Controversy of angiotensin receptor blockers (ARBs) and angiotensin converting enzymeinhibitors (ACEIs) prescription for hypertension patients in coronavirus disease 2019 (COVID-19) pandemic

Yuliana Yuliana(1*)

(1) Anatomy Department Faculty of Medicine, Udayana University.
(*) Corresponding Author


Coronavirus disease 2019 (COVID-19) pandemic has made all the world in a mess. Novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 infects human cells through angiotensin-converting enzyme 2 receptors (ACE receptors). Angiotensin-converting enzyme 2 (ACE) is upregulated in diabetes and cardiovascular diseases including hypertension. Hypertension patients commonly consume angiotensin receptor blockers (ARBs) and/or angiotensin-converting enzyme inhibitors (ACEIs) which could increase ACE receptors. It was suspected that the ARBs or ACEIs administration may worsen the clinical outcome for the hypertension patients with COVID-19. However, no clinical trial had significantly revealed how appropriate management and prescription of ARBs and ACEIs for the hypertension patients with COVID-19. The use of ARBs and ACEIs for these patients is still controversy. Studies concerning the side effect of single or combination use of ARBs and ACEIs in the hypertension patients with COVID-19 as well as specific morbidity and mortality are needed. This review was aimed to provide understanding concerning the appropriate management and prescription of ARBs and ACEIs for hypertension patients with COVID-19.


COVID-19; ACE inhibitor; ARBs; hypertension; management;

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  1. Raoult D, Zumla A, Locatelli F, Ippolito G, Kroemer G. Coronavirus infections: Epidemiological, clinical and immunological features and hypotheses. Cell Stress 2020; 4(4):66-75.
  2. Aronson JK, Ferner R. ACE inhibitors and angiotensin receptorblockers (ARBs) in COVID-19? 2020. BMJ Editorial: Drugs and the renin-angiotensin system in covid-19.
  3. Patel AB, Verma A. COVID-19 and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers:what is the evidence? JAMA 2020; 24. 2020.4812
  4. Xu J, Zhao S, Teng T, Abdalla AE, Zhu W, Xie L, et al.Systematic comparison of two animal-to-human transmitted human coronaviruses: SARS-CoV-2and SARS-CoV. Viruses 2020; 12(2):E244.
  5. Burhan E, Susanto AD, Nasution SA, Ginanjar E, Pitoyo CW, Susilo A, et al.Protokol tata laksana COVID-19, Ed. 1. Jakarta: Perhimpunan Dokter Paru Indonesia (PDPI) Perhimpunan Dokter Spesialis Kardiovaskular Indonesia (PERKI) Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI) Perhimpunan Dokter Anestesiologi dan Terapi Intensif Indonesia (PERDATIN) Ikatan Dokter Anak Indonesia (IDAI), 2020. pp. 25-26.
  6. Dashboard corona virus. Available at: index.html#/85320e2ea5424dfaaa75ae62e5c06e61. Accessed on April 15th 2020, 12.32 pm.
  7. Kawal informasi seputar COVID-19 secara tepat dan akurat. Availableat: htpps;// Accessed on April 30th 2020.
  8. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; 382:1702-20.
  9. Ippolito G, Hui DS, Ntoumi F, Maeurer M and Zumla A. Toning down the 2019-nCoV media hype- and restoring hope. Lancet Respir Med 2020; 8(3):230-1.
  10. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi 2020; 41(2):145-51.
  11. Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA 2020; 21.
  12. 12. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020.
  13. 13. de Wit E, van Doremalen N, Falzarano D and Munster VJ. SARS and MERS: recent insights into emerging coronaviruses. Nat Rev Microbiol 2016; 14(8):523-34.
  14. Cao Y, Li L, Feng Z, Wan S, Huang P, Sun X, et al.Comparative genetic analysis of the novel coronavirus (2019-nCoV/SARS-CoV-2) receptor ACE2 in different populations. Cell Discov 2020; 6:11.
  15. 1Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD.Renin–angiotensin–aldosterone system inhibitors in patients with Covid-19. N Engl J Med 2020; 382(17):1653-9.
  16. Tignanelli CJ, Ingraham NE, Sparks MA, Reilkoff R, Bezdicek T, Benson B, et al. Antihypertensive drugs and risk of COVID-19? Lancet Respir Med 2020.
  17. Simone, DG. Position statement of the ESC Council on Hypertension on ACE-inhibitors and angiotensin receptor blockers. European Society of Cardiology 2020. Accessed on April 15th 2020.
  18. Asenjo RM, Bueno H, Mcintosh M. Cardio protective drugs: Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin II receptor blockers (ARBs). ACE inhibitors and ARBs, a cornerstone in the prevention and treatment of cardiovascular disease2017. Accessed on April 15th 2020.
  19. Henry BM, Vikse JM, Lippi G. Response to the emerging novel coronavirus outbreakCOVID-19 induced Renin–Angiotensin System (RAS) imbalance may drive acute lung injury: the evidence and therapeutic options. BMJ 2020; 368.
  20. Zhang P, Zhu L, Cai J, Lei F, Qin JJ, Xie J, et al. Association of inpatient use of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers with mortality among patients with hypertension hospitalized with COVID-19. CirRes 2020.
  21. Ferrario CM, Jessup J, Chappell MC, Averill DB, Brosnihan KB, Tallant EA, et al.Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation 2005; 111:2605-10.
  22. Igase M, Kohara K, Nagai T, Miki T, Ferrario CM. Increased expression of angiotensin converting enzyme 2 in conjunction with reduction of neointima by angiotensin II type 1 receptor blockade. Hypertens Res 2008; 31:553-9.
  23. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020.
  24. Khan A, Benthin C, Zeno B, Albertson TE, Boyd J, Christie JD, et al. A pilot clinical trial of recombinant human angiotensin-converting enzyme 2 in acute respiratory distress syndrome. Crit Care 2017; 21(1):234.
  25. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395(10229):1054-62.
  26. Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, Huang H, Zhang Li, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020; e200994.
  27. Gorbiano MI. Indonesia reports first death from COVID-19. Available at: Accessed on April 30th2020.
  28. Indonesian Heart Association (Perhimpunan Dokter Spesialis Kardiovaskular Indonesia, PERKI). Rekomendasi RAAS antagonis pada COVID-19. Available at: Accessed on 30 April 2020.
  29. Colson P, Rolain JM, Raoult D. Chloroquine for the 2019 novel coronavirus SARS-CoV-2. Int J Antimicrob Agents 2020; 55(3):105923.
  30. Gao J, Tian Z, Yang X. Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends 2020; 14(1):72-3.
  31. Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, Shi Z, ZHong W, Xiao G. Remsidivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res 2020; 30(3):269-71.


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