We are covering an update on blood pressure medications and COVID-19, ACE (Angiotensin Converting Enzyme) inhibitors, and ARBs (Angiotensin-II Receptor Blockers).

There’s been a lot of work going on. The recommendations haven’t changed much, but I thought it would be helpful to go through some of the continued research and continued standards committee development.

We’ll review why ACE inhibitors and ARBs are significant for COVID. We’ll do a brief update on COVID-19 and diabetes/ prediabetes. So it has been a while since we have known the association between diabetes, prediabetes, and COVID-19. It even reached mainstream media.

My YouTube channel is about a far more significant and more damaging pandemic than COVID-19. The prediabetes pandemic. In America, over 80,000 people live with prediabetes; more than a third of American adults. It is now clear that this old CDC estimate is way too conservative.

If you fast-forward to the age of COVID-19, the folks with the most risk are those same people. It’s not young people. It’s not healthy, people. The risk is for people with insulin resistance or prediabetes—90% of those who don’t know it.

The classic example of patients in my office says: “My doctors have been telling me I’ve got just a little touch of sugar. So I decreased the sugar in my coffee”. That’s not where you’re getting most of your carbs. Most general practitioners and other doctors in the US don’t know how to diagnose prediabetes, let alone manage it.

So we’re going to talk about ACE-Is and ARBs. What does that mean? We introduced the terms a few paragraphs before; this is Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. These medications are beneficial for the management of blood pressure. Especially blood pressure associated with diabetes and prediabetes.

They’ve come under a lot of criticism. There was an article in Lancet Respiratory Medicine on March 11th, 2020, by Lei Fang, George Karakiulakis, and Michael Roth. These researchers discussed the situation where the SARS-CoV-2 uses the ACE2 receptor blocker to get into the cell. They talked about the fact that these medications are involved in blocking that receptor. Their logic, and some of the data they quoted, indicated that when you’re using ACE-Is and ARBs, it may increase the number of ACE2 receptors that you have in your cell membranes as a response to that medication.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118626/pdf/main.pdf

This data suggests an increased expression of ACE2 in diabetes and treatment with ACE inhibitors. ARBs increase ACE2 expression; consequently, the increased expression of ACE2 would facilitate infection with COVID-19. They hypothesized that diabetes and hypertension treatment with ACE2 stimulating drugs increases the risk of developing severe and fatal COVID-19.

A lot of people think that was irresponsible. I will tell you this – it got reactions everywhere. ARBs, and especially even more so ACE inhibitors, are suitable for managing blood pressure and decreasing the damage to tissue associated with blood pressure. Especially blood pressure associated with prediabetes. Most blood pressure is associated with prediabetes.

I’m on one of those medications- benazepril. I used to be on ramipril until we started running into problems sourcing it. I don’t plan on missing a dose.

People started asking questions very soon after the Lei Fang article. The European Society of Cardiology responded quickly that their position with the Council on Hypertension strongly recommended that physicians and patients continue treatment with their usual antihypertensive therapy. They said no clinical or scientific evidence suggests stopping ACE inhibitors or ARB’s use during COVID-19 infection.

Other groups have studied it more profoundly and weighed in. In another article titled “Respiratory Medicine Antihypertensive Drugs and the Risk of COVID19”, Christopher Tignanelli and others suggest withholding ACE inhibitors and ARBs and changing them for Calcium channel blockers instead was a premature recommendation and clinical trials were necessary to support it.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194709/pdf/main.pdf

It was a premature hypothesis because of confusion across media, the medical community, and many other places. Despite calls from the European Society of Cardiology, The Hypertension Group of Canada, the United Kingdom Renal Association, and the International Society of Hypertension are all saying, “don’t make that change now.”

Since then, the New England Journal has published an article weighing in on this issue and said, “yes, of course, guidance is needed. Withdrawal can be dangerous”. They came up with the alternative hypothesis that ACE2 inhibitors may be beneficial.

The underlying recommendation was: to continue your medications. Clinical trials are currently underway. Don’t make a change at this point.

Patients will say, “Dr. Brewer, you gave me a lot of information. I’m still unsure what I want to do”. My perspective is: I will provide you with the information. You’re the executive. I’m your consultant. I don’t feel it’s a problem if you feel strongly about switching. I don’t recommend that you do.

I would not switch at this point. I think there is enough validity to this alternative hypothesis. It may help.

Since then, the American Heart Association has offered guidance consistent with the second article. “Don’t stop.” The American Heart Association’s new recommendation quoted what they knew about Wuhan. Early information showed mortality of 10.5% among people with cardiovascular disease. It wasn’t clear about the diabetes question – 7.3% with diabetes, 6.3% with lung disease, and 6% with high blood pressure.

After going through all of the data and a lot of follow-up data since then, the recommendation from the American Heart Association was “don’t stop your ACE inhibitors or your ARBs now.” On the other hand, watch medications that increase your blood pressure- prevalent medications like NSAIDs (non-steroidal anti-inflammatories) like ibuprofen, oral contraceptives, and alcohol can increase the blood pressure.

They also commented about caffeine after that third cup of coffee in the day and licorice.

I have no problem arguing with and using options of medicine that are outside of some of the standards committees. I dig deep looking at that, especially in cardiovascular care.
I focus less on statins. I don’t recommend statins based on LDL level alone or cholesterol level alone. I recommend statins only when people have documented plaque.

I’m very comfortable not following the advice of standards committees, especially in the cardiovascular area. However, I think they’re right on this one. I haven’t seen a single one that is going the other way. I’m continuing my ACE inhibitor.

Let’s go back and cover the information in that first news and video about prediabetes now.

An exciting clip from the Fox News channel; they hosted Dr. Stephen Smith, an infectious diseases specialist. He showed some compelling data on patients with COVID-19 he had treated; he found out that out of 72 patients, almost 30% were prediabetic and 47% had diabetes; 18 out of 20 patients were diabetic, and two were prediabetic.

Information from another article published by his team showed that 50% of COVID-19 patients in an ICU had diabetes.


That fits with our data, but people haven’t focused that prediabetics are also at risk, especially if they have a high BMI.

One factor to consider is that food can be addictive, especially if sugar is involved; I’ve made several videos on my food and sweets addictions. I’ve suggested that I’ve made more progress on a lifetime sweets addiction with Gymnema Sylvestre. At Hopkins, one of my primary research topics was addictions. One of the things I learned from the mental health researchers at Hopkins about addiction is that addicts tend to be much better off when breaking away from the source of the substance of their addiction. When it becomes close, they break out into a sweat, becoming a big deal.

As I continue to work on my addiction to sweets, I am fine until all of these ads for junk food get in front of my face. I try not to shame people. I do try to make people aware of the challenges.

Sometimes I have come across as “the worst saint is a reformed sinner.” If it helps somebody becomes aware of this and start dealing with their problem, I’ll take that hit.

Another thing to consider is the debuting age of prediabetes, and I used to think that the prediabetes problem started in the 50s and 60s. It does ramp up in the 50s and 60s, but with the obesity epidemic, it’s getting younger and younger.

A couple of years ago, UCLA published an article that showed that it’s not waiting till the 50s and 60s. Over half of the people in California two years ago had either prediabetes or full-blown diabetes. However, the studies did not include oral glucose tolerance tests or a Kraft insulin survey. They only included fasting blood glucose and hemoglobin A1c. Both are notoriously bad for having a lot of false negatives. You have recently heard about false negatives in the news with COVID.

I can say that prediabetes is a more significant and more common factor for COVID-19 than antihypertensive medications.

Join us next week for another exciting blog, and visit our youtube page, where I’m sure you will find life-saving information.

1. https://pubmed.ncbi.nlm.nih.gov/32171062/
2. https://pubmed.ncbi.nlm.nih.gov/32222166/
3. https://prevmedhealth.com/covid-19-a-pandemic-risk/
4. https://prevmedhealth.com/asymptomatic-transmission-of-covid-19-is-rare-said-who/
5. https://prevmedhealth.com/what-vitamin-d-can-do-to-your-immune-system-cv-health/
6. https://prevmedhealth.com/inflammation-not-cholesterol-is-the-bigger-heart-disease-risk/
7. https://prevmedhealth.com/new-risk-factors-for-type-2-diabetes-part-1/
8. https://prevmedhealth.com/how-to-test-for-cardiovascular-inflammation/
9. https://prevmedhealth.com/prediabetes-a-risk-for-heart-attack-stroke/

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