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Prudent use of NSAIDs in patients with COVID-19, dengue, and chikungunya

Article-Prudent use of NSAIDs in patients with COVID-19, dengue, and chikungunya

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Non-steroidal anti-inflammatory drugs may lead to complications affecting the immune function in patients. Read on to learn more.

Non-steroidal anti-inflammatory drugs (NSAIDs) are considered the mainstay of current therapies for viral arthropathies, albeit they frequently only offer partial relief. Numerous studies have documented widespread abuse of NSAIDs among COVID-19, dengue, and chikungunya patients. NSAIDs can be used to treat severe arthralgia, however, the World Health Organization (WHO) advises against doing so in suspected chikungunya patients until it has been determined that they do not have dengue. Acetaminophen is recommended by consensus guidelines for treating dengue fever from the WHO and US Centers for Disease Control and Prevention (CDC), although NSAIDs are contraindicated due to a possible increase in bleeding risk, which could result in thrombocytopenia as a side effect. 

At least 165,000 fatalities, 650,000 hospitalisations, and 30 per cent of Adverse Drug Reaction (ADR) related hospital admissions around the globe are attributable to NSAIDs, mostly because of bleeding, heart attacks, strokes, and renal impairment. Additionally, overusing this class of medications can result in kidney damage, and kidney patients may experience its side effects at a high rate of three to four times. This is particularly crucial because clinical experience and publications have shown that kidney involvement was found in up to 75 per cent of patients with COVID-19. Similarly, obese, elderly and liver compromised patients with COVID-19 are at increased risk of hospitalisation or ICU admission. Also, liver injury and abnormal liver function were reported in nearly one-fourth to half of the hospitalised patients or patients who recovered from COVID-19. Acetaminophen and antibiotics were the most reported drugs for liver injury among hospitalised patients. Liver function tests should be performed among these types of hospitalised patients before prescribing NSAIDs and Acetaminophen.  

Hypertension or cardiac involvement was the most common pre-existing comorbidity in foetal cases of COVID-19 and chikungunya patients. NSAIDs have numerous potentially deleterious effects on immune function, and they interact with many drugs which are used in patients with cardio- or cerebrovascular disorders: they attenuate the effects of diuretics, beta-blockers, Angiotensin-converting enzyme (ACE) inhibitors and Angiotensin II receptor type 2 (AT-2) blockers, thus leading to uncontrolled hypertension or aggravation of heart failure.  

Related: The Growing Threat of Zika, Dengue and Chikungunya

Sleep disturbance is reported in close to 40 per cent of COVID-19 and some 30 per cent to 60 per cent chikungunya patients (due to severe arthropathy). The use of benzodiazepines is contraindicated among COVID-19 patients with various antiviral medications, increases the risk of delirium and respiratory depression. However, physicians should recognise that concurrent use of Selective Serotonin Reuptake Inhibitors (SSRIs) and NSAIDs was related with a 75 per cent increased risk of upper GI bleeding and should advise patients appropriately if they choose to utilise SSRIs for the same. This is particularly concerning because NSAIDs are frequently taken daily or sometimes many times per day, and SSRIs are typically prescribed for daily usage.  

Maintaining the body's hydration level is more crucial than bringing down the temperature with painkillers, especially in dengue or COVID-19 patients. In children, using too much Acetaminophen syrup or suppositories might irritate the stomach, preventing proper digestion, leading to vomiting, and even necessitating hospitalisation. With very few exceptions, most hospitalisations or ICU admissions among those individuals might be avoided by just avoiding dehydration at home with saline and fruit juice, or by simply drinking more water. 

Some recent studies warrant concurrent administration of antioxidants and omeprazole along with NSAIDs in COVID-19 patients, which needs further investigations, of course. 

Resistance training with NSAIDs, along with professional guidance are highly recommended for post-COVID and chikungunya pain-discomfort management. Mindfulness-based therapies for insomnia management are recommended for both types of patients.  

NSAIDs are contra-indicated in dengue fever. In addition to recommending daily follow-up, dengue patients who are being followed as outpatients must be counseled on appropriate home care and on attending to warning signs warranting an earlier return to the clinic for re-evaluation. Along with tepid sponging, Acetaminophen is advised for fever relief.  

Finally, it is recommended that pain modulation therapy, especially with NSAIDs, is important for the management of outpatients with early symptoms of COVID-19. Co-administration of NSAIDs with low-dose systemic corticosteroids has been advised to reduce pain and improve quality of life in patients with chikungunya, only if the benefits outweigh the risks. In both cases, other comorbid situations should be carefully considered.  

Prevention techniques are most effective for most contagious diseases — theoretically. Along with them, some non-drug treatment options should be exercised among such patients with viral diseases after careful consideration of patients’ comorbidities. Modern care gives more emphasis to patient care and counseling over drug use. And caution should be taken before any drug intake as none of them are free of their adverse effects. Proper body workout, patient counselling for motivation, maintaining hydration, and nutritious food intake are necessary to regain body fitness, to improve immune function and quality of life. 

Disclaimer: The study does not promote the use of steroid painkillers in any forms in any of the stated viral conditions. 
References available on request. 
Abdul Kader Mohiuddin is a registered pharmacist with the Bangladesh Pharmacy Council and an alumni at the Faculty of Pharmacy at Dhaka University. His views are not biased and believes that facts can be changed with time.  
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