Risks Related to the Use of Non-Steroidal Anti-Inflammatory Drugs in Community-Acquired Pneumonia in Adult and Pediatric Patients

Abstract

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to alleviate symptoms during community-acquired pneumonia (CAP), while neither clinical data nor guidelines encourage this use. Experimental data suggest that NSAIDs impair neutrophil intrinsic functions, their recruitment to the inflammatory site, and the resolution of inflammatory processes after acute pulmonary bacterial challenge. During CAP, numerous observational data collected in hospitalized children, hospitalized adults, and adults admitted to intensive care units (ICUs) support a strong association between pre-hospital NSAID exposure and a delayed hospital referral, a delayed administration of antibiotic therapy, and the occurrence of pleuropulmonary complications, even in the only study that has accounted for a protopathic bias. Other endpoints have been described including a longer duration of antibiotic therapy and a greater hospital length of stay. In all adult series, patients exposed to NSAIDs were younger and had fewer comorbidities. The mechanisms by which NSAID use would entail a complicated course in pneumonia still remain uncertain. The temporal hypothesis and the immunological hypothesis are the two main emerging hypotheses. Current data strongly support an association between NSAID intake during the outpatient treatment of CAP and a complicated course. This should encourage experts and scientific societies to strongly advise against the use of NSAIDs in the management of lower respiratory tract infections.

Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 (April 2020)

“…While no causal evidence of adverse outcomes with NSAIDs in the management of COVID-19 have been published, there are well known risks of non-steroidal anti-inflammatory agents including cardiovascular, gastrointestinal and renal adverse events [64,65]. In the setting of bacterial pneumonia, NSAIDs may impair recruitment of polymorphonuclear cells, resulting in a delayed inflammatory response and resolution of infection, however a causal relationship has not been established [66,67]. RCTs are needed to better understand the safety of NSAIDS in the management of patients with COVID-19.…”

General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic

“…This is largely based on data regarding other respiratory infections. 61,63 The primary mechanism through which NSAIDs are hypothesized to impact COVID-19-positive patients is through inhibition of cyclooxygenases. 63 However, there remains no evidence that NSAIDs worsen disease outcomes in COVID-19 patients.…”

“…61,63 The primary mechanism through which NSAIDs are hypothesized to impact COVID-19-positive patients is through inhibition of cyclooxygenases. 63 However, there remains no evidence that NSAIDs worsen disease outcomes in COVID-19 patients. 61,62,64,65 Further, some studies have actually suggested a benefit to NSAID use.…”

Considerations for pharmacoepidemiological analyses in the SARS‐CoV‐2 pandemic

“…Relevant to the study of COVID-19, this has previously been shown to be a particular concern in the association between recent use of NSAIDs and pneumonia complications. 16,17 Similar patterns could be hypothesised for, for example, other analgesics, antibiotics, and inhaled glucocorticoids.…”