No Evidence Supporting Discontinuing RAAS Inhibitors in COVID-19 Patients

ACE and ARBs provide benefit to cardiac patients and harm to COVID-19 patients remains unproven, NEJM

April 8, 2020 — There has been debate in the past month or so during the novel coronavirus (COVID-19) pandemic whether the renin-angiotensin-aldosterone system (RAAS) inhibitors, such as angiotensin-converting–enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), should be stopped in COVID-19 patients. An article in the New England Journal of Medicine (NEJM) suggests these medications provide known benefits to patients who need them, while potential harms remain unproven.[1]

RAAS experts have provided a useful special report summarizing the evidence about the use of ACE inhibitors and ARBs, in patients with COVID-19. The data may provide context for the recommendations from several professional groups. The article suggests treatment with RAAS inhibitors should not be changed out of concerns that they might increase or decrease risk in patients with COVID-19, said Harlan M. Krumholz, M.D., director of the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, who reviewed the article in NEJM Journal Watch.

SARS-CoV-2, the virus that causes COVID-19, enters cells by binding to ACE2 as a receptor. ACE2 counters RAAS activation, primarily by degrading angiotensin II to angiotensin-(1–7), reducing angiotensin II's effects on vasoconstriction, sodium retention, and fibrosis. Some preclinical studies indicated that RAAS inhibitors may increase the expression of ACE2, raising concerns that these medications could increase susceptibility to infection. Nevertheless, whether ACE inhibitors or ARBs harm patients with COVID-19 or, even, are protective against the disease remains unknown.

However, withdrawing these therapies in patients for whom they are indicated could be expected to increase risks from patients' underlying conditions or from COVID-19 complications. The authors strongly endorse continuing RAAS inhibitors until better evidence suggests otherwise.