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Covid-19, Blood Pressure Medication, and Ibuprofen

One of the questions that shows up often in the comments to the various Covid-19 posts here (especially this one) and very often in my own emails is whether people who are taking hypertension medications should alter their drug therapy based on the coronavirus epidemic. Most of those questions are specifically about ACE inhibitors (all the -pril drugs) or angiotensin receptor blockers (all the -sartan ones). The advice given here starts out with, as usual, I Am Not a Physician, but points out that no professional society has yet recommended doing changing such a treatment regimen.

Today there’s a review of the field of all the renin-angiotensin-aldosterone system (RAAS) drugs and their possible interactions with the viral epidemic in the New England Journal of Medicine (open access article), and I wanted to highlight it as the most recent word on the subject. Here’s the key take-away: “Until further data are available, we think that RAAS inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with Covid-19” Note that this advice applies all the way to people who are positively infected with the coronavirus; there’s not enough evidence to say that even those people should change their blood pressure treatment.

The paper points out that the idea that one or another of these drugs might be harmful or increase the risk of infection is only a hypothesis, and that there are other (equally plausible) hypotheses that this might not be the case or that some of them might actually beneficial. And it also notes, absolutely correctly, that we do not have enough information yet to distinguish between these ideas. We’ll be getting some (whether it will help or not when we get it, who knows!) but what’s for sure is that we don’t have it yet. My guess is that if there were a big worrisome effect size in the data that we might have seen it pop up already, but the search has been underway for such things, at any rate.

So that’s the answer we have now: no one should be altering their blood pressure treatment regime based on coronavirus concerns, because we don’t know enough to saw if that’s a good idea, and we do know enough to say that suddenly going off of these drugs or changing them up can be a bad one.

And since we’re on that drug-interaction topic, the related question of whether ibuprofen is safe to use during this epidemic is still going around. These two intersect, because one rationale that’s been advanced is that ibuprofen could upregulate the ACE2 protein that’s involved in the angiotensin system and is a known entry protein for the virus. But here’s the current situation: there is no overall evidence to suggest that ibuprofen increases the risk of coronavirus infection or its severity. The whole story was started off by a letter to The Lancet and accelerated by a tweet from a French minister of health, but these appear to have been based on early anecdotal reports that do not seem to have held up. The CDC, the WHO, and all other health authorities who have weighed in on the issue have come to the same conclusion: ibuprofen and the other NSAIDs do not appear to have bad effects in this epidemic. Nothing has shown up since those initial reports to confirm them; no association between coronavirus infection and anti-inflammatories has appeared in the data we have.

I definitely understand why these stories get a lot of attention and why people worry about them: these hypertension medications and NSAIDs are taken by huge numbers of people worldwide, and if there really were a heightened risk of infection or severity of disease with them, that’s something you would very much want to know. And people want to feel that there’s something that they can do, some concrete step they can take to minimize their risk. A lot of us humans also have a weakness for sudden-reversal stories and surprising explanations: under our noses all along! The very drugs we were taking to make us better are putting us at risk! And once in a while that happens (estrogen replacement therapy comes to mind). But doesn’t seem to be one of those times – fortunately.

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