In the age of coronavirus it can feel impossible to keep up with all the news swirling around the risks, possible treatments, and precautions we should be taking. Last month, our team came across this article published in Realself about the potential connection between COVID-19 susceptibility and blood pressure medications like spironolactone. That article was published at the end of March, and at that time there was no research about the effects of blood pressure medications on COVID-19 susceptibility and recovery. The underlying thesis was that spironolactone, a medication that we often prescribe to treat hormonal acne, may increase a patient’s chance of catching coronavirus.
Our team took this risk seriously and we closely watched the initial research unfold in case we had to take action. Luckily, scientists around the world are working at lightning speed to learn about this virus and just a month later we have some helpful new data in.
We (virtually) sat down with our medical director, Dr. Aimee Paik, to discuss the recent research scientists are doing around the world about coronavirus, ACE Inhibitors, and spironolactone.
When you heard about a theoretical risk of coronavirus infection with spironolactone, how did you feel?
“My first reaction was sincere concern for my patients. The first rule of medicine is “do no harm.” I have many female patients on spironolactone because I think it’s a great drug for acne. But I was alarmed that my patients could be at risk for severe consequences and even death from COVID-19 because of something I gave them. I went right to work diving into the research and trying to make sense of the true risk. I have also been paying close attention to new research and insights as they emerge.”
Can you give some background about the debate inside the medical community on ACE Inhibitors and spironolactone?
"ACE inhibitors are widely-used drugs to treat high blood pressure, AKA hypertension. Coronavirus enters the cell by attaching to an enzyme called ACE2. ACE2 normally sits on the cell’s surface where it just so happens to act as a receptor for coronavirus, ultimately allowing it entry into the cell. Theoretically, the use of ACE inhibitors could lead to an increase of ACE2 on a cell’s surface, which in turn gives the virus more entry points into the cell. As it became apparent that those who were getting sicker and dying from COVID-19 were more likely to have hypertension, scientists speculated whether these medications themselves were to blame.
Spironolactone is actually not an ACE inhibitor. It’s a blood pressure medication that works by blocking a different hormone called aldosterone. Some lab studies have found spironolactone increases the amount ACE2 in the body, which raised alarm about spironolactone potentially increasing one’s susceptibility to COVID-19.”
Can you shed some light on what the most recent research is saying about the connection between coronavirus and spironolactone?
“I think there was a premature jump from the controversy surrounding ACE Inhibitors to inferring there was a risk from spironolactone. ACE2 can exist both as a receptor on the cell’s surface and in a soluble (or free-floating) form. The soluble form of ACE2 binds to coronavirus and may actually inactivate it by blocking its entry into the cell. In fact, soluble ACE2 is currently being studied as a potential way to treat patients with COVID-19.
With spironolactone there is extra ACE2 floating around (not just on the cell) which can bind to viruses before they arrive at the cell.
"Spironolactone has been reported to increase plasma ACE2 levels by 3- to 5-fold. Rather than being harmful, it has actually been proposed as a safer alternative to ACE Inhibitors for patients with COVID-19. Furthermore, newer research suggests that even ACE Inhibitors are not in fact harmful to patients with COVID-19.
Suffice it to say that at this time, there is no data to suggest that patients on spironolactone have an increased risk of disease severity or mortality from COVID-19. I feel very comfortable keeping my female acne patients on spironolactone at this time.”
To summarize for the folks in the back: Researchers have found spironolactone increases the amount of ACE2 floating around in your body, which can stick to, and potentially deactivate, the coronavirus. This may prevent the virus from being able to enter and infect cells because it can’t latch on to ACE2 on the surface. You should note that this theory remains purely speculative.
That being said, the most current research suggests that spironolactone is not harmful during this pandemic. That’s a very different result from the theories suggested in the original Realself article written about this subject. This teaches us a few lessons that Dr. Paik summarizes:
As a doctor during the time of coronavirus, what do you think the best approach is for consumers to vet information about the virus they see online?
“COVID-19 is a novel disease caused by a virus we are just beginning to understand. The current understanding will change as more data emerges, so I think it’s important to not jump to conclusions and make drastic changes in one’s healthcare. It’s also important to be mindful of the source where information is obtained. Reputable medical journals and the CDC are the most reliable sources. It’s also important to have a conversation with your doctor if you have any specific concerns that directly affect your treatment.”
Want to read the research Dr. Paik was talking about? You can find them all below:
Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19 | Circulation Research
This aritcle was updated on May 9th, 2020 for clarity.