to data emerging from cases of Covid-19, but this might become clear in due course,” Wingfield explained.
At the end of the day, even though few experts and agencies agree with the French Health Minister’s statement that ibuprofen is causing problems, most experts concur that caution should be advised. Instead, whenever possible, patients should either avoid long-term use and excessive doses of NSAIDs such as ibuprofen and that other medications such as paracetamol or acetaminophen should be considered first.