By Monique Biryiana

It is clear that the COVID-19 pandemic is having an unprecedented impact on societies across the globe, as incidence and mortality rates continue to sharply rise.

Healthcare providers are facing immense pressure in protecting and treating affected patients, especially those with existing co-morbidities or underlying health issues – which place them at a higher risk of developing severe complications as a result.

The sudden emergence of severe acute respiratory syndrome virus 2 (SARS-CoV-2) has meant that stringent guidelines for the optimal management of COVID-19 patients is scarce – especially concerning the use of non-steroidal anti-inflammatories (NSAIDs) and corticosteroids.

As these drugs are routinely used to manage pain in patients with cancer, there must be sufficient resources available for medical professionals, to help inform their treatment decisions, in light of the most recent evidence.

Many health authorities have stated to avoid the use of NSAIDS and corticosteroids in patients with COVID-19.

But, a paper published in the journal ecancermedicalscience has gathered the relevant evidence from the existing literature to determine if these claims can be validated.

Using specific search terms, this review selected 13 studies that provide key insights into the action of NSAIDs and corticosteroids during the treatment of coronaviruses.

One study noted that SARS-CoV (the strain responsible for the 2003 outbreak) could be associated with the downregulation of ACE2, which in turn may be responsible for inadequate pulmonary function, as a consequence of the infection.^1,2

Another study reported that ACE2 expression was upregulated when ibuprofen is administered to diabetic patients and those receiving treatment with angiotensin II type-I receptor blockers (ARBs).^1,3 Therefore, it could be inferred that increased ACE2 expression could exacerbate the COVID-19 infection in patients with co-morbidities.

However, the authors noted: “Crucially, this review did not identify any strong evidence for or against the use of ibuprofen during treatment of COVID-19 specifically,” as an additional study reported that indomethacin inhibited the replication of both canine coro navirus in vitro and the human SARS-CoV in vivo.^1,4

Alternatively, there may be benefits of using corticosteroids to treat coronaviruses in the “early acute phase” of infection, as it was found that dexamethasone successfully reduced the “early pro-inflammatory response” in pigs infected with porcine respiratory coronavirus.^1,5 Although, increased viral rebound, viral replication5 and adverse events may occur with their prolonged use.

A further study conducted in China achieved encouraging patient outcomes when SARS-CoV patients were treated with a combination of early high-dose steroids and a quinolone.^1,6

Although evidence is limited, corticosteroids could be beneficial in treating the infection, while the use of NSAIDs cannot be supported nor rejected in this context.

However, the above studies are not specific to COVID-19 and until further data specific to this strain becomes available, patients should follow their medication regimen as instructed by their doctor.

References:

1. Russell B, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting? ecancermedicalscience. 2020;14.

2. Fu Y, Cheng Y, Wu Y. Understanding SARS-CoV-2-Mediated Inflammatory Responses: From Mechanisms to Potential Therapeutic Tools. Virol Sin. 2020;12250.

3. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020;2600(20):30116

4. Amici C, Di Caro A, et al. Indomethacin has a potent antiviral activity against SARS coronavirus. Antivir Ther. 2006;11(8):1021–30.

5. Zhang X, Alekseev K, Jung K, Vlasova A, Hadya N, Saif LJ. Cytokine responses in porcine respiratory coronavirus-infected pigs treated with corticosteroids as a model for severe acute respiratory syndrome. J Virol. 2008;82(9):4420–8.

6. Zhao Z, Zhang F, et al. Description and clinical treatment of an early outbreak of severe acute respiratory syndrome (SARS) in Guangzhou, PR China. J Med Microbiol. 2003;52(Pt 8):715–20.