Coronavirus | Do anti-hypertensive drugs raise the risk for COVID-19 patients?

Patients have been told not to discontinue their medication

White pad next to a manometer to measure blood pressure and a stethoscope in a hospital, conceptual image

One of the concerns highlighted during the COVID-19 pandemic is whether the use of several common hypertension treatment drugs — coming under the class of Angiotensin-Controlling Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs) — raises risks for patients who contract the novel coronavirus.

The issue gained importance in social media and elsewhere, as some reports from severely affected countries such as Italy indicated a poor outcome for COVID-19 patients who have been taking these drugs for an underlying condition.

The top United States immunologist handling the pandemic, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said in an interaction with the Journal of the American Medical Association on Wednesday that based on extrapolation of available knowledge, putting a patient on an ACE inhibitor could result in an increase in the expression of the enzyme, which is to say, the person taking the drug for hypertension may be, without knowing it, increasing the reception for the virus itself.

Entry point

That is because Angiotensin Converting Enzyme2 (ACE2) receptors have been shown to be the entry point into human cells for SARS-CoV-2, according to medical literature.

But, Dr. Fauci said, that was an extrapolation, and not based on data.

“It is a possibility that we need to address,” he said, calling for studies in the wake of media reports from Italy that said 99% of people who died had an underlying condition, and in 75% of these cases, that condition was hypertension.

Given the high medical care standards in Italy, he reasoned, if hypertension was an underlying condition, it was bound to have been treated and patients maintained well. Also, if the data appeared skewed towards the condition in spite of this, the cause would have to be investigated, he said.

On the same issue, the European Society of Cardiology (ESC), citing initial data from China, issued a position statement on March 13. It said a concern had arisen because it was observed that just as in the case of the coronavirus causing SARS [Severe Acute Respiratory Syndrome], “the COVID-19 virus binds to a specific enzyme called ACE2 to infect cells, and ACE2 levels are increased following treatment with ACE-i and ARBs.”

 

The Council of Hypertension of the ESC, however, said it “strongly recommended” that doctors and patients should continue with their usual anti-hypertensive therapy in the absence of “clinical or scientific evidence to suggest that treatment with ACE-i or ARBs should be discontinued because of the COVID-19 infection.”

The issue has snowballed, as medical societies expressed alarm that some patients were voluntarily stopping ACE inhibitors and ARBs, which are commonly prescribed for many cardiovascular diseases and to protect against damage to the kidneys, including among diabetics.

Call for research

The American College of Cardiology, American Heart Association and Heart Failure Society of America issued a joint advisory on March 17, urging that patients who were currently taking these drugs should continue to take them.

“These theoretical concerns and findings of cardiovascular involvement with COVID-19 deserve much more detailed research, and quickly,” the statement said.

“Currently there are no experimental or clinical data demonstrating beneficial or adverse outcomes with background use of ACE inhibitors, ARBs or other RAAS antagonists [which influence hypertension] among COVID-19 patients with a history of cardiovascular disease treated with such agents,” it added.

The U.S. National Library of Medicine lists nine commonly used ACE-inhibitors (such as enalapril and ramipril) and seven ARBs (such as losartan, telmisartan and olmesartan), many of which are widely prescribed in India.