COVID vs ACE vs Ibuprofen

May 12, 2020

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

"The greatest glory in living lies not in never falling, but in rising every time we fall." I love this quote from Nelson Mandela. He was imprisoned by his political rivals for 27 years, but still got back up an became the President of South Africa. It also applies to every time you have to learn a new thing. I remember teaching my kids how to ride a bike. It was so hard. It took so many falls and missteps, that I remember dressing one of them in hockey equipment to protect them. And the worst part was, I really couldn't explain how to ride a bike to them. You laugh, but imagine sitting across the table from someone who has never seen a bike before. Now try to explain how to ride it. They say they tried that, but they fell over. Now what? This is called the Curse of Knowledge. It is very difficult for an expert to explain how to do something to a complete novice.

When it comes to COVID-19, we seem to have way too few experts with actual knowledge and way too many novices all to glad to spread half-truths and complete falsehoods as "knowledge". I've been avoiding writing an article about COVID-19, because I'm not an expert. Information about the pandemic is evolving quickly and I'm not a virologist or public health official. So please keep listening the Dr. Brent Roussin about Manitoba COVID-19 issues and Dr. Theresa Tam for the national perspective. But, I've been getting more questions in the pharmacy about ACE inhibitors and ibuprofen that I thought I'd better address.

I've been asked if being on an ACE inhibitor or ARB makes it more likely for you to get COVID-19. ACE inhibitors or angiotensin converting enzyme inhibitors and ARB's or angiotensin receptor blockers are blood pressure medications. They work very well. There has been some concern about if they make someone more susceptible to COVID-19. The story goes like this. First the part, that as a pharmacist, I am familiar with. As a normal part of living, a chemical called angiotensin 1 is converted to angiotensin 2 by the enzyme ACE. Angiotensin 2 is a bit of a bad actor in the body. If we can reduce the actions of angiotensin 2, we help a reduce person's blood pressure. For example, if we reduce angiotensin 2 the blood vessels dilate, less norepinephrine is released by the sympathetic nervous system, and more water and sodium is passed by the kidneys because of less aldosterone action. That means when ACE inhibitors block the ACE enzyme from forming angiotensin 2 and ARB's block angiotensin 2 from getting to its receptors, high blood pressure goes down. That's all good. This second part, I had to read up on. It was noticed that ACE inhibitors and ARB's also increased the amount of another enzyme called ACE-2. ACE-2 is in the cell membranes, or the outside layer of the cells. There is some evidence that SARS COV-2, the virus that causes COVID-19, gets in the cells by using the ACE-2 enzyme as a doorway in the cell membranes. The hypothesis is that if you cause there to be more ACE-2 enzyme doorways in the cell membrane, that makes it easier for SARS COV-2 to infect the cell. So, does being on an ACE inhibitor or ARB for your blood pressure make you more likely to get COVID-19 or die from COVID-19? No. Let's look at what we know so far.

There was an editorial in the May 1, 2020 New England Journal of Medicine by John Jarcho et al. that looked at three studies. One study by Mehra et al. looked at records of hospitalized patient in 11 countries on three continents. They looked at 8910 patients between Dec 20,2019 and March 15, 2020 and didn't find an increase in death of people on ACE inhibitors or ARB's. Mancia et al. looked at patients in Northern Italy. They compared 6272 COVID-19 patients and 30759 non-COVID-19 patients and found that being on an ACE inhibitor or ARB didn't make you more likely to get COVID-19 or die from it. Reynolds et al. looked at health records in New York City. They looked at 12,594 records. 5894 of those tested positive for COVID-19. 1002 had severe illness which was defined as needing to be in the ICU, needing a ventilator or dying. They did some fancy statistics and found being on an ACE inhibitor or ARB did not increase the chance of getting COVID-19 or having a severe illness.

I've also been asked if taking ibuprofen to treat a fever will make it more likely for someone to get COVID-19. Ibuprofen is an NSAID and it is very good at treating fevers. People who get COVID-19 often have fevers. The excitement seems to have started when the Health Minister of France tweeted out that NSAID's made COVID-19 more severe. To the best of my knowledge, there is no evidence that ibuprofen makes COVID-19 infections worse. There is some thought that ibuprofen might cause the body to make more of those ACE-2 doorways into the cell for SARS-COV-2. There is some speculation that since ibuprofen is an anti-inflammatory, that means it suppresses the immune system a little bit. A slightly suppressed immune system might be more susceptible to a virus like SARS-COV-2. There are also some regular pharmacy concerns over ibuprofen. Ibuprofen does have some side effects. It can be hard on the stomach, cardiovascular system and kidneys. These are not usually worries in young, healthy people, but in elderly people with existing health conditions, they can be. That is why we usually recommend acetaminophen or Tylenol as a first line fever treatment. Acetaminophen might not be quite as good a fever treatment as ibuprofen, but it is safer. My bottom line is ibuprofen is still an effective and relatively safe fever treatment. I haven't seen evidence that it makes COVID-19 infections more common or more severe. However, acetaminophen is a safer fever treatment for non-COVID-19 reasons.

For COVID-19 knowledge keep listening to real experts like Dr. Brent Roussin and Dr. Theresa Tam and not to orange colored oval office residents who talk about using bleach and UV light internally. Don't do either of those. And why can't you, the bike riding expert, explain how to ride a bike to a complete novice? It's because you gloss over or omit very crucial steps in bike riding because they seem obvious to you. You don't have the language to explain how you actually turn the handbars quickly to counter your pedal pushes as you start. You just can't remember what it was like to not know how to ride a bike. You are cursed with the knowledge of knowing how to ride, so it is very difficult to explain it to someone who doesn't have that knowledge. There are actual books and papers written about how to overcome the curse of knowledge. In a way, overcoming the curse of knowledge is the whole point of the teaching profession, and one of the reasons why we are all struggling with home schooling right now. But when it comes to teaching someone how to ride a bike, I have the definitive answer. YouTube! You can learn anything on YouTube! I wonder if there is a video on how Nelson Mandela could have used his time more productively during his 27 years of imprisonment. Probably, but I bet the WiFi on Robben Island wasn't that great.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

How to teach an adult to ride a bike -

This Week in Virology -

NEJM - Inhibitors of the Renin-Angiotensin-Aldosterone System and Covid-19 -


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