Analgesia and COVID-19
William F Laughey, Imran Lodhi, Olutoba Sanni, Graham Pennick, Bruce
Charlesworth
Dear editor,
In their comprehensive review of immunomodulatory effects of opioids and
analgesics, Abdel Shaheed et al. report research indicating that some
NSAIDs demonstrate in vitro and in vivo anti-viral activity against
SARS-CoV-2, focussing particularly on indomethacin1.
They point out that ibuprofen has not shown such activity, citing the
work of Chen et al2. However, more recent in vitro
research in Caco-2 cells indicates that ibuprofen does indeed suppress
SARS-CoV-2 viral load3, albeit only at higher
concentrations than those tested by Chen at al2.
Flurbiprofen has similar anti-viral activity at higher
concentrations3. The emerging evidence base for NSAIDs
demonstrating in vitro anti-SARS-CoV-2 activity now includes
indomethacin1, naproxen4,
flurbiprofen3 and ibuprofen3.
The review also considers controversies surrounding immunisation and
whether the use of analgesics to treat post-vaccination symptoms
adversely affects immunogenicity. This is particularly relevant in the
present context of COVID-19 and concerns over vaccine hesitancy.
For vaccinations in general, Saleh et al. note observational studies are
reassuring and ‘that only few RCTS demonstrated blunted antibody
response of unknown clinical significance.5 The
authors suggest that timing of medication is paramount. In all studies
reporting a negative effect on antibody response, medications were given
prophylactically, before vaccination, rather than the more common
practice of using medication after vaccination if
required5.
The emerging evidence in COVID-19 immunisation is also reassuring. In
trials of the Oxford/AZ vaccine, a protocol amendment meant two of the
five sites allowed prophylactic paracetamol to be administered before
vaccination6. This significantly reduced adverse
effects of the vaccine without compromising immunogenicity based on
antibody titres6. A recent review by Ooi et
al. 7 considers data from the Pfizer/BioNTech and
Jansen/J&J trials in which analgesics and antipyretics were permitted,
if needed, post-vaccination. Whilst younger participants were more
likely to need medication than older participants, vaccine efficacy
remained stable across age groups7. Furthermore, the
fact that up to one-fifth of patients required analgesia did not prevent
these vaccines from demonstrating remarkable
efficacy7.
Whilst further research, particularly into cell mediated mechanisms, is
required, current evidence supports the short-term use of analgesics
after COVID vaccination7. As Omicron is currently
surging in several countries, vaccination will continue to play a key
role in limiting morbidity and mortality. Measures which reduce vaccine
hesitancy – including the availability of effective post-vaccination
symptom relief – have significant implications for public health.