by Lewis Chang, PhD
1 . What was observed among patients with COVID-19 infection?
According to three recently published studies, the most common comorbidities in patients with COVID-19 are hypertension (high blood pressure) and diabetes; roughly 20-30% of them had hypertension, and 6-22% of them had diabetes.1-3 There are other comorbidities reported, such as coronary heart disease and cerebrovascular disease. But hypertension and diabetes appear to be the most common, at least based on currently available data.
2. Do scientists suspect what might have contributed to the increased risk?
Scientists have found that the novel coronavirus (the official name of the virus is severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2) that causes COVID-19 infection binds and enters human cells via angiotensin converting enzyme 2 (ACE2) receptors on the cells. ACE2 receptors are found on the epithelial cells of the lung, intestine, kidney, and blood vessels.4 Experimental studies have found that two types of medications, the ACE inhibitors (ACE-I) and angiotensin II type-I receptor blockers (ARB), can upregulate ACE2 expression.5 Because patients with hypertension and diabetes commonly received these two types of medications, scientists thus hypothesized that hypertension and diabetes treatment with these drugs may contribute to increased risks and severity of COVID-19.
3. How clinically relevant is this recent observation?
The story is still in its early development, and the current reality is more complicated: 1. The finding is based on association. There are still no human data to confirm that upregulation of ACE2 by these two types of drug caused the higher risk or severity of COVID-19 infection. 2. Both ACE-I and ARB drugs have been shown to reduce severe lung injury in certain viral pneumonias. That means some aspect of these drugs may be beneficial in COVID-19. 3. These data came from Asian populations whose genetic predisposition for COVID-19 infection may be different from other populations.
4. What are the takeaway messages?
The American College of Cardiology, American Heart Association, and Heart Failure Society of America released a joint statement on March 17th to address this potential concern. They stated that “there are no experimental or clinical data demonstrating beneficial or adverse outcomes among COVID-19 patients using ACE-I or ARB medications.” If patients with these conditions are diagnosed with COVID-19, “individualized treatment decisions should be made according to each patient’s hemodynamic status and clinical presentation. Therefore, be advised not to add or remove any renin angiotensin aldosterone system-related treatments, beyond actions based on standard clinical practice.”
The ACC/AHA/HFSA joint statement is consistent with statements from other medical societies such as European Society of Cardiology (click here), European Society of Hypertension (click here), and Hypertension Canada (click here).
This update reflects current evidence at time of release. Metagenics Institute will follow the development closely and continue to provide updates according to novel evidence.
- Yang X et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020.
- Guan WJ et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020.
- Zhang JJ et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. 2020. (Epub ahead of print).
- Wan Y et al. Receptor recognition by novel coronavirus from Wuhan: An analysis based on decade-long structural studies of SARS. J Virol. 2020;94(7):pii:e00127-20.
- Li XC et al. The vasoprotective axes of the renin-angiotensin system: physiological relevance and therapeutic implications in cardiovascular, hypertensive and kidney diseases. Pharmacol Res. 2017;125:21-38.
Lewis Chang, PhD is Scientific Editorial Manager of R&D at Metagenics. Dr. Chang received his PhD in Nutritional Sciences at University of Washington, along with his MS in Nutrition and Public Health from Teachers College, Columbia University and BS in Pharmacy from National Taiwan University. Prior to joining Metagenics, he conducted dissertation research and completed a research assistantship and postdoctoral fellowship at the Fred Hutchinson Cancer Research Center in Seattle, WA. Dr. Chang has authored or co-authored and managed the publication of over 30 peer-reviewed journal articles and numerous scientific abstracts and posters. He has quite a green thumb, enjoys opera, theater and jazz, and loves cooking, collecting art, and learning to play gypsy jazz guitar.