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Is indomethacin a better choice than ibuprofen in covid-19?

Interview and article by Christine Clark.

Compared with ibuprofen, indomethacin has additional beneficial actions, argues Dr Rajan Ravichandran

Commenting on the LIBERATE* study (NCT04334629) that is now in progress in London, Dr Ravichandran said that indomethacin might have been a good choice of non-steroidal anti-inflammatory agent (NSAID), because of its additional properties.

Compared with ibuprofen, indomethacin has additional beneficial actions, such as its anti-viral properties and, possibly, prevention of [blood] clots in the lungs, says Dr Rajan Ravichandran.  In a study of rats dying of septicaemia with multi-organ failure, indomethacin prevented thrombin clots in the lungs, he explains.  One of the post-mortem findings in patients dying of covid-19 is the presence of clots [in the lungs]. Indomethacin’s anti-inflammatory and antiviral properties could be useful here, he suggests.

Possibly, ibuprofen was chosen because prescribers are more familiar with ibuprofen these days.  Indomethacin is a 60-year-old drug that is less well-known and may be perceived as toxic whereas ibuprofen is generally seen as a ‘safe’ drug.

Dr Ravichandran speculated that the LIBERATE study could perhaps be extended to include the use of indomethacin in association with other drugs. 

Indomethacin could be most beneficial when used in mild or moderate covid-19 infection, when patients have fever and coughing but before hypoxaemia develops. This is the time when it could prevent the cytokine reaction and therefore reduce the severity of the disease. As Dr Leibowitz [Watch the video here] has shown, even just two doses of indomethacin can dramatically reduce the cough

“The medical community needs to be made more aware of the fact that indomethacin is a fairly safe drug that has both anti-inflammatory and anti-viral properties.  The drug should be given a fair trial in patients with mild disease so that hospitalisation can be avoided”, says Dr Ravichandran. This is particularly important where resources are stretched. For example, in India, many patients with mild disease are hospitalised and this has a serious impact on the whole healthcare system.

The LIBERATE study aims to evaluate the reduction in severity and progression of lung injury with three doses of lipid ibuprofen in patients with SARS-CoV-2 infections. Participants will be patients who already have acute hypoxaemic respiratory failure.  Based on an interview with Dr Rajan Ravichandran MD FACP FRCP, Director, Nephrology, MIOT Hospitals, Chennai, INDIA

Watch the other videos in the series

Indomethacin to combat cytokine release syndrome in covid-19

Indomethacin – dual antiviral and anti-inflammatory for covid-19?