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Publication Briefs

Common Drugs for Hypertension and Diabetes Not Associated with Severe COVID-19 Illness or Testing Positive for COVID-19

Concerns exist that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) – medications widely used to treat hypertension and diabetes – increase susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – the viral agent that causes the disease COVID-19, and the likelihood of severe COVID-19 illness. Originally requested by the World Health Organization (WHO), this systematic review examined the relationship between ACEI or ARB use and COVID-19 illness. Literature databases including MEDLINE and the Cochrane Database of Systematic Reviews (January 2003 – May 2020), in addition to and the WHO’s database of COVID-19 publications (inception – April 2020) were searched. As a “living review”, ongoing surveillance of the literature (and update of conclusions, if needed) is planned through March 2021. Ultimately, 14 observational studies involving 23,565 adults with COVID-19 from the U.S., as well as Italy, China, and the United Kingdom, were included in this review.


  • High-certainty evidence suggests that ACEI or ARB use is not associated with more severe COVID-19 illness, and moderate-certainty evidence suggests no association between the use of these medications and positive SARS-CoV-2 test results among symptomatic patients.


  • Findings from this rapidly expanding literature show no indication to prophylactically stop ACEI or ARB treatment because of concerns about COVID-19. Moreover, withdrawal of long-term ACEIs or ARBs may be harmful, especially in patients with heart failure, because observational studies and trials have suggested that discontinuation of ACEI or ARB therapy is associated with worse outcomes.


  • Half of the studies in this review were small and did not adjust for important confounding variables.
  • Whether these medications increase the risk for mild or asymptomatic disease – or are beneficial in COVID-19 treatment remains uncertain.

An editorial in the same issue of Annals states that this systematic review provides “reasonable reassurance that drugs that alter the renin-angiotensin system do not pose substantial threats as either COVID-19 risk factors or severity multipliers. Furthermore, withdrawing these drugs if they are prescribed for evidence-based indications could harm patients, especially those with heart failure.”

Drs. Mackey and Kansagara are investigators with VA’s Evidence Synthesis Program in Portland, OR, and Dr. Kansagara also is part of HSR&D’s Center to Improve Veteran Involvement in Care.

Mackey K, King V, Gurley S, Kiefer M, Liederbauer E, Vela K, Sonnen P, and Kansagara D. Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. A Living Systematic Review. Annals of Internal Medicine. May 15, 2020; Epub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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