Should patients stop ACE inhibitors (ACEi) and Angiotensin blockers (ARBs) to reduce their risk of COVID-19 infection?

In a letter published March 7, 2020, in the international journal Lancet1, Lei Fang and colleagues ask the question whether treatment with ACE inhibitor increases the risk of developing COVID-19 infection by SARS-CoV-2 virus. This is an important issue because a majority of patients with CKD, especially those with diabetic nephropathy are currently receiving ACE inhibitor or ARB therapy. Besides, an even greater number of patients are on ACE inhibitors or ARB for the treatment of hypertension. Both ACE inhibitors and ARBs have been proven to slow progression of kidney disease, are effective in treating systemic hypertension, and are generally well tolerated. Still, asking the question is legitimate given the mechanism of action (pathogenicity) of SARSCoV-2.

A very well written article in Drug Target Review2 summarizes how the SARSCoV-2 spike (S) glycoprotein binds to target cells through cell membrane protein angiotensin-converting enzyme 2 (ACE2) to enter human cells). Cells in the lung, intestine, kidney, and blood vessels express this receptor. Since ACE2 expression is higher among patients treated with ACE inhibitors and ARBs (as well as those treated with ibuprofen and thiazolidinediones), it has been hypothesized that these patients could be more susceptible to COVID-19 infection. Recent studies describing COVID-19 infection among Chinese patients (cited in the Fang letter to the Lancet) have reported a prevalence of diabetes and hypertension 20-30%.

Could the increased expression of ACE2 among diabetic and hypertensive patients treated with ACEi or ARB make them more vulnerable to infection with COVID-19? The answer is we don’t know. This is because it’s a big leap to suggest that an increase ACE2 expression on cells increases COVID-19 infection rates and to suggest that diabetics and hypertensive patients are at higher risk for COVID-19.  It certainly does not support the following statement published in the Lancet: We suggest that patients with cardiac diseases, hypertension, or diabetes, who are treated with ACE2-increasing drugs, are at higher risk for severe COVID-19 infection.”

Indeed, in a statement from the European Society of Cardiology3 website published March 13 2020, they forcefully state:

“Because of the social media-related amplification, patients taking these drugs for their high blood pressure and their doctors have become increasingly concerned, and, in some cases, have stopped taking their ACE-I or ARB medications.”

This speculation about the safety of ACE-i or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it. Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.

The Council on Hypertension of the European Society of Cardiology [their bolding] strongly recommends that physicians and patients should continue treatment with their usual anti-hypertensive therapy because there is no clinical or scientific evidence to suggest that treatment with ACEi or ARBs should be discontinued because of the COVID-19 infection.”

The key message: keep your patients on ACE inhibitors and ARBs!