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Jorge is a 46-year-old man who comes into your pharmacy quite concerned, asking you about an article he recently read in a newspaper. The article reported that some blood pressure medicines, angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) can increase the risk of infection with COVID-19 and make the condition more severe. Jorge doesn’t have any symptoms but is concerned because he takes ramipril 5mg once a day for his blood pressure.
Jorge has been abiding by all recommended measures to minimise his risk of catching COVID-19 but after reading the article, is considering stopping his blood pressure medicine to further reduce his risk of catching the virus.
What advice can you give Jorge?
What are ACEIs and ARBs?
ACEIs and ARBs are medicines used for a variety of cardiovascular conditions. They are most commonly used to treat high blood pressure (hypertension), heart failure and kidney disease. They work by disrupting the effects of angiotensin II in the body – a potent vasoconstrictor that causes an increase in blood pressure and therefore an increase in workload on the heart. ACEIs work by stopping an enzyme responsible for producing angiotensin II, whereas ARBs stop the effect of angiotensin II at receptors.
How has use of antihypertensives been linked to COVID-19?
Media reports have suggested there is a link between treatment with an ACEI or ARB and an increased risk of infection with COVID-19 and a more severe course of illness.(1) This link has been reported based on findings that the COVID-19 virus uses the same enzyme as the severe acute respiratory syndrome (SARS) virus to enter cells, Angiotensin converting enzyme 2 (ACE2). Animal experiments have shown that ACE2 levels are increased when undergoing treatment with an ACEI or an ARB.(2)
What evidence supports this link?
The link between these two observations has not been proven and is not supported by sound scientific evidence.(1) Currently, there is no evidence from epidemiological or clinical studies to support a link between treatment with these medicines and a risk of infection, or more severe infection with COVID-19.(3) Research is being undertaken in order to better understand how COVID-19 causes disease, interacts with the immune system, as well as the effect ACEIs and ARBs may have on the prognosis of the disease.(4)
What advice can you give concerned patients?
Patients currently taking an ACEI or ARB are advised to continue taking the medicine, unless they are advised otherwise by their doctor.(2) Patients should be reminded the link between these medicines and being more severely affected by COVID-19 is not supported by evidence and does not have a sound scientific basis.(5) The Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency and European Societies of Cardiology have all issued similar recommendations advising patients not to interrupt treatment and not to switch to other medicines.(2,4,5) There is some evidence suggesting that these medicines may be protective against lung complications in patients that have been affected by COVID-19.(5)
Advise patients to regularly check the MHRA website for the most up to date information. If they are unable to find information online and are still concerned about the potential risk advise them to call the NHS 111 coronavirus service.
- Pulse (2020) GPs should continue with ACE inhibitors and ARBs.
- British Medical Journal (2020) Preventing a covid-19 pandemic: ACE inhibitors as a potential risk factor for fatal COVID-19.
- Medicines and Healthcare products Regulatory Agency (2020) Coronavirus (COVID-19) and high blood pressure medication.
- European Medicines Agency (2020) EMA advises continued use of medicines for hypertension, heart or kidney disease during COVID-19 pandemic.
- Guys and St Thomas, NHS Foundation Trust, Position statement of King’s Health Partners cardiovascular department (2020) ACE-inhibitor and angiotensin receptor blocker use during the COVID-19 outbreak.