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Gonçalves J, Santos CD, Fresco P, Fernandez-Llimos F. Potential use of renin-angiotensin-aldosterone system inhibitors to reduce COVID-19 severity. Rev Port Cardiol 2023; 42:373-383. [PMID: 36893838 PMCID: PMC9999244 DOI: 10.1016/j.repc.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 03/09/2023] Open
Abstract
SARS-CoV-2 infection and its clinical manifestations (COVID-19) quickly evolved to a pandemic and a global public health emergency. The limited effectivity of available treatments aimed at reducing virus replication and the lessons learned from other coronavirus infections (SARS-CoV-1 or NL63) that share the internalization process of SARS-CoV-2, led us to revisit the COVID-19 pathogenesis and potential treatments. Virus protein S binds to the angiotensin-converting enzyme 2 (ACE2) initiating the internalization process. Endosome formation removes ACE2 from the cellular membrane preventing its counter-regulative effect mediated by the metabolism of angiotensin II to angiotensin (1-7). Internalized virus-ACE2 complexes have been identified for these coronaviruses. SARS-CoV-2 presents the highest affinity for ACE2 and produces the most severe symptoms. Assuming ACE2 internalization is the trigger for COVID-19 pathogenesis, accumulation of angiotensin II can be viewed as the potential cause of symptoms. Angiotensin II is a strong vasoconstrictor, but has also important roles in hypertrophy, inflammation, remodeling, and apoptosis. Higher levels of ACE2 in the lungs explain the acute respiratory distress syndrome as primary symptoms. Most of the described findings and clinical manifestations of COVID-19, including increased interleukin levels, endothelial inflammation, hypercoagulability, myocarditis, dysgeusia, inflammatory neuropathies, epileptic seizures and memory disorders can be explained by excessive angiotensin II levels. Several meta-analyses have demonstrated that previous use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were associated with better prognosis for COVID-19. Therefore, pragmatic trials to assess the potential therapeutic benefits of renin-angiotensin-aldosterone system inhibitors should be urgently promoted by health authorities to widen the therapeutic options for COVID-19.
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Affiliation(s)
- Jorge Gonçalves
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal; I(3)S: Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal.
| | - Catarina D Santos
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | - Paula Fresco
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal; I(3)S: Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Fernando Fernandez-Llimos
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal; CINTESIS - Centro de Investigação em Tecnologias e Serviços de Saúde, Porto, Portugal
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2
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Kurdi A, Mueller T, Weir N. An umbrella review and meta-analysis of renin-angiotensin system drugs use and COVID-19 outcomes. Eur J Clin Invest 2023; 53:e13888. [PMID: 36205627 PMCID: PMC9874890 DOI: 10.1111/eci.13888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite the availability of extensive literature on the effect of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin-receptor blockers (ARBs) on COVID-19 outcomes, the evidence is still controversial. We aimed to provide a comprehensive assessment of the effect of ACEIs/ARBs on COVID-19-related outcomes by summarising the currently available evidence. METHODS An umbrella review was conducted using Medline (OVID), Embase, Scopus, Cochrane library and medRxiv from inception to 1 February 2021. Systematic reviews with meta-analysis that evaluated the effect of ACEIs/ARBs on COVID-19-related clinical outcomes were eligible. Studies' quality was appraised using the AMSTAR 2 Critical Appraisal Tool. Data were analysed using the random-effects modelling including several subgroup analyses. Heterogenicity was assessed using I2 statistic. The study protocol was registered in PROSPERO (CRD42021233398) and reported using PRISMA guidelines. RESULTS Overall, 47 reviews were eligible for inclusion. Out of the nine COVID-19 outcomes evaluated, there was significant associations between ACEIs/ARBs use and each of death (OR = 0.80, 95%CI = 0.75-0.86; I2 = 51.9%), death/ICU admission as composite outcome (OR = 0.86, 95%CI = 0.80-0.92; I2 = 43.9%), severe COVID-19 (OR = 0.86, 95%CI = 0.78-0.95; I2 = 68%) and hospitalisation (OR = 1.23, 95%CI = 1.04-1.46; I2 = 76.4%). The significant reduction in death/ICU admission, however, was higher among studies which presented adjusted measure of effects (OR = 0.63, 95%CI = 0.47-0.84) and were of moderate quality (OR = 0.74, 95%CI = 0.63-0.85). CONCLUSIONS Collective evidence from observational studies indicate a good quality evidence on the significant association between ACEIs/ARBs use and reduction in death and death/ICU admission, but poor-quality evidence on both reducing severe COVID-19 and increasing hospitalisation. Our findings further support the current recommendations of not discontinuing ACEIs/ARBs therapy in patients with COVID-19.
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Affiliation(s)
- Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, Scotland, UK.,Department of Pharmacology and Toxicology, College of Pharmacy, Kurdistan Region Government, Hawler Medical University, Erbil, Iraq.,Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Tanja Mueller
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, Scotland, UK
| | - Natalie Weir
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, Scotland, UK
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3
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Liu Q, Fu W, Zhu CJ, Ding ZH, Dong BB, Sun BQ, Chen RC. Effect of continuing the use of renin-angiotensin system inhibitors on mortality in patients hospitalized for coronavirus disease 2019: a systematic review, meta-analysis, and meta-regression analysis. BMC Infect Dis 2023; 23:53. [PMID: 36694122 PMCID: PMC9872739 DOI: 10.1186/s12879-023-07994-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The effect of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) on mortality was preliminarily explored through the comparison of ACEIs/ARBs with non-ACEIs/ARBs in patients with coronavirus disease 2019 (COVID-19). Reaching a conclusion on whether previous ACEI/ARB treatment should be continued in view of the different ACE2 levels in the comparison groups was not unimpeachable. Therefore, this study aimed to further elucidate the effect of ACEI/ARB continuation on hospital mortality, intensive care unit (ICU) admission, and invasive mechanical ventilation (IMV) in the same patient population. METHODS We searched PubMed, the Cochrane Library, Ovid, and Embase for relevant articles published between December 1, 2019 and April 30, 2022. Continuation of ACEI/ARB use after hospitalization due to COVID-19 was considered as an exposure and discontinuation of ACEI/ARB considered as a control. The primary outcome was hospital mortality, and the secondary outcomes included 30-day mortality, rate of ICU admission, IMV, and other clinical outcomes. RESULTS Seven observational studies and four randomized controlled trials involving 2823 patients were included. The pooled hospital mortality in the continuation group (13.04%, 158/1212) was significantly lower than that (22.15%, 278/1255) in the discontinuation group (risk ratio [RR] = 0.45; 95% confidence interval [CI], 0.28-0.72; P = 0.001). Continuation of ACEI/ARB use was associated with lower rates of ICU admission (10.5% versus 16.2%, RR = 0.63; 95% CI 0.5-0.79; P < 0.0001) and IMV (8.2% versus 12.5%, RR = 0.62; 95% CI 0.46-0.83, P = 0.001). Nevertheless, the effect was mainly demonstrated in the observational study subgroup (P < 0.05). Continuing ACEI/ARB had no significant effect on 30-day mortality (P = 0.34), acute myocardial infarction (P = 0.08), heart failure (P = 0.82), and acute kidney injury after hospitalization (P = 0.98). CONCLUSION Previous ACEI/ARB treatment could be continued since it was associated with lower hospital deaths, ICU admission, and IMV in patients with COVID-19, although the benefits of continuing use were mainly shown in observational studies. More evidence from multicenter RCTs are still needed to increase the robustness of the data. Trial registration PROSPERO (CRD42022341169). Registered 27 June 2022.
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Affiliation(s)
- Qi Liu
- grid.412633.10000 0004 1799 0733Translational Medicine Center, Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, 1st Jianshe East Road, Zhengzhou, 450052 Henan People’s Republic of China
| | - Wei Fu
- grid.470124.4State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151st Yanjiang Road, Guangzhou, 510120 Guangdong People’s Republic of China
| | - Chang-ju Zhu
- grid.412633.10000 0004 1799 0733Department of Emergency Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan People’s Republic of China
| | - Zi-heng Ding
- grid.412633.10000 0004 1799 0733Translational Medicine Center, Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, 1st Jianshe East Road, Zhengzhou, 450052 Henan People’s Republic of China
| | - Bin-bin Dong
- grid.412633.10000 0004 1799 0733Translational Medicine Center, Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, 1st Jianshe East Road, Zhengzhou, 450052 Henan People’s Republic of China
| | - Bao-qing Sun
- grid.470124.4State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151st Yanjiang Road, Guangzhou, 510120 Guangdong People’s Republic of China
| | - Rong-chang Chen
- grid.470124.4State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151st Yanjiang Road, Guangzhou, 510120 Guangdong People’s Republic of China ,grid.440218.b0000 0004 1759 7210Department of Shenzhen Institute of Respiratory Diseases, Shenzhen People’s Hospital, Shenzhen, 518020 Guangdong People’s Republic of China
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4
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Landolfo M, Maino A, Di Salvo E, Fiorini G, Peterlana D, Borghi C. Renin-angiotensin system modulation and outcomes in patients hospitalized for interstitial SARS-CoV2 pneumonia: a cohort study. Intern Emerg Med 2022; 17:1335-1341. [PMID: 35064437 PMCID: PMC8782218 DOI: 10.1007/s11739-022-02929-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/08/2022] [Indexed: 12/15/2022]
Abstract
AIM The role of cardiovascular (CV) pharmacotherapies in patients with severe COVID-19 pneumonia remains controversial. This study aims to assess the impact of renin-angiotensin system modulation (RASi) (either angiotensin-converting enzymes (ACEIs) or angiotensin-receptor blockers (ARBs)) on COVID-19 outcome. METHODS We performed a cohort study on consecutive patients admitted for COVID-19 pneumonia at the Internal Medicine Unit of Sant'Orsola-Malpighi Hospital in Bologna, Italy. Patients with a possible alternative cause of respiratory failure other than COVID-19 were excluded. Clinical, pharmacological and laboratory data at admission and during the hospitalization were collected. Patients were treated with intravenous dexamethasone, low molecular weight heparin and nasal flow or Venturi mask oxygen. Subjects were followed until discharge, Intensive Care Unit (ICU) admission or death. Severe cases were defined by acute respiratory distress syndrome (arterial oxygen partial pressure and the fraction of inhaled oxygen ratio (P/F) ≤ 100 mmHg/%, or P/F ≤ 150 mmHg/% and respiratory rate ≥ 26/min). Patients with chronic use of RAS modulation were compared with those without for the composite outcome of in-hospital mortality or ICU admission. Hazard ratios (HR) were obtained by Cox regression, adjusted for several clinical factors. RESULTS Of the 268 patients enrolled in the study, 93 (35%, mean age 68 ± 13 years, 67% males) were treated with RASi (58% ACEIs and 42% ARBs). There were no meaningful differences between the RASI and no RASI group regarding clinical and laboratory parameters at admission. As expected, patients in the RASi group had a higher prevalence of hypertension, diabetes mellitus, atrial fibrillation, and ischemic heart disease. One hundred eight patients (40%) were admitted to ICU during hospitalization due to severe respiratory failure, and 24 (9%) died. The risk of in-hospital death or ICU admission was lower in the RASI group than in the non-RASI group (age and sex-adjusted HR 0.57, 95% CI 0.37-0.8), even after adjustment for several comorbidities (fully adjusted HR 0.44, 95% CI 0.26-0.74). Seven (7.5%) patients died in the RASi group vs 17 (9.7%) in the non-RASi group, leading to a non-statistically significant mortality risk reduction (fully adjusted HR 0.69, 95% CI 0.18-1.90). The lower risk in the RASi group was primarily related to ARBs use compared to ACEIs (HR 0.5, 95% CI 0.28-0.92 and HR 0.82, 95% CI 0.51-1.32, respectively). CONCLUSIONS Our study showed an inverse association between the chronic use of RASi and COVID-19 pneumonia severity (either ICU admissions or in-hospital death), even when significant comorbidities are considered.
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Affiliation(s)
- Matteo Landolfo
- Department of Medicine, Internal Medicine Unit, Ospedale Santa Chiara, Trento, Italy.
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, Bologna, Italy.
| | - Alberto Maino
- Department of Medicine, Internal Medicine Unit, Ospedale Santa Chiara, Trento, Italy
| | | | | | - Dimitri Peterlana
- Department of Medicine, Internal Medicine Unit, Ospedale Santa Chiara, Trento, Italy
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Jeffery MM, Oliveira J E Silva L, Bellolio F, Garovic VD, Dempsey TM, Limper A, Cummins NW. Association of outpatient use of renin-angiotensin-aldosterone system blockers on outcomes of acute respiratory illness during the COVID-19 pandemic: a cohort study. BMJ Open 2022; 12:e060305. [PMID: 35793915 PMCID: PMC9260198 DOI: 10.1136/bmjopen-2021-060305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Evaluate the associations between patients taking ACE inhibitors and angiotensin receptor blockers (ARBs) and their clinical outcomes after an acute viral respiratory illness (AVRI) due to COVID-19. DESIGN Retrospective cohort. SETTING The USA; 2017-2018 influenza season, 2018-2019 influenza season, and 2019-2020 influenza/COVID-19 season. PARTICIPANTS People with hypertension (HTN) taking an ACEi, ARB or other HTN medications, and experiencing AVRI. MAIN OUTCOME MEASURES Change in hospital admission, intensive care unit (ICU) or coronary care unit (CCU), acute respiratory distress (ARD), ARD syndrome (ARDS) and all-cause mortality, comparing COVID-19 to pre-COVID-19 influenza seasons. RESULTS The cohort included 1 059 474 episodes of AVRI (653 797 filled an ACEi or ARB, and 405 677 other HTN medications). 58.6% were women and 72.9% with age ≥65. The ACEi/ARB cohort saw a larger increase in risk in the COVID-19 influenza season than the other HTN medication cohort for four out of five outcomes, with an additional 1.5 percentage point (pp) increase in risk of an inpatient stay (95% CI 1.2 to 1.9 pp) and of ICU/CCU use (95% CI 0.3 to 2.7 pp) as well as a 0.7 pp (0.1 to 1.2 pp) additional increase in risk of ARD and 0.9 pp (0.4 to 1.3 pp) additional increase in risk of ARDS. There was no statistically significant difference in the absolute risk of death (-0.2 pp, 95% CI -0.4 to 0.1 pp). However, the relative risk of death in 2019/2020 versus 2017/2018 for the ACEi/ARB group was larger (1.40 (1.36 to 1.44)) than for the other HTN medication cohort (1.24 (1.21 to 1.28)). CONCLUSIONS People with AVRI using ACEi/ARBs for HTN had a greater increase in poor outcomes during the COVID-19 pandemic than those using other medications to treat HTN. The small absolute magnitude of the differences likely does not support changes in clinical practice.
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Affiliation(s)
- Molly Moore Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Visiting Fellow, OptumLabs, Eden Prairie, Minnesota, USA
| | | | | | - Vesna D Garovic
- Department of Medicine, Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy M Dempsey
- David Grant Medical Center, US Air Force, Travis Air Force Base, California, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Limper
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan W Cummins
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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6
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Loader J, Taylor FC, Lampa E, Sundström J. Renin-Angiotensin Aldosterone System Inhibitors and COVID-19: A Systematic Review and Meta-Analysis Revealing Critical Bias Across a Body of Observational Research. J Am Heart Assoc 2022; 11:e025289. [PMID: 35624081 PMCID: PMC9238740 DOI: 10.1161/jaha.122.025289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Renin‐angiotensin aldosterone system (RAAS) inhibitor—COVID‐19 studies, observational in design, appear to use biased methods that can distort the interaction between RAAS inhibitor use and COVID‐19 risk. This study assessed the extent of bias in that research and reevaluated RAAS inhibitor—COVID‐19 associations in studies without critical risk of bias. Methods and Results Searches were performed in MEDLINE, EMBASE, and CINAHL databases (December 1, 2019 to October 21, 2021) identifying studies that compared the risk of infection and/or severe COVID‐19 outcomes between those using or not using RAAS inhibitors (ie, angiotensin‐converting enzyme inhibitors or angiotensin II type‐I receptor blockers). Weighted hazard ratios (HR) and 95% CIs were extracted and pooled in fixed‐effects meta‐analyses, only from studies without critical risk of bias that assessed severe COVID‐19 outcomes. Of 169 relevant studies, 164 had critical risks of bias and were excluded. Ultimately, only two studies presented data relevant to the meta‐analysis. In 1 351 633 people with uncomplicated hypertension using a RAAS inhibitor, calcium channel blocker, or thiazide diuretic in monotherapy, the risk of hospitalization (angiotensin‐converting enzyme inhibitor: HR, 0.76; 95% CI, 0.66–0.87; P<0.001; angiotensin II type‐I receptor blockers: HR, 0.86; 95% CI, 0.77–0.97; P=0.015) and intubation or death (angiotensin‐converting enzyme inhibitor: HR, 0.64; 95% CI, 0.48–0.85; P=0.002; angiotensin II type‐I receptor blockers: HR, 0.74; 95% CI, 0.58–0.95; P=0.019) with COVID‐19 was lower in those using a RAAS inhibitor. However, these protective effects are probably not clinically relevant. Conclusions This study reveals the critical risk of bias that exists across almost an entire body of COVID‐19 research, raising an important question: Were research methods and/or peer‐review processes temporarily weakened during the surge of COVID‐19 research or is this lack of rigor a systemic problem that also exists outside pandemic‐based research? Registration URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021237859.
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Affiliation(s)
- Jordan Loader
- Department of Medical Sciences Uppsala University Uppsala Sweden.,Inserm U1300 - HP2 CHU Grenoble Alpes Grenoble France
| | - Frances C Taylor
- Baker Heart and Diabetes Institute Melbourne Victoria Australia.,Mary MacKillop Institute for Health Research, Australian Catholic University Melbourne Victoria Australia
| | - Erik Lampa
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Sundström
- Department of Medical Sciences Uppsala University Uppsala Sweden.,The George Institute for Global Health University of New South Wales Sydney Australia
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Shafiekhani M, Dehghani A, Shahisavandi M, Nabavizadeh SA, Kabiri M, Hassani AH, Haghpanah A. Pharmacotherapeutic approach toward urological medications and vaccination during COVID-19: a narrative review. Ther Adv Urol 2021; 13:17562872211046794. [PMID: 34603508 PMCID: PMC8481748 DOI: 10.1177/17562872211046794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/30/2021] [Indexed: 01/08/2023] Open
Abstract
One year after the prevalence of the novel coronavirus pandemic, some aspects of the physiopathology, treatment and progression of coronavirus 2019 disease (COVID-19) have remained unknown. Since no comprehensive study on the use of urological medications in patients with COVID-19 has been carried out, this narrative review aimed to focus on clinically important issues about the treatment of COVID-19 and urologic medications regarding efficacy, modifications, side effects and interactions in different urologic diseases. In this review, we provide information about the pharmacotherapeutic approach toward urologic medications in patients with COVID-19 infection. This study provides an overview of medications in benign prostatic hyperplasia, prostate cancer, impotence and sexual dysfunction, urolithiasis, kidney transplantation and hypertension as the most frequent diseases in which the patients are on long-term medications. Also, the effect of urologic drugs on the efficacy of vaccination is briefly discussed.
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Affiliation(s)
- Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, IranDepartment of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Anahita Dehghani
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mina Shahisavandi
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Maryam Kabiri
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Abdolreza Haghpanah
- Assistant Professor of Urology, Endourology Ward, Urology Department, Shiraz University of Medical Sciences, Shiraz, 71348-44119, Iran Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, 71348-44119, Iran
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8
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Jia N, Zhang G, Sun X, Wang Y, Zhao S, Chi W, Dong S, Xia J, Zeng P, Liu D. Influence of angiotensin converting enzyme inhibitors/angiotensin receptor blockers on the risk of all-cause mortality and other clinical outcomes in patients with confirmed COVID-19: A systemic review and meta-analysis. J Clin Hypertens (Greenwich) 2021; 23:1651-1663. [PMID: 34320275 PMCID: PMC8420264 DOI: 10.1111/jch.14329] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/22/2021] [Accepted: 07/05/2021] [Indexed: 01/01/2023]
Abstract
Since the COVID-19 pandemic, physicians concerned about the potential adverse effects of angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). To explore the relationship between ACEIs/ARBs and the risk of mortality and other clinical outcomes in COVID-19 patients, the authors conducted a systemic review and meta-analysis. An electronic search was performed from inception to November 12, 2020 in PubMed, Medline, EMBASE, ClinicalTrials, TRIP, the Cochrane Library, CNKI, Wanfang, and CBM database. Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool. The primary outcome was in-hospital all-cause mortality. Secondary outcomes included all-cause mortality measured at 30-day or longer term, mechanical ventilation, length of hospital stay, readmission, and cardiac adverse events. A total of 28 studies with 73 465 patients was included. Twenty-two studies with 19 871 patients reported the incidence of all-cause mortality. Results showed no association between using ACEIs/ARBs and risk of mortality crude odds ratio (OR) of 1.02, 95% CI 0.71-1.46, p = .90, I2 = 88%, adjusted OR in 6260 patients of 0.96, 95% CI 0.77-1.18, p = .68, I2 = 0%. While six studies with 10 030 patients reported a lower risk of mortality in ACEIs/ARBs group hazard ratio (HR) of 0.53, 95% CI 0.34-0.84, p = .007, I2 = 68%. Similar association (for HR) was found in hypertension subgroup. There was no significant association for the secondary outcomes. Based on the available data, we concluded that ACEIs/ARBs is not associated with the risk of in-hospital all-cause mortality in COVID-19 patients, but may be associated with a decreased risk of 30-day all-cause mortality. Patients with hypertension may benefit from using ACEIs/ARBs.
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Affiliation(s)
- Na Jia
- Department of CardiologyBeijing HospitalNational Center of GerontologyInstitute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Guifang Zhang
- Department of EpidemiologyThe Key Laboratory of GeriatricsBeijing Institute of GeriatricsBeijing HospitalNational Center of GerontologyInstitute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Xuelin Sun
- Department of PharmacologyBeijing HospitalNational Center of GerontologyInstitute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Yan Wang
- Department of Respiratory and Critical Care MedicineBeijing HospitalNational Center of GerontologyInstitute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Sai Zhao
- Systematic Review Solutions LtdShanghaiChina
| | - Wenjie Chi
- Systematic Review Solutions LtdShanghaiChina
| | - Sitong Dong
- Systematic Review Solutions LtdShanghaiChina
| | - Jun Xia
- Nottingham China Health InstituteThe University of NottinghamNingboChina
| | - Ping Zeng
- Department of EpidemiologyThe Key Laboratory of GeriatricsBeijing Institute of GeriatricsBeijing HospitalNational Center of GerontologyInstitute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Deping Liu
- Department of CardiologyBeijing HospitalNational Center of GerontologyInstitute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
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9
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Ravichandran B, Grimm D, Krüger M, Kopp S, Infanger M, Wehland M. SARS-CoV-2 and hypertension. Physiol Rep 2021; 9:e14800. [PMID: 34121359 PMCID: PMC8198473 DOI: 10.14814/phy2.14800] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 01/08/2023] Open
Abstract
The objective of this review is to give an overview of the pathophysiological effects of the Coronavirus Disease 2019 (COVID-19) in relation to hypertension (HT), with a focus on the Renin-Angiotensin-Aldosterone System (RAAS) and the MAS receptor. HT is a multifactorial disease and a public health burden, as it is a risk factor for diseases like stroke, coronary artery disease, and heart failure, leading to 10.4 million deaths yearly. Blood pressure is regulated by the RAAS. The system consists of two counter-regulatory axes: ACE/ANG-II/AT1 R and ACE2/ANG-(1-7)/MAS. The main regulatory protein in balancing the RAAS is angiotensin-converting enzyme 2 (ACE2). The protein also functions as the main mediator of endocytosis of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the host cell. SARS-CoV-2 is the cause of COVID-19 and has caused a worldwide pandemic; however, the treatment and prophylaxis of COVID-19 are limited. Several drugs and vaccines are currently being tested in clinical trials with a few already approved by EMA and FDA. HT is a major risk factor regarding the severity and fatality of COVID-19, and the RAAS plays an important role in COVID-19 infection since SARS-CoV-2 can lead to a dysregulation of the system by reducing the ACE2 expression. The exact mechanisms of HT in relation to COVID-19 remain uncertain, and more research is needed for further elucidation.
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Affiliation(s)
| | - Daniela Grimm
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Microgravity and Translational Regenerative Medicine, University Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Marcus Krüger
- Department of Microgravity and Translational Regenerative Medicine, University Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Sascha Kopp
- Department of Microgravity and Translational Regenerative Medicine, University Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Manfred Infanger
- Department of Microgravity and Translational Regenerative Medicine, University Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Markus Wehland
- Department of Microgravity and Translational Regenerative Medicine, University Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
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10
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Jansen van Vuren E, Steyn SF, Brink CB, Möller M, Viljoen FP, Harvey BH. The neuropsychiatric manifestations of COVID-19: Interactions with psychiatric illness and pharmacological treatment. Biomed Pharmacother 2021; 135:111200. [PMID: 33421734 PMCID: PMC7834135 DOI: 10.1016/j.biopha.2020.111200] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/15/2020] [Accepted: 12/26/2020] [Indexed: 12/12/2022] Open
Abstract
The recent outbreak of the corona virus disease (COVID-19) has had major global impact. The relationship between severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection and psychiatric diseases is of great concern, with an evident link between corona virus infections and various central and peripheral nervous system manifestations. Unmitigated neuro-inflammation has been noted to underlie not only the severe respiratory complications of the disease but is also present in a range of neuro-psychiatric illnesses. Several neurological and psychiatric disorders are characterized by immune-inflammatory states, while treatments for these disorders have distinct anti-inflammatory properties and effects. With inflammation being a common contributing factor in SARS-CoV-2, as well as psychiatric disorders, treatment of either condition may affect disease progression of the other or alter response to pharmacological treatment. In this review, we elucidate how viral infections could affect pre-existing psychiatric conditions and how pharmacological treatments of these conditions may affect overall progress and outcome in the treatment of SARS-CoV-2. We address whether any treatment-induced benefits and potential adverse effects may ultimately affect the overall treatment approach, considering the underlying dysregulated neuro-inflammatory processes and potential drug interactions. Finally, we suggest adjunctive treatment options for SARS-CoV-2-associated neuro-psychiatric symptoms.
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Affiliation(s)
- Esmé Jansen van Vuren
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa.
| | - Stephan F Steyn
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Christiaan B Brink
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Marisa Möller
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Francois P Viljoen
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Brian H Harvey
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa; South African MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
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11
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Gressens SB, Leftheriotis G, Dussaule JC, Flamant M, Levy BI, Vidal-Petiot E. Controversial Roles of the Renin Angiotensin System and Its Modulators During the COVID-19 Pandemic. Front Physiol 2021; 12:624052. [PMID: 33692701 PMCID: PMC7937723 DOI: 10.3389/fphys.2021.624052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/12/2021] [Indexed: 12/15/2022] Open
Abstract
Since December 2019, the coronavirus 2019 (COVID-19) pandemic has rapidly spread and overwhelmed healthcare systems worldwide, urging physicians to understand how to manage this novel infection. Early in the pandemic, more severe forms of COVID-19 have been observed in patients with cardiovascular comorbidities, who are often treated with renin-angiotensin aldosterone system (RAAS)-blockers, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), but whether these are indeed independent risk factors is unknown. The cellular receptor for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the membrane-bound angiotensin converting enzyme 2 (ACE2), as for SARS-CoV(-1). Experimental data suggest that expression of ACE2 may be increased by RAAS-blockers, raising concerns that these drugs may facilitate viral cell entry. On the other hand, ACE2 is a key counter-regulator of the RAAS, by degrading angiotensin II into angiotensin (1-7), and may thereby mediate beneficial effects in COVID-19. These considerations have raised concerns about the management of these drugs, and early comments shed vivid controversy among physicians. This review will describe the homeostatic balance between ACE-angiotensin II and ACE2-angiotensin (1-7) and summarize the pathophysiological rationale underlying the debated role of the RAAS and its modulators in the context of the pandemic. In addition, we will review available evidence investigating the impact of RAAS blockers on the course and prognosis of COVID-19 and discuss why retrospective observational studies should be interpreted with caution. These considerations highlight the importance of solid evidence-based data in order to guide physicians in the management of RAAS-interfering drugs in the general population as well as in patients with more or less severe forms of SARS-CoV-2 infection.
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Affiliation(s)
- Simon B Gressens
- Department of Infectious and Tropical Diseases, Assistance Publique-Hôpitaux de Paris, Bichat-Claude Bernard University Hospital, Paris, France
| | - Georges Leftheriotis
- Laboratory of Molecular Physiology and Medicine, Université Cote d'Azur, Nice, France
| | - Jean-Claude Dussaule
- Sorbonne Université, INSERM, Unité des Maladies Rénales Fréquentes et Rares: des Mécanismes Moléculaires à la Médecine Personnalisée, AP-HP, Hôpital Tenon, Paris, France.,Faculty of Medicine, Sorbonne University, Paris, France
| | - Martin Flamant
- Department of Physiology, Assistance Publique-Hôpitaux de Paris, Bichat-Claude Bernard University Hospital, Paris, France.,Inserm U1149, Centre for Research on Inflammation, Université de Paris, Paris, France
| | | | - Emmanuelle Vidal-Petiot
- Department of Physiology, Assistance Publique-Hôpitaux de Paris, Bichat-Claude Bernard University Hospital, Paris, France.,Inserm U1149, Centre for Research on Inflammation, Université de Paris, Paris, France
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12
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Bertagnin E, Greco A, Bottaro G, Zappulla P, Romanazzi I, Russo MD, Lo Presti M, Valenti N, Sollano G, Calvi V. Remote monitoring for heart failure management during COVID-19 pandemic. IJC HEART & VASCULATURE 2021; 32:100724. [PMID: 33532544 PMCID: PMC7843025 DOI: 10.1016/j.ijcha.2021.100724] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/12/2021] [Accepted: 01/17/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND COVID-19 pandemic impacted on heart failure patients' lifestyle and quality of life, affecting both physical activity levels and state of health. METHODS Demographic data and device records were extracted for patients with heart failure in the 16 weeks at the turn of lockdown during pandemic. To explore the variability across the lockdown period, a week-to-week analysis was performed. Patients were interviewed to investigate physical activity and psychological insights. The primary endpoint was the variation in physical activity at the turn of lockdown. RESULTS At our facility, 2225 patients implanted with a cardiac device were screened and data were collected for 211 patients fulfilling the inclusion criteria. Patients' physical activity significantly decreased in the lockdown period compared with the control period (active time per day 8.0% vs. 10.8%; relative reduction [RRR] 25.9%; p < 0.0001). A small decrease was noted for mean heart rate (70.1 vs. 71.7 beats per minute [bpm]; RRR 2.2%; p < 0.0001), while thoracic impedance slightly increased (82.2 vs. 82.7 ohm; RRR 0.6%; p = 0.001). Patients' physical activity decreased from week 7 to week 11 (10.9% vs. 6.9%; RRR 36.7%; P < 0.0001) with an increase between week 11 and week 16 (6.9% vs. 8.5%; RRR 18.8%; P < 0.0001). Patients' perceptions about physical activity showed a very low correlation with remote monitoring-assessed physical activity levels (r2 = 0.035, p = 0.039). CONCLUSIONS Telemedicine and remote monitoring can explore the impact of COVID-19 pandemic on vital signs and physical activity levels of heart failure patients, playing a crucial role in the prediction of heart failure worsening during circumstances discouraging outpatient visits.
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Affiliation(s)
- Enrico Bertagnin
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Antonio Greco
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Giuseppe Bottaro
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Paolo Zappulla
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Imma Romanazzi
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Maria Daniela Russo
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Marco Lo Presti
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Noemi Valenti
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Giuseppe Sollano
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
| | - Valeria Calvi
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Italy
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13
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Mackey K, Kansagara D, Vela K. Update Alert 7: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. Ann Intern Med 2021; 174:W25-W29. [PMID: 33395346 PMCID: PMC7791405 DOI: 10.7326/l20-1446] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Kathryn Vela
- VA Portland Health Care System, Portland, Oregon
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14
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Lim JH, Jung HY, Choi JY, Park SH, Kim CD, Kim YL, Cho JH. Hypertension and Electrolyte Disorders in Patients with COVID-19. Electrolyte Blood Press 2020; 18:23-30. [PMID: 33408744 PMCID: PMC7781764 DOI: 10.5049/ebp.2020.18.2.23] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/21/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023] Open
Abstract
The worldwide coronavirus disease 2019 (COVID-19) pandemic is still in progress, but much remains unknown about the disease. In this article, we review the association of hypertension or the renin-angiotensin system (RAS) with COVID-19 and the correlation between electrolyte disorders and disease severity. Underlying hypertension is likely to be associated with severe or critical COVID-19, but the relationship is not clear owing to confounding factors. Angiotensin-converting enzyme 2 (ACE2) plays an important role in the non-classical RAS pathway and binds to a receptor binding domain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The RAS blockade is known to increase ACE2 levels, but controversy remains regarding the effect of RAS blockade therapy in the course of COVID-19. Some reports have indicated a protective effect of RAS blockade on COVID-19, whereas others have reported an association of RAS blockade therapy with the occurrence of severe complications such as acute kidney injury and admission to the intensive care unit. Electrolyte disorders are not uncommon in patients with COVID-19, and severe COVID-19 has frequently shown hypokalemia, hyponatremia, and hypocalcemia. Electrolyte imbalances are caused by alteration of RAS, gastrointestinal loss, effects of proinflammatory cytokines, and renal tubular dysfunction by the invasion of SARS-CoV-2.
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Affiliation(s)
- Jeong-Hoon Lim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hee-Yeon Jung
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sun-Hee Park
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chan-Duck Kim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong-Lim Kim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
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15
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Mackey K, Kansagara D, Vela K. Update Alert 5: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. Ann Intern Med 2020; 173:167-168. [PMID: 33105094 PMCID: PMC7596735 DOI: 10.7326/l20-1293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Katherine Mackey
- VA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.)
| | - Devan Kansagara
- VA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.)
| | - Kathryn Vela
- VA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.)
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16
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Hasan SS, Kow CS, Hadi MA, Zaidi STR, Merchant HA. Mortality and Disease Severity Among COVID-19 Patients Receiving Renin-Angiotensin System Inhibitors: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2020; 20:571-590. [PMID: 32918209 PMCID: PMC7486167 DOI: 10.1007/s40256-020-00439-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of renin-angiotensin system (RAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), was alleged to cause a more severe course of novel coronavirus disease 2019 (COVID-19). METHODS We systematically reviewed the published studies to assess the association of RAS inhibitors with mortality as well as disease severity in COVID-19 patients. A systematic literature search was performed to retrieve relevant original studies investigating mortality and severity (severe/critical disease) in COVID-19 patients with and without exposure to RAS inhibitors. RESULTS A total of 59 original studies were included for qualitative synthesis. Twenty-four studies that reported adjusted effect sizes (24 studies reported mortality outcomes and 16 studies reported disease severity outcomes), conducted in RAS inhibitor-exposed and unexposed groups, were pooled in random-effects models to estimate overall risk. Quality assessment of studies revealed that most of the studies included were of fair quality. The use of an ACEI/ARB in COVID-19 patients was significantly associated with lower odds (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.56-0.95; n = 18,749) or hazard (hazard ratio [HR] = 0.75, 95% CI 0.60-0.95; n = 26,598) of mortality compared with non-use of ACEI/ARB. However, the use of an ACEI/ARB was non-significantly associated with lower odds (OR = 0.91, 95% CI 0.75-1.10; n = 7446) or hazard (HR = 0.73, 95% CI 0.33-1.66; n = 6325) of developing severe/critical disease compared with non-use of an ACEI/ARB. DISCUSSION Since there was no increased risk of harm, the use of RAS inhibitors for hypertension and other established clinical indications can be maintained in COVID-19 patients.
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Affiliation(s)
- Syed Shahzad Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK.
| | - Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, 57000, Malaysia
| | - Muhammad Abdul Hadi
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Syed Tabish Razi Zaidi
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Hamid A Merchant
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK
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Adverse impact of renin-angiotensin system blockade on the clinical course in hospitalized patients with severe COVID-19: a retrospective cohort study. Sci Rep 2020; 10:20250. [PMID: 33219294 PMCID: PMC7680105 DOI: 10.1038/s41598-020-76915-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/03/2020] [Indexed: 01/08/2023] Open
Abstract
The association between angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) and the risk of mortality in hospitalized patients with severe coronavirus disease 2019 (COVID-19) was investigated. This retrospective cohort study was performed in all hospitalized patients with COVID-19 in tertiary hospitals in Daegu, Korea. Patients were classified based on whether they received ACE-I or ARB before COVID-19 diagnosis. The analysis of the primary outcome, in-hospital mortality, was performed using the Cox proportional hazards regression model. Of 130 patients with COVID-19, 30 (23.1%) who received ACE-I or ARB exhibited an increased risk of in-hospital mortality (adjusted hazard ratio, 2.20; 95% confidence interval [CI], 1.10–4.38; P = 0.025). ACE-I or ARB was also associated with severe complications, such as acute respiratory distress syndrome (ARDS) (adjusted odds ratio [aOR], 2.58; 95% CI, 1.02–6.51; P = 0.045) and acute kidney injury (AKI) (aOR, 3.06; 95% CI, 1.15–8.15; P = 0.026). Among the patients with ACE-I or ARB therapy, 8 patients (26.7%) used high equivalent doses of ACE-I or ARB and they had higher in-hospital mortality and an increased risk of ARDS and AKI (all, P < 0.05). ACE-I or ARB therapy in patients with severe COVID-19 was associated with the occurrence of severe complications and increased in-hospital mortality. The potentially harmful effect of ACE-I or ARB therapy may be higher in patients who received high doses.
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18
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Campana P, Flocco V, Aruta F, Cacciatore F, Abete P. Can aldosterone increase interleukin-6 levels in Covid-19 pneumonia? J Med Virol 2020; 93:622-623. [PMID: 32749708 PMCID: PMC7436813 DOI: 10.1002/jmv.26382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/25/2020] [Accepted: 08/02/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Pasquale Campana
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Veronica Flocco
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Francesco Aruta
- Department of Neuroscience, University Federico II, Naples, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
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