Could Acetylsalicylic Acid be Useful in Adults with COVID-19?

This virus has been shown to affect several organs, particularly the respiratory tract. COVID-19 is characterized by stimulation of an immune response with pro-inflammatory cytokine release, overactivation of the coagulation cascade as well as platelet aggregation, which gives way to micro- and macrovascular thrombosis.²

This is a grim situation and no medication has been proven to be safe and efficacious for COVID-19 treatment as yet. However, several drugs are being used off-label or as investigational therapies to tackle this unprecedented health crisis.

Acetylsalicylic acid (ASA) is a drug with anti-inflammatory, analgesic, antipyretic as well as antithrombotic potential. The drug has a potential role in limiting inflammation and platelet aggregation. It has also been proposed to have antiviral effects against DNA as well as RNA viruses, including human coronaviruses.²

A review published recently in the journal Drugs looked into the benefits and risks of using ASA in adults with COVID-19.

ASA acts as a nonselective inhibitor of cyclo-oxygenase (COX-1 and COX-2) enzymes. When used at intermediate-to-high doses, the drug causes irreversible inhibition of COX-1 and COX-2. It has been used in the treatment of severe inflammatory disorders, including rheumatic fever, Kawasaki disease, recurrent pericarditis, etc. The drug has also been shown to improve symptoms related to inflammation and decrease plasma levels of inflammatory markers, like white blood cell count, erythrocyte sedimentation rate, and C-reactive protein.

ASA inhibits thromboxane A2 (TXA2) and exerts a significant antithrombotic effect. Several studies have validated the efficacy of low-dose ASA as an antiplatelet agent. Low doses of ASA are known to inhibit platelet aggregation and prevent ischemic events, such as myocardial infarction and stroke in patients considered to be at higher thrombotic risk. The drug has also been shown to reduce venous thromboembolism.

The antiviral effects of ASA have often been shown in in vitro and experimental studies. It remains to be seen if similar effects can be extended to humans.

ASA use has been linked with reduced thrombo-inflammation and reduced rates of clinical complications as well as in-hospital mortality among patients with different infections.

The use of non-steroidal anti-inflammatory drugs (NSAIDs), including ASA, in COVID-19 patients has constantly been debated. Some earlier reports on acute respiratory infections have also raised concerns on a likely increased risk of adverse events with NSAID use in COVID-19.

However, it is important to note that among NSAIDs, ASA has versatile therapeutic properties, which could support its use as supportive treatment in COVID-19 patients. It could act as an analgesic and antipyretic and may exert anti-inflammatory, antithrombotic, and antiviral effects, thus inhibiting the pathophysiological processes resulting in severe COVID-19.

It seems reasonable to investigate the potential of ASA as a therapeutic candidate in COVID-19. The timing of drug initiation, dosing, duration of treatment, and subgroups of COVID-19 patients that can obtain benefit from the drug need to be ascertained.

Safety issues, in terms of bleeding risk and development of rare but serious liver and brain damage, particularly among children, also need to be considered.

Author : Dr KK Aggarwal , President CMAAO, HCFI and Past National President IMA