What is the recommended treatment for fever associated with Covid-19 (Coronavirus disease 2019)?

Treatment of Fever in COVID-19

For fever associated with COVID-19, use acetaminophen (paracetamol) as the first-line antipyretic agent, reserving ibuprofen and other NSAIDs for cases where acetaminophen is insufficient or contraindicated. 1

First-Line Antipyretic Approach

• Acetaminophen (paracetamol) is the preferred antipyretic for COVID-19 patients with fever, particularly when temperature exceeds 38.5°C 1
• Acetaminophen has no significant drug interactions with COVID-19 antivirals including lopinavir/ritonavir, remdesivir, hydroxychloroquine, tocilizumab, or interferon beta 1
• For critically ill COVID-19 patients with fever, acetaminophen is specifically recommended over no treatment 1

When to Use NSAIDs

• Ibuprofen and other NSAIDs can be safely used when acetaminophen is insufficient or contraindicated 1
• Ibuprofen dosing: 0.2 g per dose, every 4-6 hours as needed for persistent fever, not exceeding 4 doses in 24 hours 1
• Ibuprofen and diclofenac have no significant interactions with COVID-19 antivirals 1

Important Caveat on NSAIDs

• In patients with established or strongly suspected SARS-CoV-2 infection, apply a precautionary principle: avoid prescribing NSAIDs when alternatives exist 1
• Despite early concerns, there is no scientific evidence linking NSAID use to worsening COVID-19 severity or increased mortality 1
• For asymptomatic patients, there appears to be no contraindication to NSAID use if their benefit is established 1

The Rationale: Fever as a Defense Mechanism

While treating fever for comfort is reasonable, recognize that fever is an evolved defense mechanism against infection. The heat of fever augments immune cell performance and induces stress on pathogens directly 2. Observational trials suggest a survival benefit from fever, and randomized trials do not support routine fever reduction in patients with infection 2. However, symptomatic relief remains a valid clinical goal, particularly for patient comfort 1, 3.

Practical Algorithm

1. Temperature >38.5°C with discomfort: Start acetaminophen 1
2. Inadequate response to acetaminophen: Add or switch to ibuprofen (if no contraindications) 1
3. Asymptomatic or mild fever (<38.5°C): Consider allowing fever to run its course unless patient requests treatment 2
4. Check for drug interactions: If patient is on COVID-19 antivirals, acetaminophen and ibuprofen are safe choices 1

Additional Supportive Measures

• Advise patients to drink fluids regularly to avoid dehydration, with a maximum of 2 liters per day 1
• Continue treatment only while symptoms persist 1
• OTC medicines used for common cold and flu symptoms are safe and effective for the same symptoms associated with COVID-19 3