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NSAIDs, ACE inhibitors and Fear

Dr Neal Tucker - 18 Mar, 2020

Fear is the enemy of reason.

The last thing we need during this unprecedented world pandemic is fake news fueling anxiety and yet on social media yesterday a story about ibuprofen use worsening Covid-19 raced around the world throwing people into a panic. The psychology of this is hugely interesting but our time is precious right now so let’s focus on the science.

NSAIDs and Covid-19

This originated from a French doctor who tweeted about the potential risks of NSAIDs during fever and illness, a message which was then shared by the French Health Minister, who said ibuprofen should not be used during the illness. This prompted global public and scientific debate on the issue.

The concerns raised are based around theoretical risks and data regarding other ‘routine’ infections. UK Professor of Primary Care, Paul Little, recently discussed in a BMJ editorial that NSAIDs may cause an increase of pyelonephritis when taken for UTI management, but also quoted data suggesting prolonged illness or the complications of respiratory infections may be more common when NSAIDs are used (ref 1 and 2).

The theoretical mechanism here is that NSAIDs may dampen the immune response, prolonging illness, and that Covid-19 may lead to a reduction in an enzyme required in fluid and electrolyte homeostasis that was seen in SARS, given the viruses similarities.

However, there is currently no published data on the effects of NSAIDs in Covid-19 infection. Today Stephen Powis, NHS England Medical Director, clarified the position saying that:

  • “In view of the current lack of clarity the Committee of Human Medicines (an advisory body of MHRA) and NICE have been asked to review the evidence. It is therefore suggested that, in the interim, for patients who have confirmed Covid-19 or believe they have Covid-19, that they use paracetamol in preference to NSAIDs. Those currently on NSAIDs for other medical reasons (e.g. arthritis) should not stop them.”

ACEi/ARB and Covid-10

The other big medical scare this week was that ACEi/ARB use may also lead to worsening outcomes in Covid-19. This was another piece of speculation blown out of proportion and disseminated globally via social media.

Some Covid-19 cases in China demonstrated evidence of arterial hypertension, increasing the risk of mortality. This was then spuriously linked to how the virus infects humans: it binds to ACE2, similar to SARS. Levels of the enzyme may be raised by treatment with ACEi or ARB therefore it was suggested this may be the reason for increased mortality.

The European Society of Cardiology was quick to release a statement to reassure patients on these medications that there is no scientific basis to the claim or evidence to support it. It also reported that animal studies suggest they may in fact have a protective effect from serious lung complications although it stresses there is no data in humans as of yet.

Bottom line: do not stop your ACEi or ARB. The last thing health services around the world need right now is an increase in MIs and stroke.

Fighting the Fear

We are supporting patients through this anxious time, and a huge part of that is calm, reasoned advice based on the best information we have at the time.

New data emerges every day, we are all trying to stay on top of it. NB will do its best to help.

There will no doubt be more fake news, we need to recognise it as such and stop it in its tracks.


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