Intended for healthcare professionals


Covid-19: NICE advises against using NSAIDs for fever in patients with suspected cases

BMJ 2020; 369 doi: (Published 06 April 2020) Cite this as: BMJ 2020;369:m1409

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  1. Ingrid Torjesen
  1. London

Paracetamol should be used in preference to non-steroidal anti-inflammatory drugs for managing fever in patients with suspected covid-19 until more evidence is available on the safety of NSAIDs, the National Institute for Health and Care Excellence advises in a rapid guideline on managing symptoms of covid-19 in the community.1

Patients with cough symptoms should take honey and avoid lying on their backs “because this makes coughing ineffective,” says NICE. If cough is distressing, short term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution can be considered to suppress coughing in adults.

Remaining in a cool room with an open window are among strategies advised for managing breathlessness, along with relaxation, breathing techniques, and changing body positions, and finally a trial of oxygen, if available. Breathlessness can cause anxiety, which can exacerbate the problem, says NICE. If pharmacological management of anxiety is required it recommends benzodiazepines initially.

Opioids may be prescribed for breathlessness in patients nearing the end of life and in combination with benzodiazepines if breathlessness is moderate to severe and distressing, although the combination is unlicensed. Drug shortages may mean that smaller quantities of anticipatory medicines need to be prescribed to patients nearing the end of life. Subcutaneous, rectal, or long acting formulations of these drugs may need to be administered by carers or family members because of a lack of health and care staff, NICE points out.

NICE published three other rapid guidelines for managing conditions during the covid-19 pandemic: suspected or confirmed pneumonia in the community,2 severe asthma,3 and rheumatological autoimmune, inflammatory, and metabolic bone disorders.4 The rapid guidelines have been designed to maximise the safety of patients while enabling services to make the best use of NHS resources.

The guideline on pneumonia says that as covid-19 becomes more common in the community, the virus is more likely to be the cause of pneumonia than bacteria, so antibiotics should be offered only when bacteria are considered the likely cause, the cause is unclear, or the patient is at high risk of developing complications.

To minimise the risk of infection, patients with severe asthma should attend only essential appointments and then ideally alone, says NICE. Patients should also clean equipment such as face masks and mouth pieces regularly and not share their inhalers and devices.

The guideline on rheumatological autoimmune, inflammatory, and metabolic bone disorders emphasises that patients with covid-19 should not stop taking their medications suddenly and should seek medical advice on whether any need to be stopped temporarily. Although there are concerns about the use of NSAIDs by patients with covid-19,5 NICE says that patients taking them for long term conditions such as rheumatoid arthritis should not stop them. However, use of intravenous biological treatments or immunoglobulins should be assessed to see whether a switch to non-IV treatments is possible or whether the IV administration frequency can be reduced.

NICE has already issued rapid covid-19 guidelines on delivery of radiotherapy and haematopoietic stem cell transplantation,6 and more will follow. Further guidelines are likely to focus on chronic obstructive pulmonary disease, cystic fibrosis, and dermatological conditions in people receiving immunotherapy.

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