Position Statement on COVID-19 and Ace Inhibitor and Angiotensin Receptor Blocker

Clinical Affairs & Practice Management Committee:
Position Statement on COVID-19 and Ace Inhibitor and Angiotensin Receptor Blocker Use in Children with Hypertension and Kidney Disease

March 16^th, 2020

The purpose of this statement is to clarify what is known about the potential risks, if any, to pediatric nephrology patients from treatment with ACE inhibitors or angiotensin receptor blockers (ARBs). As with the original SARS-CoV, the ACE2 enzyme has been confirmed as the SARS-CoV-2 binding site in the lungs¹. ACE2 is an important part of the renin-angiotensin-aldosterone system^2,3, thus there has been recent speculation that patients who take ACE inhibitors and ARBs may be at increased risk of the infection and COVID-19. However, this is solely based on experimental studies in animals showing increased ACE2 expression in several organs, and there is additional experimental evidence based upon SARS-CoV and other models of acute lung injury that these medications may actually lessen severity of COVID-19⁴. There is currently no evidence that patients on these medications are at a higher risk of SARS-CoV-2 or COVID-19. Indeed, stopping ACE inhibitors and ARBs without good medical evidence can have significant health consequences for our patients.

Many health care providers, patients, and their families are understandably worried about continuing to use these medications during the pandemic. At this time, in line with the Position Statements from other hypertension, cardiovascular, and kidney organizations and after weighing the risks and benefits, the American Society of Pediatric Nephrology strongly recommends that patients continue to take their ACE inhibitors and ARBs, until new evidence to the contrary becomes available. We further recommend that appropriate medical management continue to be provided to patients on these medications who test positive for SARS-CoV-2 and those who have COVID-19, including discontinuation of ACE inhibitors and ARBs when medically indicated. The American Society of Pediatric Nephrology via the Clinical Affairs & Practice Management Committee will continue to work diligently to monitor this evolving situation and to inform its members, partners, and patients and their families of updated recommendations on this important topic. We fully support the ongoing research efforts into this important question and encourage the inclusion of children in such clinical trials or observational studies.

¹Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell 2020; ePub; doi: 10.1016/j.cell.2020.02.052
²Simoes e Silva AC, Flynn JT. The renin-angiotensin-aldosterone system in 2011: role in hypertension and chronic kidney disease. Pediatr Nephrol 2012; 27:1835-1845
³South AM, Shaltout HA, Washburn LK, et al. Fetal programming and the angiotensin-(1-7) axis: a review of the experimental and clinical data. Clinical Science 2019; 133:55-74
⁴Kuba K, Imai Y, Rao S, et al. A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced lung injury. Nat Med 2005;11:875-9

Other organizations:
European Society of Cardiology Council on Hypertension
European Society of Hypertension
Hypertension Canada
Canadian Cardiovascular Society and the Canadian Heart Failure Society
The Renal Association, UK
The International Society of Hypertension

Pending statements:
ASN

Renin-angiotensin system blockers and the COVID-19 pandemic (Hypertension)