Health Watch USA - COVID-19 & ACE Inhibitors
    

Have you ever wondered why hypertension appears to be the primary driver of COVID-19? 
  
(Coming off ACE Inhibitors to start another blood pressure medication can be hard to do without readily available medical care.   In the times of COVID-19 this will not be available in many areas of the nation.   One does not want to undergo a stroke or heart attack based upon discontinuation of a drug because of a controversy.  Thus, ALWAYS consult your doctor.  It is however very prudent if you are on these medications to follow strict social distancing, wear a mask and stay safe at home as much as possible.)  Health Watch USA^sm Summary of Recommendations Regarding ACE Inhibitors and ARBs with COVID-19.
   
Hypertension has been noted to be the most common comorbidity in COVID-19.
1.  In the Kirkland Nursing Home in Washington State, the most common chronic underlying conditions among facility residents (with COVID-19) were hypertension (69.1%), cardiac disease (56.8%), renal disease (43.2%), diabetes (37.0%), obesity (33.3%), and pulmonary disease (32.1%).     https://assets.documentcloud.org/documents/6812675/CDC-Life-Care-Center-of-Kirkland.pdf  
2.   Italian Ministry of Health showed the most common comorbidities in a cohort of 481 patients who died with COVID-19 were hypertension (73.8%), diabetes (33.9%), ischemic cardiopathy (30.1%), and atrial fibrillation (22%).  https://els-jbs-prod-cdn.jbs.elsevierhealth.com/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_ft95_3_5-1585588116123.pdf    
3.  In Wuhan, China:  Of 191 COVID patients who requred hospitalization, 91 had comorbidities with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients).  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext   
   
Medscape:  "Dr Fauci 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."   https://www.medscape.com/viewarticle/928099    He further stated:  “If you look at the mechanistic rationale for concern, it is there and it is firm.”  The below audio clip of Anthony Fauci, MD is from JN (JAMA Network) Learning March 19, 2020.  https://edhub.ama-assn.org/jn-learning/audio-player/18324686  
  

   
This is the receptor the COVID-19 virus uses to attack the lungs.    https://www.statnews.com/2020/04/10/coronavirus-ace-2-receptor/  
Research indicates that ACE Inhibitors will up regulate (increase) the ACE2 receptor.
    
Concerns have been expressed in two commentaries in the BMJ and Lancet.   
1.  https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30116-8/fulltext  
2.  https://www.bmj.com/content/368/bmj.m810/rr-2  
Along with epidemological data from one study: 
1.  https://els-jbs-prod-cdn.jbs.elsevierhealth.com/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_ft95_3_5-1585588116123.pdf   
And the Centre for Evidence-Based Medicine  
1.  https://www.cebm.net/covid-19/angiotensin-converting-enzyme-ace-inhibitors-and-angiotensin-receptor-blockers-in-covid-19/ 
      
Additional Data on this was raised in the NIH Director's Blog:   “The genomic data of the new coronavirus responsible for COVID-19 show that its spike protein contains some unique adaptations. One of these adaptations provides special ability of this coronavirus to bind to a specific protein on human cells called angiotensin converting enzyme (ACE2).” 
https://directorsblog.nih.gov/2020/03/26/genomic-research-points-to-natural-origin-of-covid-19/   
 
There is also an interesting factoid to be published by Sanchis-Gomar F, et al in the Mayo Proceedings. 
"Prior to hospitalization, 36% (173 of 481) offatal COVID-19 patients were ontreatment withACEIs, while 16% (77 of 481) were ontreatment with ARBs(odds ratio,2.26; 95% confidence interval, 95% CI, 1.66-3.09; p<0.001). "
https://els-jbs-prod-cdn.jbs.elsevierhealth.com/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_ft95_3_5-1585588116123.pdf    

Finally, a number of commentaries from the United States seem to advocate for the status quo, that not enough information is known.    
1.  https://www.medscape.com/viewarticle/927542 
2.  https://www.medscape.com/viewarticle/927952#vp_2  
3.  https://www.nejm.org/doi/full/10.1056/NEJMsr2005760?cid=DM89279_NEJM_COVID-19_Newsletter&bid=174664565 
 
Some articles have stated there are benefits to ACE inhibtitors which have been shown in the laboratory.  However, some of the laboratory research  in mice used losartan (angiotensin II receptor antagonist) with an acute exposure not specified, and may not be adequate time for upregulation of ACE-2 receptor. In a prior publication, only a 30 minute pre-treatment of the inhibitor was used and the effect on ACE-2 receptor expression is unknown and therefore long-term viral effect on the lung cannot be determined.    
 
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).   A proposed reatment paradyme is to the left.  (Click on Picture to Enlarge)  https://www.cebm.net/covid-19/angiotensin-converting-enzyme-ace-inhibitors-and-angiotensin-receptor-blockers-in-covid-19/  
    
Future Therapies
One research project which administered Recombinant Human Angiotensin-converting Enzyme 2 to COVID-19 patients has been withdrawn due to unfavorable results in a pilot study (Clinicaltrials.gov #NCT04287686) and a blocker of TMPRSS2, camostat mesylate, has been approved for human use in Japan for another indication. 
   
This webpage is for guidance only, always consult your healthcare provider and the CDC Website for information before making decisions relating to the coronavirus.
    
#COVID19   #ACEINHIBITORS   #HYPERTENSION #ACE2INHIBITOR
 

 
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