This article was first published in The Montreal Gazette.
In the past week, there were reports that some common medications might make COVID-19 worse. Many news reports stated that anti-inflammatories like ibuprofen and a class of common blood pressure medications might either make infection more likely or the illness more severe. While the World Health Organization initially put out a press release suggesting that people might want to avoid ibuprofen during the current outbreak, it subsequently withdrew that statement citing insufficient evidence.
The blood pressure medication story began with a research letter published in the journal Lancet Respiratory Medicine. It asked, rather provocatively, if patients with hypertension and diabetes were at increased risk of COVID-19 infection.
There is little doubt that patients with pre-existing medical conditions are at higher risk if they become infected. Of course, patients with high blood pressure and diabetes are more likely to be older, and age in and of itself would increase that risk, as well. It is, however, another thing entirely to claim that high blood pressure and diabetes make it more likely that you will catch the virus in the first place.
The hypothesis centred on the fact that this current coronavirus binds and infects cells using an enzyme called ACE2. Higher levels of ACE2 would, in theory, make it more likely for the virus to infect the cells of the lungs where this enzyme is produced. Therefore, any medications that increase ACE2 levels could potentially increase the risk of infection.
By rather unfortunate coincidence, many common blood pressure medications can increase ACE2 levels. The research letter noted that medications like ibuprofen, as well as blood pressure pills like ACE inhibitors and ARBs, can increase ACE2 levels and should be monitored during the current pandemic.
The implications of this recommendation were profound. ACE inhibitors (like ramipril/altace and peridopril/coversyl) and ARBs (like valsartan/diovan and irbesartan/avapro) are used not just to treat blood pressure, but also to protect the kidneys in patients with diabetes and to help cardiac function in patients with heart failure. It would not be going too far to state that they are a cornerstone of treatment, and stopping them in light of the COVID-19 pandemic would almost certainly be disastrous for patients.
The danger, as was pointed out by numerous cardiovascular groups and societies, is that if patients were to suddenly stop these medications, it could lead to rapid spikes in high blood pressure, which could, in turn, lead to strokes, heart attacks and acute episodes of heart failure. When it comes to cardiovascular care in stable patients, there is something to be said for not rocking the boat.
The recommendation to avoid ibuprofen is a little bit different. While there are some people who rely on anti-inflammatories to treat conditions like arthritis, they are not generally recommended for most people because of their side effects. Anti-inflammatories like these can raise your blood pressure, cause stomach ulcers and affect your kidneys in high doses. While probably not harmful if taken sparingly in small doses, most physicians, myself included, would probably recommend that patients start with acetaminophen (Tylenol) if trying to treat a fever or mild aches and pains.
I myself am somewhat unconvinced that any of these medications is really having any significant effect on the spread of COVID-19. People are understandably concerned about COVID-19 and, unfortunately, in this climate of uncertainty, preliminary studies are often given much more credence than they deserve.
So while I might recommend that people avoid ibuprofen anyway, given its side effects that have nothing to do with virology, suddenly stopping your cardiac medication would be a catastrophically bad idea that could land many people in hospital. And we can ill afford that right now.