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Ferreira-da-Silva R, Maranhão P, Dias CC, Alves JM, Pires L, Morato M, Polónia JJ, Ribeiro-Vaz I. Assessing medication use patterns by clinical outcomes severity among inpatients with COVID-19: A retrospective drug utilization study. Biomed Pharmacother 2024; 172:116242. [PMID: 38340395 DOI: 10.1016/j.biopha.2024.116242] [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: 12/10/2023] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
PURPOSE This study assessed medication patterns for inpatients at a central hospital in Portugal and explored their relationships with clinical outcomes in COVID-19 cases. METHODS A retrospective study analyzed inpatient medication data, coded using the Anatomical Therapeutic Chemical classification system, from electronic patient records. It investigated the association between medications and clinical severity outcomes such as ICU admissions, respiratory/circulatory support needs, and hospital discharge status, including mortality (identified by ICD-10-CM/PCS codes). Multivariate analyses incorporating demographic data and comorbidities were used to adjust for potential confounders and understand the impact of medication patterns on disease progression and outcomes. RESULTS The analysis of 2688 hospitalized COVID-19 patients (55.3% male, average age 62.8 years) revealed a significant correlation between medication types and intensity and disease severity. Cases requiring ICU admission or ECMO support often involved blood and blood-forming organ drugs. Increased use of nervous system and genitourinary hormones was observed in nonsurvivors. Corticosteroids, like dexamethasone, were common in critically ill patients, while tocilizumab was used in ECMO cases. Medications for the alimentary tract, metabolism, and cardiovascular system, although widely prescribed, were linked to more severe cases. Invasive mechanical ventilation correlated with higher usage of systemic anti-infectives and musculoskeletal medications. Trends in co-prescribing blood-forming drugs with those for acid-related disorders, analgesics, and antibacterials were associated with intensive interventions and worse outcomes. CONCLUSIONS The study highlights complex medication regimens in managing severe COVID-19, underscoring specific drug patterns associated with critical health outcomes. Further research is needed to explore these patterns.
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Affiliation(s)
- Renato Ferreira-da-Silva
- Porto Pharmacovigilance Centre, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal.
| | - Priscila Maranhão
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Cláudia Camila Dias
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Knowledge Management Unit, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - João Miguel Alves
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Lígia Pires
- Pulmonology Service, Algarve University Hospital Center, Faro, Portugal; Intensive Care Unit, Algarve Private Hospital, Faro, Portugal
| | - Manuela Morato
- Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy of the University of Porto, Porto, Portugal; LAQV@REQUIMTE, Faculty of Pharmacy of the University of Porto, Porto, Portugal
| | - Jorge Junqueira Polónia
- Porto Pharmacovigilance Centre, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS@RISE, Department of Medicine, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Ribeiro-Vaz
- Porto Pharmacovigilance Centre, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
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Felkle D, Zięba K, Kaleta K, Czaja J, Zyzdorf A, Sobocińska W, Jarczyński M, Bryniarski K, Nazimek K. Overreactive macrophages in SARS-CoV-2 infection: The effects of ACEI. Int Immunopharmacol 2023; 124:110858. [PMID: 37708705 DOI: 10.1016/j.intimp.2023.110858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/16/2023]
Abstract
Among various factors influencing the course of SARS-CoV-2 infection in humans, macrophage overactivation is considered the main cause of the cytokine storm that leads to severe complications of COVID-19. Moreover, the increased expression of angiotensin converting enzyme 2 (ACE2), an obligatory entry receptor of the coronavirus, caused by treatment with ACE inhibitors (ACEI) lowered overall confidence in the safety of these drugs. However, analysis of the course of coronavirus infection in patients treated with ACEI does not support these concerns. Instead, the beneficial effect of ACEI on macrophages has increasingly been emphasized. This includes their anti-inflammatory activation and the consequent reduction in the risk of severe disease and life-threatening complications. Herein, we summarize the current knowledge and understanding of the dual role of macrophages in SARS-CoV-2 infection, with a special focus on the postulated mechanisms underlying the beneficial effects of macrophage targeting by ACEI. These seem to involve the stimulation of macrophage angiotensin II type 2 and Mas receptors by angiotensin 1-7, intensively produced due to the up-regulation of ACE2 expression on macrophages, as well as the direct inhibition of macrophage hyper-responsiveness by ACEI. The impact of ACEI on macrophages may also lead to the activation of an effective antiviral response due to the increased expression of ACE2.
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Affiliation(s)
- Dominik Felkle
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Katarzyna Zięba
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Konrad Kaleta
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Julia Czaja
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Amanda Zyzdorf
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Wiktoria Sobocińska
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Mateusz Jarczyński
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Krzysztof Bryniarski
- Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Katarzyna Nazimek
- Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland.
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Luu B, Wijesinghe S, Kassem T, Lien J, Luu D, Wijesinghe R, Luu L, Kayingo G. Drugs in primary care that may alter COVID-19 risk and severity. JAAPA 2023; 36:28-33. [PMID: 37097779 DOI: 10.1097/01.jaa.0000918768.11544.e5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT This article describes drugs used in primary care that could alter patients' risk for and severity of COVID-19. The risks and benefits of each drug class were differentiated according to the strength of evidence from 58 selected randomized controlled trials, systematic reviews, and meta-analyses. Most of the studies reported on drugs affecting the renin-angiotensin-aldosterone system. Other classes included opioids, acid suppressants, nonsteroidal anti-inflammatory drugs, corticosteroids, vitamins, biguanides, and statins. Current evidence has not fully differentiated drugs that may increase risk versus benefits in COVID-19 infection. Further studies are needed in this area.
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Affiliation(s)
- Brent Luu
- Brent Luu is an associate clinical professor at the University of California Davis's Betty Irene Moore School of Nursing in Sacramento, Calif. Sampath Wijesinghe is a clinical assistant professor in the PA program at Stanford (Calif.) University. Tarek Kassem is an assistant professor at California Northstate University in Elk Grove, Calif. Justin Lien is a student at Western University's College of Osteopathic Medicine in Pomona, Calif. Darrick Luu is a student at California Northstate University College of Health Science in Rancho Cordova, Calif. Rynee Wijesinghe is a student at California State University in Fresno, Calif. Leianna Luu is a student at the University of California Riverside. Gerald Kayingo is assistant dean, executive director, and professor in the Physician Assistant Leadership and Learning Academy at the University of Maryland Baltimore. The authors have disclosed no potential conflicts of interest, financial or otherwise
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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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Gupta N, Settle L, Brown BR, Armaignac DL, Baram M, Perkins NE, Kaufman M, Melamed RR, Christie AB, Danesh VC, Denson JL, Cheruku SR, Boman K, Bansal V, Kumar VK, Walkey AJ, Domecq JP, Kashyap R, Aston CE. Association of Renin Angiotensin Aldosterone System Inhibitors and Outcomes of Hospitalized Patients With COVID-19. Crit Care Med 2022; 50:e744-e758. [PMID: 35894609 PMCID: PMC9469914 DOI: 10.1097/ccm.0000000000005627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVES To determine the association of prior use of renin-angiotensin-aldosterone system inhibitors (RAASIs) with mortality and outcomes in hospitalized patients with COVID-19. DESIGN Retrospective observational study. SETTING Multicenter, international COVID-19 registry. SUBJECTS Adult hospitalized COVID-19 patients on antihypertensive agents (AHAs) prior to admission, admitted from March 31, 2020, to March 10, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were compared between three groups: patients on RAASIs only, other AHAs only, and those on both medications. Multivariable logistic and linear regressions were performed after controlling for prehospitalization characteristics to estimate the effect of RAASIs on mortality and other outcomes during hospitalization. Of 26,652 patients, 7,975 patients were on AHAs prior to hospitalization. Of these, 1,542 patients (19.3%) were on RAASIs only, 3,765 patients (47.2%) were on other AHAs only, and 2,668 (33.5%) patients were on both medications. Compared with those taking other AHAs only, patients on RAASIs only were younger (mean age 63.3 vs 66.9 yr; p < 0.0001), more often male (58.2% vs 52.4%; p = 0.0001) and more often White (55.1% vs 47.2%; p < 0.0001). After adjusting for age, gender, race, location, and comorbidities, patients on combination of RAASIs and other AHAs had higher in-hospital mortality than those on RAASIs only (odds ratio [OR] = 1.28; 95% CI [1.19-1.38]; p < 0.0001) and higher mortality than those on other AHAs only (OR = 1.09; 95% CI [1.03-1.15]; p = 0.0017). Patients on RAASIs only had lower mortality than those on other AHAs only (OR = 0.87; 95% CI [0.81-0.94]; p = 0.0003). Patients on ACEIs only had higher mortality compared with those on ARBs only (OR = 1.37; 95% CI [1.20-1.56]; p < 0.0001). CONCLUSIONS Among patients hospitalized for COVID-19 who were taking AHAs, prior use of a combination of RAASIs and other AHAs was associated with higher in-hospital mortality than the use of RAASIs alone. When compared with ARBs, ACEIs were associated with significantly higher mortality in hospitalized COVID-19 patients.
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Affiliation(s)
- Neha Gupta
- Department of Pediatrics, Division of Pediatric Critical Care, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Lisa Settle
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Brent R Brown
- Department of Medicine, Division of Pulmonary Critical Care, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Donna L Armaignac
- Center for Advanced Analytics, Baptist Health South Florida, Coral Gables, FL
| | - Michael Baram
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Nicholas E Perkins
- Department of Medicine, Division of Hospital Medicine, Prisma Health, Greenville, SC
| | - Margit Kaufman
- Departments of Anesthesiology and Critical Care Medicine, Englewood Health, Englewood, NJ
| | - Roman R Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Amy B Christie
- Department of Critical Care, Atrium Health Navicent, Macon, GA
| | - Valerie C Danesh
- Center for Applied Health Research, Baylor Scott & White Health, Dallas, TX
| | - Joshua L Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Sreekanth R Cheruku
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX
| | - Karen Boman
- Society of Critical Care Medicine, Mount Prospect, IL
| | - Vikas Bansal
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Allan J Walkey
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, and Evans Center of Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Juan P Domecq
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Christopher E Aston
- Biomedical and Behavioral Methodology Core, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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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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Zhang K, Cao L, Xuan N, Huang T, Tian B, Cui W, Zhang G, Zhang S. The effect of renin-angiotensin-aldosterone system inhibitors in patients with hypertension and COVID-19: A meta-analysis of randomized controlled trials and propensity score-matched studies. JOURNAL OF INTENSIVE MEDICINE 2022; 2:282-290. [PMID: 36785646 PMCID: PMC9212589 DOI: 10.1016/j.jointm.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/22/2022] [Accepted: 05/14/2022] [Indexed: 12/15/2022]
Abstract
Background High-quality evidence for whether the use of renin-angiotensin-aldosterone system (RAAS) inhibitors worsens clinical outcomes for patients with coronavirus disease 2019 (COVID-19) is lacking. The present study aimed to evaluate the effect of RAAS inhibitors on disease severity and mortality in patients with hypertension and COVID-19 using randomized controlled trials (RCTs) and propensity score-matched (PSM) studies. Methods A literature search was conducted with PubMed, Embase, and Scopus databases from 31 December 2019 to 10 January 2022. We included RCTs and PSM studies comparing the risk of severe illness or mortality in patients with hypertension and COVID-19 treated or not treated with RAAS inhibitors. Individual trial data were combined to estimate the pooled odds ratio (OR) with a random-effects model. Results A total of 17 studies (4 RCTs and 13 PSM studies) were included in the meta-analysis. The use of RAAS inhibitors was not associated with an increased risk of severe illness (OR=1.00, 95% confidence interval [CI]: 0.88-1.14, I2=28%) or mortality (OR=0.96, 95% CI: 0.83-1.11, I2=16%) for patients with hypertension and COVID-19. Furthermore, there was no significant difference in the severity of COVID-19 when patients continued or discontinued treatment with RAAS inhibitors (OR=1.01, 95% CI: 0.78-1.29, I2=0%). Conclusions This study suggests that there was no association between treatment with RAAS inhibitors and worsened COVID-19 disease outcomes. Our findings support the current guidelines that RAAS inhibitors should be continued in the setting of the COVID-19 pandemic. However, the benefit of RAAS inhibitor medications for COVID-19 patients should be further validated with more RCTs.
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Affiliation(s)
- Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Lanxin Cao
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Nanxia Xuan
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Tiancha Huang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Baoping Tian
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Wei Cui
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China,Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang 310009, China;,Corresponding authors: Gensheng Zhang, Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang 310009, China; Shufang Zhang, Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China.
| | - Shufang Zhang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China.,Corresponding authors: Gensheng Zhang, Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang 310009, China; Shufang Zhang, Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China.
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8
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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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/07/2022] [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 SciencesUppsala UniversityUppsalaSweden
- Inserm U1300 – HP2CHU Grenoble AlpesGrenobleFrance
| | - Frances C. Taylor
- Baker Heart and Diabetes InstituteMelbourneVictoriaAustralia
- Mary MacKillop Institute for Health Research, Australian Catholic UniversityMelbourneVictoriaAustralia
| | - Erik Lampa
- Department of Medical SciencesUppsala UniversityUppsalaSweden
| | - Johan Sundström
- Department of Medical SciencesUppsala UniversityUppsalaSweden
- The George Institute for Global HealthUniversity of New South WalesSydneyAustralia
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9
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Fung KW, Baik SH, Baye F, Zheng Z, Huser V, McDonald CJ. Effect of common maintenance drugs on the risk and severity of COVID-19 in elderly patients. PLoS One 2022; 17:e0266922. [PMID: 35436293 PMCID: PMC9015134 DOI: 10.1371/journal.pone.0266922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 02/08/2023] Open
Abstract
Background Maintenance drugs are used to treat chronic conditions. Several classes of maintenance drugs have attracted attention because of their potential to affect susceptibility to and severity of COVID-19. Methods Using claims data on 20% random sample of Part D Medicare enrollees from April to December 2020, we identified patients diagnosed with COVID-19. Using a nested case-control design, non-COVID-19 controls were identified by 1:5 matching on age, race, sex, dual-eligibility status, and geographical region. We identified usage of angiotensin-converting enzyme inhibitors (ACEI), angiotensin-receptor blockers (ARB), statins, warfarin, direct factor Xa inhibitors, P2Y12 inhibitors, famotidine and hydroxychloroquine based on Medicare prescription claims data. Using extended Cox regression models with time-varying propensity score adjustment we examined the independent effect of each study drug on contracting COVID-19. For severity of COVID-19, we performed extended Cox regressions on all COVID-19 patients, using COVID-19-related hospitalization and all-cause mortality as outcomes. Covariates included gender, age, race, geographic region, low-income indicator, and co-morbidities. To compensate for indication bias related to the use of hydroxychloroquine for the prophylaxis or treatment of COVID-19, we censored patients who only started on hydroxychloroquine in 2020. Results Up to December 2020, our sample contained 374,229 Medicare patients over 65 who were diagnosed with COVID-19. Among the COVID-19 patients, 278,912 (74.6%) were on at least one study drug. The three most common study drugs among COVID-19 patients were statins 187,374 (50.1%), ACEI 97,843 (26.2%) and ARB 83,290 (22.3%). For all three outcomes (diagnosis, hospitalization and death), current users of ACEI, ARB, statins, warfarin, direct factor Xa inhibitors and P2Y12 inhibitors were associated with reduced risks, compared to never users. Famotidine did not show consistent significant effects. Hydroxychloroquine did not show significant effects after censoring of recent starters. Conclusion Maintenance use of ACEI, ARB, warfarin, statins, direct factor Xa inhibitors and P2Y12 inhibitors was associated with reduction in risk of acquiring COVID-19 and dying from it.
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Affiliation(s)
- Kin Wah Fung
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail:
| | - Seo H. Baik
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Fitsum Baye
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Zhaonian Zheng
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Vojtech Huser
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Clement J. McDonald
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
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10
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Cardiorenal Disease in COVID-19 Patients. J Renin Angiotensin Aldosterone Syst 2022; 2022:4640788. [PMID: 35359461 PMCID: PMC8956393 DOI: 10.1155/2022/4640788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 12/21/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is an illness caused by a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Mutations in the genetic coding and the variations in the spike proteins are critical for the virus's mechanism of facilitating fusion with the human host, making the disease more severe. Recent research indicates that comorbidities including diabetes, hypertension, renal disease, heart failure, and atherosclerosis play a significant role in the severity and high mortality rates of (COVID-19), suggesting that perhaps the metabolic syndrome and its components are associated with COVID-19 morbidity. Primarily, angiotensin-converting enzyme 2 (ACE2) receptor is identified as the entrance receptor of SARS-CoV-2. Increased ACE2 expression, endothelial dysfunction plays a vital role in the progression and severity of complications developed due to COVID-19. In this review, we will discuss the association and management of cardiorenal disease and COVID-19.
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11
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Nozari F, Hamidizadeh N. The Effects of Different Classes of Antihypertensive Drugs on Patients with COVID-19 and Hypertension: A Mini-Review. Int J Hypertens 2022; 2022:5937802. [PMID: 35075396 PMCID: PMC8783136 DOI: 10.1155/2022/5937802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/04/2021] [Accepted: 01/06/2022] [Indexed: 12/22/2022] Open
Abstract
Hypertension is a major risk factor for cardiovascular disease. Previous studies showed that patients with hypertension are at an increased risk of developing severe COVID-19 infection. Therefore, proper blood pressure control in hypertensive patients with COVID-19 is of great importance. In this review, we discussed the effects of different classes of antihypertensive drugs on patients with hypertension and COVID-19.
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Affiliation(s)
- Farnoosh Nozari
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasrin Hamidizadeh
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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12
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Rizk JG, Wenziger C, Tran D, Hashemi L, Moradi H, Streja E, Ahluwalia A. Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Use Associated with Reduced Mortality and Other Disease Outcomes in US Veterans with COVID-19. Drugs 2021; 82:43-54. [PMID: 34914085 PMCID: PMC8675115 DOI: 10.1007/s40265-021-01639-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 12/29/2022]
Abstract
Objective To determine the association between angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) use and coronavirus disease 2019 (COVID-19) severity and outcomes in US veterans. Patients and Methods We retrospectively examined 27,556 adult US veterans who tested positive for COVID-19 between March to November 2020. Logistic regression and Cox proportional hazards models using propensity score (PS) for weight, adjustment, and matching were used to examine the odds of an event within 60 days following a COVID-19–positive case date and time to death, respectively, according to ACEI and/or ARB prescription within 6 months prior to the COVID-19–positive case date. Results The overlap PS weighted logistic regression model showed lower odds of an intensive care unit (ICU) admission (odds ratio [OR] 95% CI 0.77, 0.61–0.98) and death within 60 days (0.87, 0.79–0.97) with an ACEI or ARB prescription. Veterans with an ARB-only prescription also had lower odds of an ICU admission (0.64, 0.44–0.92). The overlap PS weighted model similarly showed a lower risk of time to all-cause mortality in veterans with an ACEI or ARB prescription (HR [95% CI]: 0.87, 0.79–0.97) and an ARB only prescription (0.78, 0.67–0.91). Veterans with an ACEI prescription had higher odds of experiencing a septic event within 60 days after the COVID-19–positive case date (1.22, 1.02–1.46). Conclusion In this study of a national cohort of US veterans, we found that the use of an ACEI/ARB in patients with COVID-19 was not associated with increased mortality and other worse outcomes. Future studies should examine underlying pathways and further confirm the relationship of ACEI prescription with sepsis. Supplementary Information The online version contains supplementary material available at 10.1007/s40265-021-01639-2.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.,Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD, USA
| | - Cachet Wenziger
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Diana Tran
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Leila Hashemi
- Greater Los Angeles VA Medical Center, Los Angeles, CA, USA.,UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Hamid Moradi
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Elani Streja
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA. .,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA.
| | - Amrita Ahluwalia
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.
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13
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Sharifi Y, Payab M, Mohammadi-Vajari E, Aghili SMM, Sharifi F, Mehrdad N, Kashani E, Shadman Z, Larijani B, Ebrahimpur M. Association between cardiometabolic risk factors and COVID-19 susceptibility, severity and mortality: a review. J Diabetes Metab Disord 2021; 20:1743-1765. [PMID: 34222055 PMCID: PMC8233632 DOI: 10.1007/s40200-021-00822-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/23/2021] [Indexed: 02/08/2023]
Abstract
The novel coronavirus, which began spreading from China Wuhan and gradually spreaded to most countries, led to the announcement by the World Health Organization on March 11, 2020, as a new pandemic. The most important point presented by the World Health Organization about this disease is to better understand the risk factors that exacerbate the course of the disease and worsen its prognosis. Due to the high majority of cardio metabolic risk factors like obesity, hypertension, diabetes, and dyslipidemia among the population over 60 years old and higher, these cardio metabolic risk factors along with the age of these people could worsen the prognosis of the coronavirus disease of 2019 (COVID-19) and its mortality. In this study, we aimed to review the articles from the beginning of the pandemic on the impression of cardio metabolic risk factors on COVID-19 and the effectiveness of COVID-19 on how to manage these diseases. All the factors studied in this article, including hypertension, diabetes mellitus, dyslipidemia, and obesity exacerbate the course of Covid-19 disease by different mechanisms, and the inflammatory process caused by coronavirus can also create a vicious cycle in controlling these diseases for patients.
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Affiliation(s)
- Yasaman Sharifi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Yaas Diabetes and Metabolic Diseases Research Center, Indiana University School of Medicine, Indianapolis, IN 46202 US
| | - Moloud Payab
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Mohammadi-Vajari
- Student of Medicine, School of Medicine, Gilan University of Medical Sciences, Rasht, Iran
| | - Seyed Morsal Mosallami Aghili
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshad Sharifi
- Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Mehrdad
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Kashani
- Department of Obstetrics and Gynecology, Golestan University of Medical Sciences, Golestan, Iran
| | - Zhaleh Shadman
- Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahbube Ebrahimpur
- Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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14
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Severity of liver test abnormalities in coronavirus disease 2019 depends on comorbidities and predicts early in-hospital mortality. Eur J Gastroenterol Hepatol 2021; 33:e320-e328. [PMID: 33560687 PMCID: PMC8734572 DOI: 10.1097/meg.0000000000002055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Liver chemistry abnormalities (LCA) are common in patients with coronavirus disease 2019 (COVID-19), but their causes and clinical impact have not been adequately studied. We assessed the associations between LCA and clinical characteristics, inflammatory serum markers, in-hospital mortality. METHODS Ten thousand eight hundred fifty-six adult patients with COVID-19 hospitalized in 13 hospitals in New York (1 March to 27 April 2020) were analyzed retrospectively. Abnormalities of liver chemistries [aspartate aminotransferase (AST), alanine aminotransferase, alkaline phosphatase, or total bilirubin] were defined as absent, mild-moderate (at least one value up to four times elevated), or severe. RESULTS LCA were mild-moderate in 63.9% and severe in 7.6% at admission. Risk factors for severe LCA were male sex and chronic liver disease. Conversely, hypertension and diabetes mellitus were less likely associated with severe LCA. AST elevation correlated weakly to modestly with inflammatory markers. On adjusted analysis, in-hospital mortality was 1.56 times and 1.87 times increased in patients with mild-to-moderate and severe LCA, respectively. Diabetes, hypertension, male sex, and age greater than 60 years was associated with incremental risk of mortality with increase severity of LCA, especially in the first week of hospitalization. HTN was not associated with increased in-hospital mortality unless LCA was present. CONCLUSION Increasing severity of LCA on hospital admission predicts early in-hospital mortality in COVID-19 patients. Mortality associated with the known risk factors, hypertension, diabetes, male sex, and old age was accentuated in the presence of LCA. AST correlated modestly with inflammatory markers.
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15
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Li C, Islam N, Gutierrez JP, Lacey B, Moolenaar RL, Richter P. Diabetes, obesity, hypertension and risk of severe COVID-19: a protocol for systematic review and meta-analysis. BMJ Open 2021; 11:e051711. [PMID: 34836901 PMCID: PMC8628113 DOI: 10.1136/bmjopen-2021-051711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Previous evidence from several countries, including China, Italy, Mexico, UK and the USA, indicates that among patients with confirmed COVID-19 who were hospitalised, diabetes, obesity and hypertension might be important risk factors for severe clinical outcomes. Several preliminary systematic reviews and meta-analyses have been conducted on one or more of these non-communicable diseases, but the findings have not been definitive, and recent evidence has become available from many more populations. Thus, we aim to conduct a systematic review and meta-analysis of observational studies to assess the relationship of diabetes, obesity and hypertension with severe clinical outcomes in patients with COVID-19. METHOD AND ANALYSIS We will search 16 major databases (MEDLINE, Embase, Global Health, CAB Abstracts, PsycINFO, CINAHL, Academic Research Complete, Africa Wide Information, Scopus, PubMed Central, ProQuest Central, WHO Virtual Health Library, Homeland Security COVID-19 collection, SciFinder, Clinical Trials and Cochrane Library) for articles published between December 2019 and December 2020. We will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2016 guidelines for the design and reporting the results. We will include observational studies that assess the associations of pre-existing diabetes, obesity and hypertension in patients with COVID-19 with risk of severe clinical outcomes such as intensive care unit admission, receiving mechanical ventilation or death. Stata V.16.1 and R-Studio V.1.4.1103 statistical software will be used for statistical analysis. Meta-analysis will be used to estimate the pooled risks and to assess potential heterogeneities in risks. ETHICS AND DISSEMINATION The study was reviewed for human subjects concerns by the US CDC Center for Global Health and determined to not represent human subjects research because it uses data from published studies. We plan to publish results in a peer-reviewed journal and present at national and international conferences. PROSPERO REGISTRATION NUMBER CRD42021204371.
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Affiliation(s)
- Chaoyang Li
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nazrul Islam
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Juan Pablo Gutierrez
- Center for Policy, Population and Health Research, School of Medicine, National Autonomous University of Mexico, CDMX, Mexico
| | - Ben Lacey
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ronald L Moolenaar
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Patricia Richter
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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16
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Chamata Y, Jackson KG, Watson KA, Jauregi P. Whey-Derived Peptides at the Heart of the COVID-19 Pandemic. Int J Mol Sci 2021; 22:11662. [PMID: 34769093 PMCID: PMC8584039 DOI: 10.3390/ijms222111662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/21/2021] [Accepted: 10/26/2021] [Indexed: 12/14/2022] Open
Abstract
The renin-angiotensin system (RAS) is a key regulator of blood pressure and hypertension. Angiotensin-converting enzyme 2 (ACE2) and angiotensin-converting enzyme I (ACE) are two main components of the RAS that play a major role in blood pressure homeostasis. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) uses ACE2 as a receptor to enter cells. Despite some controversies, numerous studies have reported a significant association between the use of ACE inhibitors and reduced risk of COVID-19. In our previous studies, we produced and identified peptide sequences present in whey hydrolysates exhibiting high ACE inhibitory activity. Therefore, the aim of this work is to obtain an improved understanding of the function of these natural peptides as RAS inhibitors and investigate their potential therapeutic role in the COVID-19 pandemic. The molecular interactions between peptides IPP, LIVTQ, IIAE, LVYPFP, and human ACE2 were assessed by employing a molecular docking approach. The results show that natural whey-derived peptides have a dual inhibitory action against both ACE and ACE2. This dual activity distinguishes these ACE inhibitory peptides from synthetic drugs, such as Captopril and Lisinopril which were not shown to inhibit ACE2 activity, and may represent a potential strategy in the treatment of COVID-19.
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Affiliation(s)
- Yara Chamata
- Harry Nursten Building, Department of Food and Nutritional Sciences, University of Reading, Reading RG6 6DZ, UK; (K.G.J.); (P.J.)
| | - Kim G. Jackson
- Harry Nursten Building, Department of Food and Nutritional Sciences, University of Reading, Reading RG6 6DZ, UK; (K.G.J.); (P.J.)
| | - Kimberly A. Watson
- Health and Life Sciences Building, School of Biological Sciences, University of Reading, Reading RG6 6EX, UK;
| | - Paula Jauregi
- Harry Nursten Building, Department of Food and Nutritional Sciences, University of Reading, Reading RG6 6DZ, UK; (K.G.J.); (P.J.)
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17
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Mendes JJ, Paiva JA, Gonzalez F, Mergulhão P, Froes F, Roncon R, Gouveia J. Update of the recommendations of the Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group for the approach to COVID-19 in Intensive Care Medicine. Rev Bras Ter Intensiva 2021; 33:487-536. [PMID: 35081236 PMCID: PMC8889599 DOI: 10.5935/0103-507x.0103-507x-rbti-20210080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/20/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION The Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group have previously issued health service and management recommendations for critically ill patients with COVID-19. Due to the evolution of knowledge, the panel of experts was again convened to review the current evidence and issue updated recommendations. METHODS A national panel of experts who declared that they had no conflicts of interest regarding the development of the recommendations was assembled. Operational questions were developed based on the PICO methodology, and a rapid systematic review was conducted by consulting different bibliographic sources. The panel determined the direction and strength of the recommendations using two Delphi rounds, conducted in accordance with the principles of the GRADE system. A strong recommendation received the wording "is recommended", and a weak recommendation was written as "is suggested." RESULTS A total of 48 recommendations and 30 suggestions were issued, covering the following topics: diagnosis of SARS-CoV-2 infection, coinfection and superinfection; criteria for admission, cure and suspension of isolation; organization of services; personal protective equipment; and respiratory support and other specific therapies (antivirals, immunomodulators and anticoagulation). CONCLUSION These recommendations, specifically oriented to the Portuguese reality but that may also apply to Portuguese-speaking African countries and East Timor, aim to support health professionals in the management of critically ill patients with COVID-19. They will be continuously reviewed to reflect the progress of our understanding and the treatment of this pathology.
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Affiliation(s)
- João João Mendes
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Department of Intensive Care Medicine, Hospital Prof. Doutor
Fernando da Fonseca EPE - Lisboa, Portugal
| | - José Artur Paiva
- College of Specialties of Intensive Care Medicine, Ordem dos
Médicos- Lisboa, Portugal
- Infection and Sepsis Group - Lisboa, Portugal
- Department of Intensive Care Medicine, Centro Hospitalar
Universitário de São João EPE, Faculdade de Medicina da Universidade do Porto -
Porto, Portugal
| | - Filipe Gonzalez
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Department of Intensive Care Medicine, Hospital Garcia de Orta EPE -
Lisboa, Portugal
| | - Paulo Mergulhão
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Infection and Sepsis Group - Lisboa, Portugal
- Polyvalent Intensive Care Unit, Hospital Lusíadas Porto - Porto,
Portugal
| | - Filipe Froes
- Medical-Surgical Intensive Care Unit, Hospital de Pulido Valente,
Centro Hospitalar Universitário de Lisboa Norte EPE - Lisboa, Portugal
| | - Roberto Roncon
- Department of Intensive Care Medicine, Centro Hospitalar
Universitário de São João EPE, Faculdade de Medicina da Universidade do Porto -
Porto, Portugal
| | - João Gouveia
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Department of Intensive Care Medicine, Centro Hospitalar
Universitário de Lisboa Norte EPE - Lisboa, Portugal
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18
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Xiang Y, Wong KCY, So HC. Exploring Drugs and Vaccines Associated with Altered Risks and Severity of COVID-19: A UK Biobank Cohort Study of All ATC Level-4 Drug Categories Reveals Repositioning Opportunities. Pharmaceutics 2021; 13:1514. [PMID: 34575590 PMCID: PMC8471264 DOI: 10.3390/pharmaceutics13091514] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 01/08/2023] Open
Abstract
Effective therapies for COVID-19 are still lacking, and drug repositioning is a promising approach to address this problem. Here, we adopted a medical informatics approach to repositioning. We leveraged a large prospective cohort, the UK-Biobank (UKBB, N ~ 397,000), and studied associations of prior use of all level-4 ATC drug categories (N = 819, including vaccines) with COVID-19 diagnosis and severity. Effects of drugs on the risk of infection, disease severity, and mortality were investigated separately. Logistic regression was conducted, controlling for main confounders. We observed strong and highly consistent protective associations with statins. Many top-listed protective drugs were also cardiovascular medications, such as angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), calcium channel blocker (CCB), and beta-blockers. Some other drugs showing protective associations included biguanides (metformin), estrogens, thyroid hormones, proton pump inhibitors, and testosterone-5-alpha reductase inhibitors, among others. We also observed protective associations by influenza, pneumococcal, and several other vaccines. Subgroup and interaction analyses were also conducted, which revealed differences in protective effects in various subgroups. For example, protective effects of flu/pneumococcal vaccines were weaker in obese individuals, while protection by statins was stronger in cardiovascular patients. To conclude, our analysis revealed many drug repositioning candidates, for example several cardiovascular medications. Further studies are required for validation.
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Affiliation(s)
- Yong Xiang
- Lo Kwee-Seong Integrated Biomedical Sciences Building, School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China; (Y.X.); (K.C.-Y.W.)
| | - Kenneth Chi-Yin Wong
- Lo Kwee-Seong Integrated Biomedical Sciences Building, School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China; (Y.X.); (K.C.-Y.W.)
| | - Hon-Cheong So
- Lo Kwee-Seong Integrated Biomedical Sciences Building, School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China; (Y.X.); (K.C.-Y.W.)
- KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research of Common Diseases, Kunming Institute of Zoology, Kunming 650223, China
- CUHK Shenzhen Research Institute, Shenzhen 518172, China
- Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
- Margaret K.L. Cheung Research Centre for Management of Parkinsonism, The Chinese University of Hong Kong, Shatin, Hong Kong, China
- Brain and Mind Institute, The Chinese University of Hong Kong, Shatin, Hong Kong, China
- Hong Kong Branch of the Chinese Academy of Sciences Center for Excellence in Animal Evolution and Genetics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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19
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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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20
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Laurenzi A, Caretto A, Molinari C, Bazzigaluppi E, Brigatti C, Marzinotto I, Mercalli A, Melzi R, Nano R, Tresoldi C, Landoni G, Ciceri F, Lampasona V, Scavini M, Piemonti L. Pre-Existing Diabetes and COVID-Associated Hyperglycaemia in Patients with COVID-19 Pneumonia. BIOLOGY 2021; 10:biology10080754. [PMID: 34439986 PMCID: PMC8389579 DOI: 10.3390/biology10080754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 01/08/2023]
Abstract
Simple Summary COVID-associated hyperglycaemia is emerging as a complication of Sars-CoV-2 infection, and this clinical entity still needs to be adequately characterized in comparison to pre-existing diabetes. Few studies have comparatively characterized these two conditions in relation to the presence of comorbidities, pre-hospitalization treatments, symptoms at admission, and laboratory variables associated with COVID-19 severity. Our study generated several interesting findings. Patients with COVID-associated hyperglycaemia had significantly less comorbidities, increased levels of inflammatory markers, and indicators of multi-organ injury than those with pre-existing diabetes, while islet autoimmunity prevalence and anti-SARS-CoV-2 antibody responses were similar. COVID-associated hyperglycaemia was associated with a poorer clinical outcome and a longer viral clearance time compared to pre-existing diabetes. This strongly supports the need to screen all COVID-19 patients for hyperglycaemia at the time of admission despite a mute personal or family history of diabetes and to treat them in order to reach and maintain good glycemic control during hospitalization for COVID-19 pneumonia. Abstract Aim. The aim of the current study was to compare clinical characteristics, laboratory findings, and major outcomes of patients hospitalized for COVID-19 pneumonia with COVID-associated hyperglycaemia or pre-existing diabetes. Methods. A cohort of 176 adult patients with a diagnosis of pre-existing diabetes (n = 112) or COVID-associated hyperglycaemia (n = 55) was studied. Results. Patients with COVID-associated hyperglycaemia had lower BMI, significantly less comorbidities, and higher levels of inflammatory markers and indicators of multi-organ injury than those with pre-existing diabetes. No differences between pre-existing diabetes and COVID-associated hyperglycaemia were evident for symptoms at admission, the humoral response against SARS-CoV-2, or autoantibodies to glutamic acid decarboxylase or interferon alpha-4. COVID-associated hyperglycaemia was independently associated with the risk of adverse clinical outcome, which was defined as ICU admission or death (HR 2.11, 95% CI 1.34–3.31; p = 0.001), even after adjustment for age, sex, and other selected variables associated with COVID-19 severity. Furthermore, at the same time, we documented a negative association (HR 0.661, 95% CI 0.43–1.02; p = 0.063) between COVID-associated hyperglycaemia to swab negativization. Conclusions. Recognizing hyperglycaemia as a specific clinical entity associated with COVID-19 pneumonia is relevant for early and appropriate patient management and close monitoring for the progression of disease severity.
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Affiliation(s)
- Andrea Laurenzi
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Amelia Caretto
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Chiara Molinari
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Elena Bazzigaluppi
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Cristina Brigatti
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Ilaria Marzinotto
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Alessia Mercalli
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Raffaella Melzi
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Rita Nano
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Cristina Tresoldi
- Molecular Hematology Unit, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy;
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy;
- School of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy;
| | - Fabio Ciceri
- School of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy;
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy
| | - Vito Lampasona
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Marina Scavini
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
| | - Lorenzo Piemonti
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (A.L.); (A.C.); (C.M.); (E.B.); (C.B.); (I.M.); (A.M.); (R.M.); (R.N.); (V.L.); (M.S.)
- School of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy;
- Correspondence: ; Tel.: +39-02-2643-2706; Fax: +39-02-2643-2871
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21
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Alves M, Fernandes MA, Bahat G, Benetos A, Clemente H, Grodzicki T, Martínez-Sellés M, Mattace-Raso F, Rajkumar C, Ungar A, Werner N, Strandberg TE. Protecting older patients with cardiovascular diseases from COVID-19 complications using current medications. Eur Geriatr Med 2021; 12:725-739. [PMID: 34031865 PMCID: PMC8143992 DOI: 10.1007/s41999-021-00504-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/15/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE In the pathogenesis of severe COVID-19 complications, derangements of renin-angiotensin-aldosterone system (RAAS), vascular endothelial dysfunction leading to inflammation and coagulopathy, and arrhythmias play an important role. Therefore, it is worth considering the use of currently available drugs to protect COVID-19 patients with cardiovascular diseases. METHODS We review the current experience of conventional cardiovascular drugs [angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, anticoagulants, acetosalicylic acid, antiarrhythmic drugs, statins] as well as some other drug classes (antidiabetic drugs, vitamin D and NSAIDs) frequently used by older patients with cardiovascular diseases. Data were sought from clinical databases for COVID-19 and appropriate key words. Conclusions and recommendations are based on a consensus among all authors. RESULTS Several cardiovascular drugs have a potential to protect patients with COVID-19, although evidence is largely based on retrospective, observational studies. Despite propensity score adjustments used in many analyses observational studies are not equivalent to randomised controlled trials (RCTs). Ongoing RCTs include treatment with antithrombotics, pulmonary vasodilators, RAAS-related drugs, and colchicine. RCTs in the acute phase of COVID-19 may not, however, recognise the benefits of long term anti-atherogenic therapies, such as statins. CONCLUSIONS Most current cardiovascular drugs can be safely continued during COVID-19. Some drug classes may even be protective. Age-specific data are scarce, though, and conditions which are common in older patients (frailty, comorbidities, polypharmacy) must be individually considered for each drug group.
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Affiliation(s)
- Mariana Alves
- Faculty of Medicine, Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Serviço de Medicina III, Hospital Pulido Valente, CHULNUniversity of LisbonUniversidade de Lisboa, Lisbon, Portugal
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Gülistan Bahat
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Capa, 34093, Istanbul, Turkey
| | - Athanase Benetos
- Department of Geriatrics and FHU CARTAGE-PROFILES, CHRU de Nancy and INSERM 1116, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Hugo Clemente
- Department of Geriatrics, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Cracow, Poland
| | - Manuel Martínez-Sellés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, CIBER-CV. Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Francesco Mattace-Raso
- Division of Geriatrics, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Andrea Ungar
- Department of Geriatrics and Intensive Care Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Nikos Werner
- Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Timo E Strandberg
- Helsinki University and Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, N00029, Helsinki, Finland.
- University of Oulu, Center for Life Course Health Research, Oulu, Finland.
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22
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Hussain M, Jabeen Q, Ahmad FUD, Kashif-Ur-Rehman, Fatima M, Shaukat S, Majeed A, Barkat MQ, Wu X. COVID-19 and inhibitors of the renin-angiotensin-aldosterone system. Expert Rev Anti Infect Ther 2021; 19:815-816. [PMID: 33198546 PMCID: PMC7711737 DOI: 10.1080/14787210.2021.1851197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/11/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Musaddique Hussain
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Qaiser Jabeen
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Fiaz-Ud-Din Ahmad
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Kashif-Ur-Rehman
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Mobeen Fatima
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Saira Shaukat
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Abdul Majeed
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Mulatn, Pakistan
| | - Muhammad Qasim Barkat
- Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou City, China
| | - Ximei Wu
- Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou City, China
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23
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Aimo A, Vergaro G, Passino C, Clerico A. Evaluation of pathophysiological relationships between renin-angiotensin and ACE-ACE2 systems in cardiovascular disorders: from theory to routine clinical practice in patients with heart failure. Crit Rev Clin Lab Sci 2021; 58:530-545. [PMID: 34196254 DOI: 10.1080/10408363.2021.1942782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Despite the progressive improvements in diagnosis and therapy during the first 20 years of this century, the morbidity and mortality of patients with heart failure (HF) remain high, resulting in an enormous health and economic burden. Only a further improvement in understanding the pathophysiological mechanisms related to the development of cardiac injury and dysfunction can allow more innovative and personalized approaches to HF management. The renin-angiotensin system (RAS) has a critical role in cardiovascular physiology by regulating blood pressure and electrolyte balance. The RAS is mainly regulated by both angiotensin converting enzyme (ACE) and type 2 angiotensin converting enzyme (ACE2). However, the balance between the various peptides and peptidases constituting the RAS/ACE pathway remains in great part unraveled in patients with HF. This review summarizes the role of the RAS/ACE axis in cardiac physiology and HF pathophysiology as well as some analytical issues relevant to the clinical and laboratory assessment of inter-relationships between these two systems. There is evidence that RAS peptides represent a dynamic network of peptides, which are altered in different HF states and influenced by medical therapy. However, the mechanisms of signal transduction have not been fully elucidated under physiological and pathophysiological conditions. Further investigations are necessary to explore novel molecular mechanisms related to the RAS, which will provide alternative therapeutic agents. Moreover, monitoring the circulating levels of active RAS peptides in HF patients may enable a personalized approach by facilitating assessment of the pathophysiological status of several cardiovascular diseases and thus better selection of therapies for HF patients.
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Affiliation(s)
- Alberto Aimo
- Fondazione CNR - Regione Toscana G. Monasterio, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giuseppe Vergaro
- Fondazione CNR - Regione Toscana G. Monasterio, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Claudio Passino
- Fondazione CNR - Regione Toscana G. Monasterio, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Aldo Clerico
- Fondazione CNR - Regione Toscana G. Monasterio, Scuola Superiore Sant'Anna, Pisa, Italy
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24
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Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Withdrawal Is Associated with Higher Mortality in Hospitalized Patients with COVID-19. J Clin Med 2021; 10:jcm10122642. [PMID: 34204014 PMCID: PMC8232748 DOI: 10.3390/jcm10122642] [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: 05/22/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 01/23/2023] Open
Abstract
Our main aim was to describe the effect on the severity of ACEI (angiotensin-converting enzyme inhibitor) and ARB (angiotensin II receptor blocker) during COVID-19 hospitalization. A retrospective, observational, multicenter study evaluating hospitalized patients with COVID-19 treated with ACEI/ARB. The primary endpoint was the incidence of the composite outcome of prognosis (IMV (invasive mechanical ventilation), NIMV (non-invasive mechanical ventilation), ICU admission (intensive care unit), and/or all-cause mortality). We evaluated both outcomes in patients whose treatment with ACEI/ARB was continued or withdrawn. Between February and June 2020, 11,205 patients were included, mean age 67 years (SD = 16.3) and 43.1% female; 2162 patients received ACEI/ARB treatment. ACEI/ARB treatment showed lower all-cause mortality (p < 0.0001). Hypertensive patients in the ACEI/ARB group had better results in IMV, ICU admission, and the composite outcome of prognosis (p < 0.0001 for all). No differences were found in the incidence of major adverse cardiovascular events. Patients previously treated with ACEI/ARB continuing treatment during hospitalization had a lower incidence of the composite outcome of prognosis than those whose treatment was withdrawn (RR 0.67, 95%CI 0.63-0.76). ARB was associated with better survival than ACEI (HR 0.77, 95%CI 0.62-0.96). ACEI/ARB treatment during COVID-19 hospitalization was associated with protection on mortality. The benefits were greater in hypertensive, those who continued treatment, and those taking ARB.
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25
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Spaccarotella C, Mazzitelli M, Migliarino S, Curcio A, De Rosa S, Torti C, Indolfi C. Therapy with RAS inhibitors during the COVID-19 pandemic. J Cardiovasc Med (Hagerstown) 2021; 22:329-334. [PMID: 33795584 DOI: 10.2459/jcm.0000000000001160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is caused by the novel coronavirus first identified in Wuhan, China. The global number of confirmed cases of COVID-19 has surpassed 28,285,700 with mortality that appears higher than for seasonal influenza. About 20% of COVID-19 patients have experienced cardiac involvement and myocardial infarction in patients infected with SARS-CoV-2 had a worse prognosis. Furthermore, the widespread use of antiviral drugs can be linked to a worsening of heart function. Arrhythmias and hypertension have also been reported in patients with Covid-19. On the other hand, previous cardiac diseases are present in 30% of patients infected with SARS-CoV-2. There is uncertainty in the use of ace inhibitors and angiotensin II (Ang II) antagonists in the COVID-19 era. The mechanism of action of SARS-CoV-2 has been elucidated. It has been demonstrated that angiotensin-converting enzyme 2 (ACE2) is the cellular receptor for the new coronavirus SARS-CoV-2 and it is required for host cell entry and subsequent viral replication. The effect of the SARS-CoV-2 infection is the downregulation of ACE2 that may contribute to the severity of lung pathologies as well as the cardiac function. ACE2, a homolog of ACE, is a monocarboxypeptidase that converts Ang II into angiotensin 1-7 (Ang 1-7) that with its vasodilatory, antifibrotic, antihypertrophic effects counterbalances the negative effects of Ang II. On the other hand, angiotensin-converting enzyme inhibitors (ACEi) and AT1R blockers have been shown to upregulate the expression of ACE2. Based on the mechanism of action of SARS-CoV-2, the use of renin angiotensin system (RAS) inhibitors was questioned although all scientific societies did not recommend discontinuation when clinically recommended. The BRACE CORONA, a phase 4, randomized study tested two strategies: temporarily stopping the ACE inhibitor/angiotensin receptor blockers (ARB) for 30 days versus continuing ACE inhibitors/ARBs in patients who were taking these medications chronically and were hospitalized with a confirmed diagnosis of COVID-19 was also discussed. Therefore, the goal of this review is to summarize recent laboratory and clinical investigations concerning the use of ACEi and ARBs during the COVID-19 pandemic. The available data, based also on a randomized trial, suggest that ACEIs or ARBs, when clinically indicated, should be regularly used in the COVID-19 era.
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Affiliation(s)
| | - Maria Mazzitelli
- Division of Infectious and Tropical Diseases, 'Magna Graecia' University of Catanzaro, Catanzaro, Italy
| | | | - Antonio Curcio
- Division of Cardiology, University Magna Graecia, Catanzaro
| | | | - Carlo Torti
- Division of Infectious and Tropical Diseases, 'Magna Graecia' University of Catanzaro, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, University Magna Graecia, Catanzaro
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26
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Dai XC, An ZY, Wang ZY, Wang ZZ, Wang YR. Associations Between the Use of Renin-Angiotensin System Inhibitors and the Risks of Severe COVID-19 and Mortality in COVID-19 Patients With Hypertension: A Meta-Analysis of Observational Studies. Front Cardiovasc Med 2021; 8:609857. [PMID: 33981731 PMCID: PMC8107232 DOI: 10.3389/fcvm.2021.609857] [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: 09/24/2020] [Accepted: 02/22/2021] [Indexed: 01/10/2023] Open
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) share a target receptor with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The use of ACEIs/ARBs may cause angiotensin-converting enzyme 2 receptor upregulation, facilitating the entry of SARS-CoV-2 into host cells. There is concern that the use of ACEIs/ARBs could increase the risks of severe COVID-19 and mortality. The impact of discontinuing these drugs in patients with COVID-19 remains uncertain. We aimed to assess the association between the use of ACEIs/ARBs and the risks of mortality and severe disease in patients with COVID-19. A systematic search was performed in PubMed, EMBASE, Cochrane Library, and MedRxiv.org from December 1, 2019, to June 20, 2020. We also identified additional citations by manually searching the reference lists of eligible articles. Forty-two observational studies including 63,893 participants were included. We found that the use of ACEIs/ARBs was not significantly associated with a reduction in the relative risk of all-cause mortality [odds ratio (OR) = 0.87, 95% confidence interval (95% CI) = 0.75-1.00; I 2 = 57%, p = 0.05]. We found no significant reduction in the risk of severe disease in the ACEI subgroup (OR = 0.95, 95% CI = 0.88-1.02, I 2 = 50%, p = 0.18), the ARB subgroup (OR = 1.03, 95% CI = 0.94-1.13, I 2 = 62%, p = 0.48), or the ACEI/ARB subgroup (OR = 0.83, 95% CI = 0.65-1.08, I 2 = 67%, p = 0.16). Moreover, seven studies showed no significant difference in the duration of hospitalization between the two groups (mean difference = 0.33, 95% CI = -1.75 to 2.40, p = 0.76). In conclusion, the use of ACEIs/ARBs appears to not have a significant effect on mortality, disease severity, or duration of hospitalization in COVID-19 patients. On the basis of the findings of this meta-analysis, there is no support for the cessation of treatment with ACEIs or ARBs in patients with COVID-19.
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Affiliation(s)
- Xiao-Ce Dai
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Zhejiang, China
| | - Zhuo-Yu An
- Peking University People's Hospital, Beijing, China
| | - Zi-Yang Wang
- Peking University People's Hospital, Beijing, China
| | | | - Yi-Ren Wang
- Peking University People's Hospital, Beijing, China
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27
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Singh S, Widrich C, Nap M, Schokker E, Zwinderman AH, Pinto‐Sietsma S. Antihypertensives and their relation to mortality by SARS-CoV-2 infection. J Med Virol 2021; 93:2467-2475. [PMID: 33404127 PMCID: PMC7986392 DOI: 10.1002/jmv.26775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 01/20/2023]
Abstract
The role of antihypertensives, especially Renin-Angiotensin-Aldosterone System inhibitors, is still debatable in COVID-19-related severity and outcome. Therefore, we search for a more global analysis of antihypertensive medication in relation to SAS-CoV-2 severity using prescription data worldwide. The association between the percentage use of different types of antihypertensive medications and mortality rates due to a SARS-CoV-2 infection during the first 3 weeks of the pandemic was analyzed using random effects linear regression models for 30 countries worldwide. Higher percentages of prescribed angiotensin receptor blockers (ARBs) (β, 95% confidence interval [CI]; -0.02 [-0.04 to -0.0012]; p = .042) and calcium channel blockers (CCBs) (β, 95% CI; -0.023 [-0.05 to -0.0028]; p = .0304) were associated with a lower first 3-week SARS-CoV-2-related death rate, whereas a higher percentage of prescribed angiotensin-converting enzyme inhibitors (ACEis) (β, 95% CI; 0.03 [0.0061-0.05]; p = .0103) was associated with a higher first 3-week death rate, even when adjusted for age and metformin use. There was no association between the amount of prescribed beta-blockers (BBs) and diuretics (Diu) and the first 3-week death rate. When analyzing the combination of drugs that is used by at least 50% of antihypertensive users, within the different countries, countries with the lowest first 3-week death rates had at least an angiotensin receptor blocker as one of the most often prescribed antihypertensive medications (ARBs/CCBs: [β, 95% CI; -0.02 [-0.03 to -0.004]; p = .009], ARBs/BBs: [β, 95% CI; -0.03 [-0.05 to -0.006]; p = .01]). Finally, countries prescribing high-potency ARBs had lower first 3-week ARBs. In conclusion, ARBs and CCB seem to have a protective effect against death from SARS-CoV-2 infection.
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Affiliation(s)
- Sandeep Singh
- Departments of Clinical Epidemiology, Biostatistics and Bio‐InformaticsAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
- Department of Vascular MedicineAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
| | - Christine Widrich
- Department of Analytics SolutionsIQVIA NederlandAmsterdamThe Netherlands
| | - Martijn Nap
- Department of Analytics and Technology SolutionsIQVIA NederlandAmsterdamThe Netherlands
| | | | - Aeilko H. Zwinderman
- Departments of Clinical Epidemiology, Biostatistics and Bio‐InformaticsAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
| | - Sara‐Joan Pinto‐Sietsma
- Departments of Clinical Epidemiology, Biostatistics and Bio‐InformaticsAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
- Department of Vascular MedicineAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
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28
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Li M, Wang Y, Ndiwane N, Orner MB, Palacios N, Mittler B, Berlowitz D, Kazis LE, Xia W. The association of COVID-19 occurrence and severity with the use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers in patients with hypertension. PLoS One 2021; 16:e0248652. [PMID: 33735262 PMCID: PMC7971559 DOI: 10.1371/journal.pone.0248652] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND A number of studies have reported the association between the use of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-II receptor blocker (ARB) medications and the occurrence or severity of coronavirus disease 2019 (COVID-19). Published results are inconclusive, possibly due to differences in participant comorbidities and sociodemographic backgrounds. Since ACEI and ARB are frequently used anti-hypertension medications, we aim to determine whether the use of ACEI and ARB is associated with the occurrence and severity of COVID-19 in a large study of US Veterans with hypertension. METHODS Data were collected from the Department of Veterans Affairs (VA) National Corporate Data Warehouse (VA-COVID-19 Shared Data Resource) between February 28, 2020 and August 18, 2020. Using data from 228,722 Veterans with a history of hypertension who received COVID-19 testing at the VA, we investigated whether the use of ACEI or ARB over the two years prior to the index date was associated with increased odds of (1) a positive COVID-19 test, and (2) a severe outcome (hospitalization, mortality, and use of intensive care unit (ICU) and/or mechanical ventilation) among COVID-19-positive patients. We used logistic regression with and without propensity score weighting (PSW) to estimate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between ACEI/ARB use and a positive COVID-19 test result. The association between medication use and COVID-19 outcome severity was examined using multinomial logistic regression comparing participants who were not hospitalized to participants who were hospitalized, were admitted to the ICU, used a mechanical ventilator, or died. All models were adjusted for relevant covariates, including demographics (age, sex, race, ethnicity), selected comorbidities, and the Charlson Comorbidity Index (CCI). RESULTS The use of ACEI significantly decreased the odds of a positive COVID-19 test among Veterans with hypertension (OR = 0.917, (0.887, 0.948) and OR = 0.926, (0.894, 0.958) with PSW). The use of ACEI, but not of ARB, was also associated with significantly increased odds of using mechanical ventilators (OR = 1.265, (1.010, 1.584) and OR = 1.210, (1.053, 1.39) with PSW) among all COVID-19 inpatients compared to outpatients. CONCLUSIONS In this study of Veterans with hypertension, ACEI was significantly associated with decreased odds of testing positive for COVID-19. With the exception of the association of ACEI with a small non-clinically-important increase in the odds of using mechanical ventilators, neither ACEI nor ARB was found to be associated with clinical severity or mortality among COVID-19-positive Veterans. The results of this study need further corroboration and validation in other cohort samples outside the VA.
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Affiliation(s)
- Mingfei Li
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Healthcare System, Bedford, Massachusetts, United States of America
- Department of Mathematical Sciences, Bentley University, Waltham, Massachusetts, United States of America
| | - Ying Wang
- Department of Mathematical Sciences, Bentley University, Waltham, Massachusetts, United States of America
| | - Ndindam Ndiwane
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Healthcare System, Bedford, Massachusetts, United States of America
| | - Michelle B. Orner
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Healthcare System, Bedford, Massachusetts, United States of America
| | - Natalia Palacios
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, Massachusetts, United States of America
- Geriatric Research Education Clinical Center, Bedford VA Healthcare System, Bedford, Massachusetts, United States of America
| | - Brant Mittler
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Dan Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, Massachusetts, United States of America
| | - Lewis E. Kazis
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Healthcare System, Bedford, Massachusetts, United States of America
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Weiming Xia
- Geriatric Research Education Clinical Center, Bedford VA Healthcare System, Bedford, Massachusetts, United States of America
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, Massachusetts, United States of America
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29
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Salvador P, Oliveira P, Costa T, Fidalgo M, Neto R, Silva ML, Figueiredo C, Afreixo V, Gregório T, Malheiro L. Clinical Features and Prognostic Factors of 245 Portuguese Patients Hospitalized With COVID-19. Cureus 2021; 13:e13687. [PMID: 33833912 PMCID: PMC8019144 DOI: 10.7759/cureus.13687] [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] [Accepted: 03/03/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Since the declaration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in March 2020, Portugal was considered a role model with regards to the first COVID-19 wave. However, a third wave started in 2021 started, turning the country into the worst in the world regarding new infections and death rate per capita in the last weeks of January 2021. No significant data regarding the country's first wave of hospitalized patients have been published. Those data may help understand the differences over time regarding patients and the clinical approach to them. Herein, we present data of COVID-19 patients hospitalized at the main tertiary hospital of the second-most affected county at the time and identify risk factors associated with disease progression and outcomes. Materials and methods We performed a prospective observational study of patients admitted with COVID-19 to a central hospital between March 20 and June 1, 2020. The primary endpoint of this study was 30-day mortality or the need for ventilatory support and the secondary outcomes were both outcomes individually. Results 245 patients were included, with a median age of 79 years, 52% males. Hypertension (n = 172) and dyslipidemia (n = 114) were the most frequent comorbidities. Half of the patients (n = 121) were treated with hydroxychloroquine. The primary outcome occurred in 114 patients; mortality at 30 days was 35%. Age (OR 1.05; 1.02-1.07) and active cancer (OR 3.89; 1.43-10.57) were associated with the primary outcome, with dyslipidemia being protective (OR 0.46; 0.25-0.80). Treatment with hydroxychloroquine or lopinavir/ritonavir was not associated with the main outcome. Patients who had been symptomatic for more than 7 days had lower mortality (OR 0.23; 0.09-0.63). Discussion In the present study, age and cancer were associated with higher mortality, as noted in prior articles. The population had a higher median age than reported in previous studies, which may explain the increased mortality. The protective association of dyslipidemia was not previously described. This association was not related to statin intake. Conclusion The reported high mortality of COVID-19 is rarely seen in other infectious diseases. Our elderly population probably reflects more reliably the incidence of COVID-19 in European countries with constricted age pyramids.
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Affiliation(s)
- Pedro Salvador
- Internal Medicine Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova de Gaia, PRT
| | - Pedro Oliveira
- Internal Medicine Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova de Gaia, PRT
| | - Tiago Costa
- Internal Medicine Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova De Gaia, PRT
| | - Mariana Fidalgo
- Internal Medicine Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova De Gaia, PRT
| | - Raul Neto
- Intensive Medicine Department, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, PRT
| | - Maria Leonor Silva
- Internal Medicine Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova De Gaia, PRT
| | - Cristóvão Figueiredo
- Infectious Diseases Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova De Gaia, PRT
| | - Vera Afreixo
- Center for Research and Development in Mathematics and Applications, Department of Mathematics, University of Aveiro, Aveiro, PRT
| | - Tiago Gregório
- Internal Medicine Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova De Gaia, PRT
| | - Luís Malheiro
- Infectious Diseases Department, Centro Hospitalar Vila Nova De Gaia, Vila Nova De Gaia, PRT
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30
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Baral R, Tsampasian V, Debski M, Moran B, Garg P, Clark A, Vassiliou VS. Association Between Renin-Angiotensin-Aldosterone System Inhibitors and Clinical Outcomes in Patients With COVID-19: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e213594. [PMID: 33787911 PMCID: PMC8013817 DOI: 10.1001/jamanetworkopen.2021.3594] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE The chronic receipt of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) has been assumed to exacerbate complications associated with COVID-19 and produce worse clinical outcomes. OBJECTIVE To conduct an updated and comprehensive systematic review and meta-analysis comparing mortality and severe adverse events (AEs) associated with receipt vs nonreceipt of ACEIs or ARBs among patients with COVID-19. DATA SOURCES PubMed and Embase databases were systematically searched from December 31, 2019, until September 1, 2020. STUDY SELECTION The meta-analysis included any study design, with the exception of narrative reviews or opinion-based articles, in which COVID-19 was diagnosed through laboratory or radiological test results and in which clinical outcomes (unadjusted or adjusted) associated with COVID-19 were assessed among adult patients (≥18 years) receiving ACEIs or ARBs. DATA EXTRACTION AND SYNTHESIS Three authors independently extracted data on mortality and severe AEs associated with COVID-19. Severe AEs were defined as intensive care unit admission or the need for assisted ventilation. For each outcome, a random-effects model was used to compare the odds ratio (OR) between patients receiving ACEIs or ARBs vs those not receiving ACEIs or ARBs. MAIN OUTCOMES AND MEASURES Unadjusted and adjusted ORs for mortality and severe AEs associated with COVID-19. RESULTS A total of 1788 records from the PubMed and Embase databases were identified; after removal of duplicates, 1664 records were screened, and 71 articles underwent full-text evaluation. Clinical data were pooled from 52 eligible studies (40 cohort studies, 6 case series, 4 case-control studies, 1 randomized clinical trial, and 1 cross-sectional study) enrolling 101 949 total patients, of whom 26 545 (26.0%) were receiving ACEIs or ARBs. When adjusted for covariates, significant reductions in the risk of death (adjusted OR [aOR], 0.57; 95% CI, 0.43-0.76; P < .001) and severe AEs (aOR, 0.68; 95% CI, 0.53-0.88; P < .001) were found. Unadjusted and adjusted analyses of a subgroup of patients with hypertension indicated decreases in the risk of death (unadjusted OR, 0.66 [95% CI, 0.49-0.91]; P = .01; aOR, 0.51 [95% CI, 0.32-0.84]; P = .008) and severe AEs (unadjusted OR, 0.70 [95% CI, 0.54-0.91]; P = .007; aOR, 0.55 [95% CI, 0.36-0.85]; P = .007). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, receipt of ACEIs or ARBs was not associated with a higher risk of multivariable-adjusted mortality and severe AEs among patients with COVID-19 who had either hypertension or multiple comorbidities, supporting the recommendations of medical societies. On the contrary, ACEIs and ARBs may be associated with protective benefits, particularly among patients with hypertension. Future randomized clinical trials are warranted to establish causality.
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Affiliation(s)
- Ranu Baral
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Vasiliki Tsampasian
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Maciej Debski
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Brendan Moran
- National Health Service 111 COVID-19 Clinical Assessment Service, Bicester, United Kingdom
- Neasden Medical Centre, London, United Kingdom
- Healix International, Esher, United Kingdom
| | - Pankaj Garg
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Allan Clark
- Department of Medical Statistics, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Vassilios S. Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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31
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Choi HM, Moon SY, Yang HI, Kim KS. Understanding Viral Infection Mechanisms and Patient Symptoms for the Development of COVID-19 Therapeutics. Int J Mol Sci 2021; 22:1737. [PMID: 33572274 PMCID: PMC7915126 DOI: 10.3390/ijms22041737] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, has become a worldwide pandemic. Symptoms range from mild fever to cough, fatigue, severe pneumonia, acute respiratory distress syndrome (ARDS), and organ failure, with a mortality rate of 2.2%. However, there are no licensed drugs or definitive treatment strategies for patients with severe COVID-19. Only antiviral or anti-inflammatory drugs are used as symptomatic treatments based on clinician experience. Basic medical researchers are also trying to develop COVID-19 therapeutics. However, there is limited systematic information about the pathogenesis of COVID-19 symptoms that cause tissue damage or death and the mechanisms by which the virus infects and replicates in cells. Here, we introduce recent knowledge of time course changes in viral titers, delayed virus clearance, and persistent systemic inflammation in patients with severe COVID-19. Based on the concept of drug reposition, we review which antiviral or anti-inflammatory drugs can effectively treat COVID-19 patients based on progressive symptoms and the mechanisms inhibiting virus infection and replication.
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Affiliation(s)
- Hyung Muk Choi
- Department of Clinical Pharmacology and Therapeutics, Kyung Hee University School of Medicine, Seoul 02447, Korea;
| | - Soo Youn Moon
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Gandong-gu, Seoul 02447, Korea;
| | - Hyung In Yang
- East-West Bone & Joint Disease Research Institute, Kyung Hee University Hospital at Gangdong, Gandong-gu, Seoul 02447, Korea;
| | - Kyoung Soo Kim
- Department of Clinical Pharmacology and Therapeutics, Kyung Hee University School of Medicine, Seoul 02447, Korea;
- East-West Bone & Joint Disease Research Institute, Kyung Hee University Hospital at Gangdong, Gandong-gu, Seoul 02447, Korea;
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32
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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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33
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Semenzato L, Botton J, Drouin J, Baricault B, Vabre C, Cuenot F, Penso L, Herlemont P, Sbidian E, Weill A, Dray-Spira R, Zureik M. Antihypertensive Drugs and COVID-19 Risk: A Cohort Study of 2 Million Hypertensive Patients. Hypertension 2021; 77:833-842. [PMID: 33423528 PMCID: PMC7884243 DOI: 10.1161/hypertensionaha.120.16314] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Supplemental Digital Content is available in the text. After initially hypothesizing a positive relationship between use of renin-angiotensin-aldosterone system inhibitors and risk of coronavirus disease 2019 (COVID-19), more recent evidence suggests negative associations. We examined whether COVID-19 risk differs according to antihypertensive drug class in patients treated by ACE (angiotensin-converting enzyme) inhibitors and angiotensin receptor blockers (ARBs) compared with calcium channel blockers (CCBs). Three exclusive cohorts of prevalent ACE inhibitors, ARB and CCB users, aged 18 to 80 years, from the French National Health Insurance databases were followed from February 15, 2020 to June 7, 2020. We excluded patients with a history of diabetes, known cardiovascular disease, chronic renal failure, or chronic respiratory disease during the previous 5 years, to only consider patients treated for uncomplicated hypertension and to limit indication bias. The primary end point was time to hospitalization for COVID-19. The secondary end point was time to intubation/death during a hospital stay for COVID-19. In a population of almost 2 million hypertensive patients (ACE inhibitors: 566 023; ARB: 958 227; CCB: 358 306) followed for 16 weeks, 2338 were hospitalized and 526 died or were intubated for COVID-19. ACE inhibitors and ARBs were associated with a lower risk of COVID-19 hospitalization compared with CCBs (hazard ratio, 0.74 [95% CI, 0.65–0.83] and 0.84 [0.76–0.93], respectively) and a lower risk of intubation/death. Risks were slightly lower for ACE inhibitor users than for ARB users. This large observational study may suggest a lower COVID-19 risk in hypertensive patients treated over a long period with ACE inhibitors or ARBs compared with CCBs. These results, if confirmed, tend to contradict previous hypotheses and raise new hypotheses.
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Affiliation(s)
- Laura Semenzato
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Jérémie Botton
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Jérôme Drouin
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Bérangère Baricault
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Clémentine Vabre
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - François Cuenot
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Laetitia Penso
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Philippe Herlemont
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Emilie Sbidian
- Epidemiology in Dermatology and Evaluation of Therapeutics Research Unit, University Paris-Est Créteil (E.S.)
| | - Alain Weill
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Rosemary Dray-Spira
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Mahmoud Zureik
- University Paris-Saclay, UVSQ, University Paris-Sud, Inserm, Anti-Infective Evasion and Pharmacoepidemiology, CESP, 78180, Montigny le Bretonneux, France (M.Z.)
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Hanna R, Dalvi S, Sălăgean T, Pop ID, Bordea IR, Benedicenti S. Understanding COVID-19 Pandemic: Molecular Mechanisms and Potential Therapeutic Strategies. An Evidence-Based Review. J Inflamm Res 2021; 14:13-56. [PMID: 33447071 PMCID: PMC7802346 DOI: 10.2147/jir.s282213] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/29/2020] [Indexed: 12/15/2022] Open
Abstract
Initially, the SARS-CoV-2 virus was considered as a pneumonia virus; however, a series of peer reviewed medical papers published in the last eight months suggest that this virus attacks the brain, heart, intestine, nervous and vascular systems, as well the blood stream. Although many facts remain unknown, an objective appraisal of the current scientific literature addressing the latest progress on COVID-19 is required. The aim of the present study was to conduct a critical review of the literature, focusing on the current molecular structure of SARS-CoV-2 and prospective treatment modalities of COVID-19. The main objectives were to collect, scrutinize and objectively evaluate the current scientific evidence-based information, as well to provide an updated overview of the topic that is ongoing. The authors underlined potential prospective therapies, including vaccine and phototherapy, as a monotherapy or combined with current treatment modalities. The authors concluded that this review has produced high quality evidence, which can be utilized by the clinical scientific community for future reference, as the knowledge and understanding of the SARS-CoV-2 virus are evolving, in terms of its epidemiological, pathogenicity, and clinical manifestations, which ultimately map the strategic path, towards an effective and safe treatment and production of a reliable and potent vaccine.
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Affiliation(s)
- Reem Hanna
- Department of Surgical Sciences and Integrated Diagnostics, Laser Therapy Centre, University of Genoa, Genoa, Italy
- Department of Oral Surgery, Dental Institute, King’s College Hospital NHS Foundation Trust, London, UK
| | - Snehal Dalvi
- Department of Surgical Sciences and Integrated Diagnostics, Laser Therapy Centre, University of Genoa, Genoa, Italy
- Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, India
| | - Tudor Sălăgean
- Department of Land Measurements and Exact Sciences, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, Cluj-Napoca, Romania
| | - Ioana Delia Pop
- Department of Land Measurements and Exact Sciences, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, Cluj-Napoca, Romania
| | - Ioana Roxana Bordea
- Department of Oral Rehabilitation, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Stefano Benedicenti
- Department of Surgical Sciences and Integrated Diagnostics, Laser Therapy Centre, University of Genoa, Genoa, Italy
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35
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Barochiner J, Martínez R. Use of inhibitors of the renin-angiotensin system in hypertensive patients and COVID-19 severity: A systematic review and meta-analysis. J Clin Pharm Ther 2020; 45:1244-1252. [PMID: 32767823 PMCID: PMC7436708 DOI: 10.1111/jcpt.13246] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 06/29/2020] [Accepted: 07/10/2020] [Indexed: 12/13/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Controversy has arisen in the scientific community on whether the use of renin-angiotensin system (RAS) inhibitors in the context of COVID-19 would be beneficial or harmful. A meta-analysis of eligible studies comparing the occurrence of severe and fatal COVID-19 in infected hypertensive patients who were under treatment with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) vs no treatment or other antihypertensives was conducted. METHODS PubMed, Google Scholar, the Cochrane Library, medRxiv and bioRxiv were searched for relevant studies. Fixed-effects models or random-effects models were used depending on the heterogeneity between estimates. RESULTS AND DISCUSSION A total of eighteen studies with 17 311 patients were included. The use of RAS inhibitors was associated with a significant 16% decreased risk of the composite outcome (death, admission to intensive care unit, mechanical ventilation requirement or progression to severe or critical pneumonia): RR: 0.84 (95% CI: 0.73-0.95), P = .007, I2 = 65%. WHAT IS NEW AND CONCLUSION The results of this pooled analysis suggest that the use of ACEI/ARB does not worsen the prognosis of COVID-19, and could even be protective in hypertensive subjects. Hypertensive patients should continue these drugs even if they become infected with SARS-CoV-2.
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Affiliation(s)
- Jessica Barochiner
- Hypertension SectionInternal Medicine DepartmentHospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Rocío Martínez
- Hypertension SectionInternal Medicine DepartmentHospital Italiano de Buenos AiresBuenos AiresArgentina
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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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Mackey K, Kansagara D, Vela K. Update Alert 4: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. Ann Intern Med 2020; 173:W147-W148. [PMID: 32956599 PMCID: PMC7516553 DOI: 10.7326/l20-1177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] 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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Tadic M, Cuspidi C. COVID‐19, hypertension, and renin‐angiotensin‐aldosterone system inhibitors: Much ado about nothing or real problem to be solved? J Clin Hypertens (Greenwich) 2020; 22:1984-1986. [PMID: 32951351 PMCID: PMC7537010 DOI: 10.1111/jch.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Marijana Tadic
- University Hospital “Dr. Dragisa Misovic ‐ Dedinje” Department of Cardiology Belgrade Serbia
| | - Cesare Cuspidi
- University of Milan‐Bicocca Milan Italy
- Istituto Auxologico Italiano IRCCS Italy
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Hrenak J, Simko F. Renin-Angiotensin System: An Important Player in the Pathogenesis of Acute Respiratory Distress Syndrome. Int J Mol Sci 2020; 21:ijms21218038. [PMID: 33126657 PMCID: PMC7663767 DOI: 10.3390/ijms21218038] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 02/08/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by massive inflammation, increased vascular permeability and pulmonary edema. Mortality due to ARDS remains very high and even in the case of survival, acute lung injury can lead to pulmonary fibrosis. The renin-angiotensin system (RAS) plays a significant role in these processes. The activities of RAS molecules are subject to dynamic changes in response to an injury. Initially, increased levels of angiotensin (Ang) II and des-Arg9-bradykinin (DABK), are necessary for an effective defense. Later, augmented angiotensin converting enzyme (ACE) 2 activity supposedly helps to attenuate inflammation. Appropriate ACE2 activity might be decisive in preventing immune-induced damage and ensuring tissue repair. ACE2 has been identified as a common target for different pathogens. Some Coronaviruses, including SARS-CoV-2, also use ACE2 to infiltrate the cells. A number of questions remain unresolved. The importance of ACE2 shedding, associated with the release of soluble ACE2 and ADAM17-mediated activation of tumor necrosis factor-α (TNF-α)-signaling is unclear. The roles of other non-classical RAS-associated molecules, e.g., alamandine, Ang A or Ang 1-9, also deserve attention. In addition, the impact of established RAS-inhibiting drugs on the pulmonary RAS is to be elucidated. The unfavorable prognosis of ARDS and the lack of effective treatment urge the search for novel therapeutic strategies. In the context of the ongoing SARS-CoV-2 pandemic and considering the involvement of humoral disbalance in the pathogenesis of ARDS, targeting the renin-angiotensin system and reducing the pathogen's cell entry could be a promising therapeutic strategy in the struggle against COVID-19.
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Affiliation(s)
- Jaroslav Hrenak
- Department of Cardiovascular Surgery, Inselspital – University Hospital of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland;
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08 Bratislava, Slovak
| | - Fedor Simko
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08 Bratislava, Slovak
- 3rd Department of Internal Medicine, Faculty of Medicine, Comenius University, Limbova 5, 833 05 Bratislava, Slovak
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Dúbravská cesta 9, 845 05 Bratislava, Slovak
- Correspondence:
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