BLOG: Consider NSAID use in orthopedic patients during the COVID-19 pandemic
by Ian D. Hutchinson, MD, MCh
NSAIDs provide effective symptom relief for a myriad of arthralgias and inflammatory conditions for the orthopedic patient. NSAIDs are also successfully employed as part of a perioperative multimodal pain management strategies, treatment of inflammatory processes and in joint convalescence strategies during the longer term. Overall, the frequent prescription of NSAIDs in our patient population reflects a favorable risk-benefit profile.
On March 14, the French Minister of Health Olivier Véran released a statement cautioning about the use of NSAIDs for symptomatic relief of COVID-19 symptoms. Contextually, his advice was consistent with the National Agency for the Safety of Medicines and Health Products in France, whose recommendations cautioning NSAID use in active infectious disease predated the COVID-19 pandemic.
Subsequently, a report from the British Medical Journal also cautioned the use of NSAIDs for the management of COVID-19 symptoms, citing expert opinion from the United Kingdom and France with some speculation regarding the potential mechanisms, ranging from dampening of the immune system to altered fluid shifts exacerbating pneumonia. At the same time, The Lancet reported that human pathogenic coronaviruses bind target cells together using angiotensin-converting enzyme 2 (ACE2), which can be increased by treatment with ACE inhibitors and angiotensin II type-I receptor blockers, thiazolidinediones and ibuprofen.
In an open letter in Science, Garret A. Fitzgerald, MD, further qualified speculations on the effects of NSAIDs during COVID infection while offering some insight into previous research on the SARS coronavirus that identified indomethacin as a candidate treatment molecule for its role in blocking coronavirus RNA synthesis. Interestingly, the Center for Evidence Based Medicine in Oxford, the United Kingdom, reported on the benefits of fever during viral illness on viral replication and pro-inflammatory signaling. Currently, the FDA, the European Medicines Agency and the WHO have issued statements acknowledging the lack of evidence linking NSAID use with worsening COVID-19 symptoms.
In the absence of objective data, it remains plausible that the risk-benefit profile of NSAIDs for musculoskeletal indications may be negatively altered during COVID-19 infection. This is of particular concern in our “at risk” patient populations, including the elderly and the immunocompromised. In the interest of shared decision-making, patients should be educated about concerns from the medical community that continued NSAID use during COVID-19 infection may worsen the condition, despite sparse evidence. Patients should be instructed that treatment of COVID-19 symptoms with acetaminophen (paracetamol) provides an alternative to NSAIDs and is not linked to this controversy.
In the event of COVID-19 infection, they should understand that pausing extended NSAID use for musculoskeletal indications may result is some return of symptoms but is unlikely to change the disease course or cause long-term harm. Finally, patients should have a clear understanding of the content of their prescriptions to avoid exceeding doses for both acetaminophen and NSAIDs should they require them to treat the symptoms of COVID-19. In summary, NSAID avoidance during active COVID-19 infection is deliverable in the orthopedic patient population with relatively low negative effects. Primum non nocere.
Day M. BMJ. 2020; 368 doi:https://doi.org/10.1136/bmj.m1086.
FitzGerald GA. Science. 2020;doi:10.1126/science.abb8034.
Ian D. Hutchinson, MD, MCh, is a PGY-4 resident physician at the Division of Orthopaedic Surgery, Albany Medical Center, Albany New York.
Disclosure: Hutchinson reports no relevant financial disclosures.
Acknowledgement: Hutchinson would like to acknowledge James P. Lawrence, MD, MBA, attending physician in the division of orthopedic surgery at Albany Medical Center in Albany, New York, for his insight.