#15,249
Like millions of other people around the world, I take a daily blood pressure pill, and so the ongoing debate over the potential risks (and possible benefits) of taking ACE Inhibitors and ARBs during this COVID-19 pandemic are of more than just academic interest to me.
On the one hand, we've seen a number of hypothesized downsides, including:
Patients who Take ACEIs and ARBs May Be at Increased Risk of Severe COVID-19
Mar 25, 2020 by
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the risk of severe COVID-19 cases, according to a hypothesis proposed by Professor James Diaz of Louisiana State University Health Sciences Center.
(Continue . . . )
But on the other hand, we get this opposite take:
ACEI/ARB Treatment May Benefit Patients With COVID-19 and Hypertension
Florence Chaverneff, Ph.D.
Treatment of patients with hypertension who are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II type 1 receptor blockers (ARBs) may improve clinical outcomes, according to study results published in Emerging Microbes and Infections.(Continue . . . )
While both studies (and many others) describe plausible mechanisms for their hypothesized outcomes, solid evidence has been hard to come by. Meanwhile, doctors and their patients who are on these common drugs, are left in a quandary.
A number of leading journals have cautioned against halting ACE or ARB therapy, citing insufficient evidence of harm (see AHA news release).Two days ago the World Health Organization published a scientific brief that reviews the (scant) existing literature - and while not exactly a ringing endorsement - finds `. .. low-certainty evidence that patients on long-term therapy with ACE inhibitors or ARBs are not at higher risk of poor outcomes from COVID-19.'
First the report, then I'll return with a bit more.
COVID-19 and the use of angiotensin-converting enzyme inhibitors and receptor blockers
Scientific Brief
7 May 2020
Background
Concerns exists that angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) increase susceptibility to coronavirus SARS CoV-2 (the viral agent that causes the disease COVID-19) and the likelihood of severe COVID-19 illness.1 These concerns are based on considerations of biological plausibility,2 and the observation that there is an overrepresentation of patients with hypertension and other cardiovascular comorbidities among patients with COVID-19 who have poor outcomes.3
Millions of people around the world are on treatment with ACE-Is and ARBs for hypertension, heart failure, coronary artery disease, or kidney disease. Speculation about worse outcomes among patients on these medications during the COVID-19 pandemic has caused widespread anxiety among patients and their care providers.
On the other hand, the harms of indiscriminate withdrawal of these medications on cardiovascular outcomes are well documented.4 There is also widespread speculation about the potential benefits of ACE-Is and ARBs, based on biological plausibility arguments and animal data and small clinical studies on patients with other viral respiratory infections.5
This brief summarizes the current evidence on the impact of ACE inhibitors or angiotensin receptor blockers on severe acute respiratory illness due to SARS CoV-2.
Methods
A rapid review was carried out using Ovid MEDLINE and the Cochrane Database of Systematic Reviews from 1 January 2003 to 24 April 2020 as well as the World Health Organization database of COVID-19 publications, clinicaltrials.gov, and medRxiv.org from inception to 17 April 2020 using terms for COVID-19, SARS virus, Middle East Respiratory Syndrome, angiotensin-converting enzyme inhibitors, and angiotensin receptor antagonists. Additional citations were identified from hand-searching reference lists. Studies in all languages were included. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale.
Review of the evidence
The rapid review identified 11 observational studies,6-16 eight of which were conducted in China,8-10, 12-16 along with single studies from Italy,11 the United Kingdom,7 and the United States.6 Nearly all studies included only patients with lab-confirmed COVID-19.
No studies were found that were designed to directly assess whether ACE inhibitors or ARBs increase the risk of acquiring COVID-19. After adjustment for confounders, history of ACE inhibitor or ARB use was not found to be associated with increased severity of COVID-19 illness. There were no studies that address the potential benefits and harms of initiating ACE inhibitors or ARBs as treatment for patients with COVID-19.
Conclusion
There is low-certainty evidence that patients on long-term therapy with ACE inhibitors or ARBs are not at higher risk of poor outcomes from COVID-19.
While less reassuring than we might like, there have been several recent studies that appear to point in the same direction, four of which are reviewed in the following Medscape article.
While encouraging, these findings are based on observational studies not more robust randomized studies, and more rigorous research will be needed to confirm these conclusions.
As usual, I am not a doctor and none of this constitutes medical advice. Always consult your doctor before changing or stopping your medications.
New Angiotensin Studies in COVID-19 Give More Reassurance
Sue Hughes
May 05, 2020
Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.
Four more studies of the relationship of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) with COVID-19 have been published in the past few days in top-tier peer-reviewed journals, and on the whole, the data are reassuring.
Three of the new studies were published in the New England Journal of Medicine on May 1, and one study was published in JAMA Cardiology on May 5.
Although all the studies are observational in design and have some confounding factors, overall, the results do not suggest that continued use of ACE inhibitors and ARBs causes harm. However, there are some contradictory findings in secondary analyses regarding possible differences in the effects of the two drug classes.
(Continue . . . )
While encouraging, these findings are based on observational studies not more robust randomized studies, and more rigorous research will be needed to confirm these conclusions.
As usual, I am not a doctor and none of this constitutes medical advice. Always consult your doctor before changing or stopping your medications.
