Viewpoint: What To Do About ACE Inhibitors During COVID-19 Pandemic

UPDATED APRIL 13, 2020

Many who are on ACE (angiotensin converting enzyme) Inhibitors and ARBs want to know what they should do in the midst of the COVID-19 pandemic. First and foremost, always consult a physician before making any decisions. The interaction between ACE Inhibitors and the COVID-19 virus has not been verified by clinical studies, but there is laboratory and animal evidence that raises concerns. Concerns which the NIH Director’s Blog further fueled by reiterating that the virus can adapt to bind to angiotensin converting enzymes (ACE2).¹ 

Concerns have also been raised regarding a number of studies which found that the COVID-19 co-morbidity with the highest incidence was hypertension.^2,3,4The CDC does not list hypertension as a co-morbidity for the flu.⁵   Anthony Fauci^, MD, the director of the US Centers for Disease Control and Prevention’s National Institute of Allergy and Infectious Diseases, recently reported to state the following: “wondered why someone with well-controlled hypertension would have a much greater chance of dying from COVID-19. He urged delving into this deeper and finding out which medications those individuals were taking,”⁶ according to MedScape. He also stated, “If you look at the mechanistic rational for concern, it is there and it is firm.”⁷

Authorities are split on what to do if a person is already on ACE Inhibitors and ARBs. Many in the United States have advocated to stay the course, until more information is known.^8,9 Switching medications may be difficult at best due to possible hypertensive rebound and exacerbation of high-blood pressure, especially in high risk patients.

A few authors feel these drugs may help COVID-19 patients.¹⁰  However, some of the underlying Chinese laboratory research bolstering this contention may have methodological flaws¹¹ and one clinical trial regarding the provision of Recombinant Human Angiotensin-converting Enzyme 2 to COVID-19 patients has been withdrawn because of unfavorable results in a small pilot study.¹²

Another research group out of England has recommended attempting to withdraw these medications if a COVID-19 infection develops in patients with mild diabetes or cardiovascular disease; and possibly those with mild disease and high risk of infection (such as healthcare workers).¹³    

Thus, to put it simply, if you are on an ACE Inhibitor at home during this COVID-19 epidemic and you do not have COVID-19, you have two choices:

1. You can stay at home performing reverse isolation and have little risk of contracting the virus. And come off your medications you may increase your risk of a stroke or heart attack.

2. You can stay at home performing reverse isolation and have little risk of contracting the virus. And stay on your medications without increasing your risk of a stroke or heart attack.

It seems in an environment of decreased medical access and monitoring due to COVID-19, the latter may well be the safest choice. However, patients should always consult their physician for recommendations regarding their care. Changing medication that treats high blood pressure or heart failure can be a complicated process and should never be attempted without professional guidance.It is also important to weigh the risk and benefits depending on the prevalence of the COVID-19 virus in your area and your comorbidities for severe COVID-19 disease. 

Similar theoretical concerns exist for ibuprofen (Advil) and thiazolidinediones (a diabetic drug). There is less data regarding these drugs, since they are not designed to target the angiotensin pathways. 

At the least, until this controversy can be resolved, if you are on one of these medications one should perform strict social distancing, and reverse isolation and protect yourself from contracting COVID-19. Staying safe at home is best and follow strict recommendations when contacting the public. Providers should be cautious starting new patients on these medications, especially for mild conditions.

Summary of Recommendations:  http://www.healthwatchusa.org/downloads/20200412-ACE-Inhibitor-COVID-19_Health_Watch_USA.pdf  

References:

1)  Collins, F.  Genomic Study Points to Natural Origin of COVID-19.  NIH Director’s Blog.  Mar. 26, 2020.   https://directorsblog.nih.gov/2020/03/26/genomic-research-points-to-natural-origin-of-covid-19/
  
(2)  McMichael TM, et al., COVID-19 in a Long-Term Care Facility - King County, Washington, February 27–March 9, 2020.  MMWR.  March 18, 2020.  https://assets.documentcloud.org/documents/6812675/CDC-Life-Care-Center-of-Kirkland.pdf
  
(3)  Sanchis-Gomar F, et al.  Angiotensin-Converting Enzyme 2 and Anti-Hypertensives (Angiotensin Receptor Blockers and Angiotensin Converting Enzyme Inhibitors) in Coronavirus Disease 2019 (COVID-19). Mayo Clinic Proceedings. March 30, 2020.   https://els-jbs-prod-cdn.jbs.elsevierhealth.com/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_ft95_3_5-1585588116123.pdf
  
(4) Zhou, F, et al.,     Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.  The Lancet.  March 28, 2020.  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
  
(5)  Centers for Disease Control and Prevention.  People at High Risk For Flu Complications.  Updated August 27, 2018.   https://www.cdc.gov/flu/highrisk/index.htm
  
(6)  Fryhofer SA.  Antihypertensive Drugs During COVID-19:  Still Up in the Air.   Medscape.  April 11, 2020.  https://www.medscape.com/viewarticle/928099  

(7)  COVID-19 Update with NIAID’s Anthony Fauci, MD; March 18, 2020.  JN (JAMA Network) Learning March 19, 2020.  https://edhub.ama-assn.org/jn-learning/audio-player/18324686  
  
(8)  Kuster GM, Pfister O, Burkard, T, et al.  SARS-CoV2: should inhibitors of the renin–angiotensin system be withdrawn in patients with COVID-19?  European Heart Journal.  2020.  0:1–3.  https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa235/5810479
    
(9)   Vaduganathan M, et al.    NEJM. March 30, 2020.  DOI: 10.1056/NEJMsr2005760   Renin–Angiotensin–Aldosterone System Inhibitors in Patients with Covid-19   https://www.nejm.org/doi/full/10.1056/NEJMsr2005760?cid=DM89279_NEJM_COVID-19_Newsletter&bid=174664565
     
(10)   Phend C.  Don't Stop ACE, ARB Drugs Over COVID-19 Concern, Groups Urge - Clear potential for harm from withdrawal trumps questionable theoretical risk from continuing   Med Page Today.  April 6, 2020.  https://www.medpagetoday.com/infectiousdisease/covid19/85817
  
(11)  Kavanagh KT, Calderon LE   Infection Control Today.  March 26, 2020 (updated March 31, 2020)  https://www.infectioncontroltoday.com/covid-19/evidence-continues-link-ace-inhibitors-severe-covid-19-symptoms
  
(12)  Recombinant Human Angiotensin-converting Enzyme 2 (rhACE2) as a Treatment for Patients With COVID-19.   ClinicalTrials.gov Identifier: NCT04287686  https://clinicaltrials.gov/ct2/show/NCT04287686
  
(13)   Aronson JK and Ferner RE.  ACE Inhibitors and Angiotensin Receptor Blockers (ARBVs) in COVID-19?  https://www.cebm.net/covid-19/angiotensin-converting-enzyme-ace-inhibitors-and-angiotensin-receptor-blockers-in-covid-19/