Covid-19 France: Experts defend stance on ibuprofen

French medicine experts have defended France’s cautious position against taking ibuprofen for Covid-19 symptoms, despite some international bodies stating that there is no evidence that it is harmful.

30 March 2020
By Oliver Rowland

Several leading French pharmacology professors take the view that a combination of scientific knowledge of how anti-inflammatory drugs like ibuprofen work, plus observations on the ground that many people becoming severely ill with Covid-19 - especially young previously healthy people - had taken such drugs, is enough to justify France’s position that they should be avoided.

The French advice is to take paracetamol instead, though not to stop taking an anti-inflammatory drug without medical advice if you already take it for another condition (see this previous article about drugs to avoid).

Some other international bodies, on the other hand, refuse to rule out taking drugs such as ibuprofen against Covid-19 symptoms because they say there are no official studies yet proving that they cause harm.

France’s position may be compared to the ‘principal of precaution’ that is part of French law with regard to protection of the environment and use of agricultural chemicals or GMOs, which states that the absence of complete scientific certainty that something is harmful should not outweigh taking a proportionate measures if it is possible there is a risk of serious, irreversible harm from not doing so.

The European Medicines Agency takes a different approach, putting out a recent statement that: “There exists currently no scientific proof establishing a link between ibuprofen and aggravation of Covid-19”.

Similarly, several researchers published a letter in respected American academic journal Science, entitled ‘Misguided advice for Covid’, also referring to the absence of proof that NSAIDs (non-steroidal anti-inflammatories) like ibuprofen and aspirin are harmful for Covid-19 patients.

A maker of a popular ibuprofen brand Nurofen, Reckitt Benckiser, also hit out against the French position, which has included statements by Health Minister Olivier Véran that “taking anti-inflammatories (ibuprofen, cortisone…) could be an aggravating factor in the infection”.

The company said that there was no proof of this and added that it had not been asked to take part in any new evaluations of the use of the drug in a Covid-19 case.

The Canadian health service Santé Canada said that while it is aware of the issue being flagged up “notably on social media… there is at the current time no scientific data establishing a link between ibuprofen and aggravation of Covid-19 symptoms”, adding that if you have such symptoms you should talk to your doctor about what they advise to take so as to ease your fever or pain.

In fact it continues to recommend that people in isolation due to Covid-19 symptoms keep to hand drugs suitable to fight fever, including ibuprofen.

However Santé Canada said the Canadian government is continuing to monitor the situation closely and will examine any new information that comes out.

In France, concerns were initially raised about the use of NSAIDs when doctors noted severe respiratory conditions in young Covid-19 patients with no prior health problems, who had all taken such drugs and had no other factor in common.

A pharmacology professor at Bordeaux University, Bernard Bégaud, told Le Figaro: “It is true that at the current time we have no clear demonstration that NSAIDs increase the risk of infection and increase the risk of the most serious forms of the illness or of death.

“However we know that inflammation is a normal response of the body in the case of an infection – it is a defense mechanism. In taking an anti-inflammatory we can block this defence mechanism.”

Another pharmacologist, Prof Jean-Louis Montrastruc from the Toulouse teaching hospital and a member of the National Academy of Medicine, said: “It’s a measure of precaution. The situation is so serious that we mustn’t play with fire.”

He told radio station RTL that use of anti-inflammatories may increase risks of complications when a patient has a fever or infection.

Already last year France’s National Agency of Safety of Medicines alerted that it was possible that taking such medicines may make viral infection cases worse.

It said a study by the French pharmacovigilance centres – a national network studying effects of medicines – had showed that in the case of a viral infection, taking ibuprofen increased the risk of a secondary infection from bacteria.

In the UK the NHS is taking a middle line. It advises: “There is currently no strong evidence that ibuprofen can make coronavirus (Covid-19) worse. But until we have more information, take paracetamol to treat the symptoms of coronavirus, unless your doctor has told you paracetamol is not suitable for you. If you are already taking ibuprofen or another NSAID on the advice of a doctor, do not stop taking it without checking first.”

A Canadian expert, Louis Flamand from the Univerité Laval, told Radio Canada that it may be “a little premature” to recommend that people avoid such drugs.

He said it is true that they can inhibit the body from defending itself against the infection, but any risks associated with this would only apply in the case of very serious inflammation.

A colleague from the same hospital, Denis Leclerc, meanwhile supported France’s stance against anti-inflammatories, especially in the case of cortisone.

“You have to understand that to fight as well as possible against infection, we need our immune system, and consequently there will be inflammation at the infection site,” he said. “But if you use a powerful anti-inflammatory, it’s possible that the immune response will not be sufficient to slow down the progression of the virus.”

However he said the French minister’s warning about ibuprofen, a less powerful anti-inflammatory, seemed to him “a little excessive”.

A new paper in respected British medical journal The Lancet has put out another hypothesis as to why it is possible that taking ibuprofen could make it easier for the body to become infected with Covid-19, and could also increase risks of the more severe or fatal forms.

It said that the coronavirus binds to the body’s cells through the action of a certain enzyme, ACE2, which may be found in the lungs, intestines, kidneys and blood vessels.

The production of ACE2 “can… be increased by… ibuprofen” the article said.

It said other drugs with this effect include certain drugs taken by diabetics and high-blood pressure patients - ACE inhibitors and ARBs as well as thiazolidinedione (used in certain diabetes medicines).

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