Renin-angiotensin-aldosterone system inhibitors and COVID-19 infection or hospitalization: a cohort study

Dublin, S; Walker, R; Floyd, J S; Shortreed, S M; Fuller, S; Albertson-Junkans, L; Harrington, L B; Greenwood-Hickman, M A; Green, B B; Psaty, B M

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the risk of COVID-19 infection or affect disease severity. Prior studies have not examined the association of medication dose with risks. METHODS: This retrospective cohort study included people aged ≥18 years enrolled in a US integrated healthcare system for at least 4 months as of 2/29/2020. Current ACEI and ARB use was identified from pharmacy data, and the estimated daily dose was calculated and standardized across medications. COVID-19 infections and hospitalizations were identified through 6/14/2020 from laboratory and hospitalization data. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals, adjusting for race/ethnicity, obesity and other covariates. RESULTS: Among 322,044 individuals, 826 developed COVID-19 infection. Among people using ACEI/ARBs, 204/56,105 developed COVID-19 (3.6 per 1000 individuals) compared with 622/265,939 without ACEI/ARB use (2.3 per 1000), yielding an adjusted OR of 0.91 (95% CI 0.74-1.12). For use of < 1 defined daily dose vs. nonuse, the adjusted OR for infection was 0.92 (95% CI 0.66-1.28); for 1 to < 2 defined daily doses, 0.89 (95% CI 0.66-1.19); and for ≥2 defined daily doses, 0.92 (95% CI 0.72-1.18). The OR was similar for ACEIs and ARBs and in subgroups by age and sex. 26% of people with COVID-19 infection were hospitalized; the adjusted OR for hospitalization in relation to ACEI/ARB use was 0.98 (95% CI 0.63-1.54), and there was no association with dose. CONCLUSIONS: These findings support current recommendations that individuals on these medications continue their use.