Is it safe to prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to a patient with acute chikungunya infection who is IgG positive?

NSAIDs Are Safe in Chikungunya IgG-Positive Patients

NSAIDs can be safely prescribed to patients with chikungunya infection who are IgG positive, as IgG positivity indicates past infection (typically appearing after 5-7 days from symptom onset) rather than acute viremia, and NSAIDs are a recommended treatment for chikungunya-associated arthralgia. 1

Understanding Chikungunya Serology and Disease Phases

The presence of IgG antibodies indicates you are dealing with either:

• Post-viremic acute phase (IgG positive, IgM positive, PCR negative) - typically 5-7 days after symptom onset 1
• Chronic/convalescent phase (IgG positive, IgM may be positive or negative, PCR negative) - weeks to months after initial infection 1

The critical distinction is that IgG positivity means the patient is no longer in the viremic phase where theoretical concerns about NSAIDs might apply. 1

NSAID Use is Standard Treatment for Chikungunya Arthralgia

• NSAIDs are explicitly recommended as symptomatic treatment for chikungunya-associated joint pain, both in acute and chronic phases of the disease. 2
• A Brazilian guideline specifically addresses pharmacologic management of chikungunya pain and supports NSAID use for the arthralgia that characterizes this infection. 3
• Non-steroidal anti-inflammatory drugs help patients recover from chikungunya infections when combined with proper diet and adequate rest. 2

Evidence from Clinical Trials

• In a randomized controlled trial of early chikungunya arthritis, NSAIDs (Naproxen 1 gm/day or Etoricoxib 120 mg/day) achieved remission in 93% of patients with persistent post-chikungunya arthritis at 6 months. 4
• The NSAID arm in this trial showed comparable efficacy to methotrexate for managing subacute post-chikungunya arthritis. 4

Addressing the COVID-19 NSAID Controversy (Not Applicable Here)

The evidence you may have encountered regarding NSAID caution pertains exclusively to COVID-19, not chikungunya:

• Early pandemic concerns about NSAIDs worsening COVID-19 outcomes were raised but never substantiated. 1
• Multiple rheumatology guidelines from 2020 concluded that NSAIDs may be continued in COVID-19 patients with rheumatic disease, except in severe COVID-19 with organ injury. 1
• These COVID-19-specific recommendations do not apply to chikungunya infection. 1

Clinical Algorithm for NSAID Use in Chikungunya IgG-Positive Patients

1. Confirm IgG positivity indicates post-viremic or chronic phase (not acute viremia) 1

2. Assess for standard NSAID contraindications:

   • Severe renal impairment (eGFR <30 mL/min) 5
   • Active peptic ulcer disease or recent GI bleeding 1
   • Severe cardiovascular disease or heart failure 1
   • Concurrent anticoagulation therapy 1

3. If no contraindications exist, prescribe NSAIDs:

   • Naproxen 500 mg twice daily 4
   • Etoricoxib 120 mg daily 4
   • Continue for duration of symptomatic arthralgia 2

4. If NSAID contraindications are present, use corticosteroids instead:

   • Prednisone 30-35 mg daily for 5 days 5, 6
   • This is the safer alternative in patients with renal impairment, cardiovascular disease, or GI risk 5, 6

Important Caveats

• Chikungunya arthralgia is notoriously poorly responsive to analgesics, including NSAIDs, particularly in chronic cases. 3 Patients should be counseled that pain relief may be incomplete even with appropriate therapy.

• Joint involvement in chikungunya is characterized by asymmetrical bilateral polyarthralgia affecting lower and small joints (98% and 74.8% respectively), with swelling and intense pain. 7 The severity of symptoms does not contraindicate NSAID use.

• Avoid confusing chikungunya management with dengue management, where NSAIDs are contraindicated due to bleeding risk. The two arboviruses require different approaches despite similar geographic distribution. 1

• If NSAIDs fail to provide adequate relief after 2 months in persistent post-chikungunya arthritis, consider adding methotrexate rather than continuing NSAIDs indefinitely. 4