Go to the NEJM Journal Watch. Reference the article entitled “Ace inhibitors and ARBs during COVID 19 pandemic” date April 9, 2020.
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ACE Inhibitors and ARBs During the COVID-19 Pandemic
Allan S. Brett, MD and David M. Rind, MD reviewing Patel AB and Verma A. JAMA 2020 Mar 24 Gurwitz D. Drug Dev Res 2020 Mar 4 American College of Cardiology. 2020 Mar 17
How should clinicians navigate clinical uncertainty for patients who are taking angiotensin-converting–enzyme inhibitors or angiotensin-receptor blockers?
Many patients and clinicians are aware of the recently publicized interplay between SARS-CoV-2, the coronavirus responsible for COVID-19 illness, and the renin-angiotensin system. Patients concerned about susceptibility to coronavirus already have asked whether to continue taking their prescribed angiotensin-converting–enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), and patients who test positive for the virus likely will have the same concern.
The problem is as follows: Experts have postulated both potentially harmful and potentially beneficial effects of these drugs on the natural history of COVID-19.1,2 Membrane-bound angiotensin-converting enzyme 2 (ACE2) participates in the entry of SARS-CoV-2 into human cells, and animal studies show that ACE inhibitors and ARBs upregulate ACE2 expression. In theory, this effect could increase risk for or severity of COVID-19. Conversely, some researchers speculate that ACE inhibitors and ARBs could benefit patients with COVID-19 through various mechanisms. For example, ACE2 converts angiotensin II to angiotensin-(1–7), which has potentially beneficial vasodilatory and anti-inflammatory properties; upregulating ACE2 (with ACE inhibitors or ARBs) could enhance this process. Observational studies have not yielded compelling data on whether COVID-19 patients who take these drugs fare better or worse than otherwise similar patients.
https://www.jwatch.org/na51345/2020/04/09/ace-inhibitors-and-arbs-during-covid-19-pandemic
Decision-making under uncertainty is necessarily stressful, both in medicine and more generally. Some people become immobilized by true equipoise around available options. A sensible position for overworked and stressed clinicians facing a global pandemic is to recognize that, for now, the effect of ACE inhibitors and ARBs on the natural history of COVID-19 is unknown. Clinicians should attempt to make decisions that will minimize future regret for themselves and for their patients if the decision eventually is proven “wrong.”