Nonsteroidal anti-inflammatory drugs in community-acquired pneumonia

To the Editor:

We read with interest the editorial by Riccard and Medissa [1], which accompanied the paper by Tagami et al. [2] that reviewed the effects of corticosteroids on mortality in community-acquired pneumonia (CAP).

However, we would like to urge caution regarding one of the conclusions drawn by the authors of the editorial, namely that clinicians should refrain from giving nonsteroidal anti-inflammatory drugs (NSAIDs) to patients in the early stages of CAP [1].

The editorial by Riccard and Medissa [1] references two studies that have shown “patients exposed to NSAIDs during the early stage of CAP had a worse presentation of CAP, more pleuropulmonary complications and required noninvasive ventilatory support more often, such as high-flow oxygen therapy”.

One of the referenced articles, a study conducted by the editorial authors, was a retrospective case note review of 106 patients over a 12-year period, 20 of whom had been prescribed NSAIDs [3]. The explanations offered for the findings were two-fold: 1) that the administration of NSAIDs delayed antibiotic prescription, although this observed trend did not reach statistical significance in their study; and 2) that the NSAIDs might have a direct, dampening effect on patients' immune response, something for which there is little supporting evidence in humans.

The second referenced article was a prospective, but uncontrolled, observational study looking to document the presentation and course of CAP with a particular focus on NSAID use [4]. They found that 32 patients using NSAIDs in the early stages of CAP had a more subacute presentation, evidenced by a delayed referral to hospital and more pleuropulmonary complications, but they had no more severe systemic inflammations than the 58 patients who had not received NSAIDs during their pneumonic episodes.

NSAIDs have not been shown in either of these studies to be the cause of the observed differences in presentation and the disease course of patient episodes of CAP. A more intuitive explanation, not explored by the authors of either paper, is that those patients taking NSAIDs in the context of a pneumonic illness are doing so in order to gain symptomatic relief of pleuritic pain. These patients are likely to be a self-selecting group and at risk of pleural complications as well as suffering from a more severe pneumonia, not because they are taking NSAIDs but because of their requirement for them.

Issuing guidance to general practitioners advising them to avoid NSAIDs in patients with clinical signs suggestive of pneumonia would be an inappropriate interpretation of the available evidence and risks harm by potentially denying patients a powerful analgesic that may be indicated. One should also be wary of extrapolating data from intensive care populations to guide treatment of all patients in the wider community where presentation and the course of the disease are much more variable.