What analgesics, antitussives (cough suppressants), or antipyretics (fever reducers) can be prescribed for a patient with Covid-19 (Coronavirus disease 2019)?

Symptomatic Treatment for COVID-19 Patients

For fever and pain management in COVID-19 patients, acetaminophen (paracetamol) is the preferred first-line antipyretic and analgesic, while ibuprofen and other NSAIDs can be safely used when acetaminophen is insufficient or contraindicated. 1, 2

Antipyretics and Analgesics

First-Line: Acetaminophen/Paracetamol

• Use acetaminophen for fever control when temperature exceeds 38.5°C 1
• Dosing: Standard adult dosing per FDA labeling 3
• For critically ill COVID-19 patients with fever, acetaminophen is specifically recommended over no treatment 1
• The British Medical Journal recommends paracetamol for fever and other symptoms that antipyretics would help treat, continuing only while symptoms persist 2
• Acetaminophen was the most commonly used analgesic (40% during acute COVID-19,31% in post-acute phase) 4

NSAIDs (Including Ibuprofen)

• Ibuprofen can be used for antipyretic effect at 0.2 g per dose, every 4-6 hours as needed for persistent fever, not exceeding 4 doses in 24 hours 1
• Despite early concerns, there is no scientific evidence linking NSAID use to worsening of COVID-19 severity or increased mortality 5, 6, 7
• In a cohort of 403 COVID-19 patients, ibuprofen use showed no difference in mortality (3.4% vs 2.8%) or need for respiratory support (10.3% vs 11%) compared to non-ibuprofen users 6
• For asymptomatic patients, there appears to be no contraindication to NSAID use if their benefit is established 1
• However, in patients with established or strongly suspected SARS-CoV-2 infection, a precautionary principle applies and prescription of NSAIDs should be avoided when alternatives exist 1
• Other NSAIDs (29.5%) were also commonly used in post-acute COVID-19 for persistent arthralgia and myalgia 4

Important Temperature Management Caveat

• Maintain temperature below 38°C but avoid excessive temperature reduction, as much lower body temperature is not conducive to antiviral treatment 1

Antitussives (Cough Suppressants)

Non-Pharmacological First

• Encourage patients to avoid lying on their back as this makes coughing ineffective 2
• Use honey for patients aged over 1 year as a simple first measure 2

Pharmacological Options for Distressing Cough

• For distressing cough, use short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 2
• Dextromethorphan is available as an over-the-counter cough suppressant 8
• For patients with dyspnea, cough, wheeze, and respiratory distress due to increased respiratory gland secretion, use selective (M1, M3) receptor anticholinergic drugs to reduce secretion, relax airway smooth muscle, relieve airway spasm, and improve pulmonary ventilation 1

End-of-Life Breathlessness Management

• For end-of-life patients with moderate to severe breathlessness, use morphine sulfate immediate-release or modified-release, with concomitant use of an antiemetic and a regular stimulant laxative 2
• Implement controlled breathing techniques including proper positioning, pursed-lip breathing, and relaxing shoulders 2

Critical Clinical Considerations

Hydration

• Advise patients to drink fluids regularly to avoid dehydration, with a maximum of 2 liters per day 2

Drug Interactions in COVID-19 Patients on Antivirals

• Paracetamol has no significant drug interactions with lopinavir/ritonavir, remdesivir, hydroxychloroquine, tocilizumab, or interferon beta 1
• Ibuprofen and diclofenac similarly have no significant interactions with COVID-19 antivirals 1
• Morphine exposure may be decreased when used with lopinavir/ritonavir, requiring dose adjustment or monitoring 1
• Oxycodone exposure increases by 160% with lopinavir/ritonavir, requiring dose adjustment 1
• Tramadol has possible interactions with lopinavir/ritonavir and hydroxychloroquine (cardiac toxicity risk), requiring monitoring 1

Common Pitfalls to Avoid

• Avoid using opioid patches in opioid-naive patients due to the time needed to reach steady state and high morphine equivalence 2
• Avoid delay in treatment escalation for patients showing signs of deterioration 2
• Do not routinely discontinue corticosteroids in patients on long-term therapy 1
• Single intraoperative injection of dexamethasone at usual doses does not appear to present over-risk in asymptomatic patients 1

Special Populations

• In older subjects with post-acute COVID-19 symptoms, acetaminophen was the most common analgesic used (54%) 4
• 84% of patients continuing analgesics in post-acute COVID-19 reported improvement in pain perception 4