
Are patients with hypertension and diabetes at increased risk for COVID-19? - sgroppino
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30116-8/fulltext#coronavirus-linkback-header
======
mrb
French sources specifically mention severe cases of covid-19 in "young and
healthy" patients (eg. see [https://lefigaro.fr/sciences/coronavirus-alerte-
sur-l-ibupro...](https://lefigaro.fr/sciences/coronavirus-alerte-sur-l-
ibuprofene-et-autres-anti-inflammatoires-20200314) ) but this important piece
of information has NOT been relayed by international medias.

Jean Paul Hamon, medical doctor and president of the Federation of French
Doctors said on TV to NOT take NSAIDs (anti-inflammatory drugs) if #covid19 is
suspected. The ONLY common point among young covid-19 patients they have
witnessed in critical care centers in France was that they all took NSAIDs.

~~~
dukha
Translation from French: paracetamol is preferred over nonsteroidal anti-
inflammatory drugs (NSAID). Dose of paracetamol should not exceed 3g/day and
doses should be spaced throughout the day.

~~~
slowmovintarget
"Paracetamol" a.k.a. "acetaminophen", common brand: Tylenol.

~~~
arcticbull
Which is itself the leading cause of acute liver failure in the US. The active
dose is very close to the lethal dose, much more so than naproxen or
ibuprofen.

~~~
calebsurfs
The active dose is nowhere near the lethal dose. It is however close to the
dose where you could see some minor damage to the liver. It causes problems
because people are addicted to opioid drugs that are typically combined with
acetaminophen, not because they are loading up on acetaminophen itself.

~~~
DanBC
Paracetamol is dangerous in overdose, and the therapeutic dose is pretty close
to the overdose amount. The therapeutic index is approx 10.

Compare that to morphine, which has a therapeutic index of about 70.

(although the therapeutic index is tricky to use because of dose response
curves)

We know that paracetamol is commonly used in both accidental and deliberate
overdose. And this is true in countries that don't have the opioid crisis, and
it was true in the US before the opioid crisis.

> It causes problems because people are addicted to opioid drugs that are
> typically combined with acetaminophen,

This is part of the problem, yes. But it's incomplete. We know that
paracetamol alone causes problems for the liver even with small overdosing.
[https://britishlivertrust.org.uk/researchers-shed-new-
light-...](https://britishlivertrust.org.uk/researchers-shed-new-light-
paracetamol-causes-liver-damage/)

------
geofft
The actual title of this article is, "Are patients with hypertension and
diabetes mellitus at increased risk for COVID-19 infection?"

The relevant portion about ibuprofen, lightly edited to make it more readable,
is:

> _Coronaviruses bind to their target cells through ACE2. The expression of
> ACE2 is substantially increased in patients with diabetes, who are treated
> with ACE inhibitors and ARBs. Hypertension is also treated with ACE
> inhibitors and ARBs, which results in an upregulation of ACE2. ACE2 can also
> be increased by thiazolidinediones and ibuprofen. These data suggest that
> ACE2 expression is increased in diabetes and treatment with ACE inhibitors
> and ARBs increases ACE2 expression. Consequently, the increased expression
> of ACE2 would facilitate infection with COVID-19. We therefore hypothesise
> that diabetes and hypertension treatment with ACE2-stimulating drugs
> increases the risk of developing severe and fatal COVID-19._

More broadly, they're saying that many of the medical notes of patients who
died mentioned that the patients also had diabetes or hypertension, and
they're wondering if the correlation is about the treatment for those
conditions and not about the conditions themselves.

It's not clear to me whether they're implying that _anyone_ who takes
ibuprofen (e.g. for a headache or even for a COVID-19 fever) will have more
ACE2 and therefore be more susceptible to severe and fatal COVID-19, or if
that effect only happens in the context of treatment for diabetes and
hypertension. I can see how you can read it in the first way, but it feels
like they would have titled it clearer if that were what they were actually
saying.

In particular, there is plenty of advice for people with mild COVID-19 cases
to do the normal things they'd do to take care of a flu at home, including
take ibuprofen. If that's a bad idea, I feel like they would have said that
more loudly.

(For instance - does it matter whether you've got more ACE2 if you're
_already_ infected and trying to keep the symptoms under control?)

EDIT: Thanks to 'FeteCommuniste in another comment for linking this Twitter
thread
[https://twitter.com/angie_rasmussen/status/12389469379166822...](https://twitter.com/angie_rasmussen/status/1238946937916682241)
which points out that this is an un-peer-reviewed hypothesis.

~~~
sdenton4
These sorts of things are exactly the reason to try to slow the spread down.

Ibuprofen /might/ be a bad idea. We currently have the time to notice that,
and hopefully find out whether it's true by looking at hundreds of cases
instead of tens of thousands.

~~~
AstralStorm
Generally taking Ibuprofen chronically might be a bad idea.

We don't know how chronic the chronic is through. So to stay on the safe side,
use as little as needed to control bigger fever and pain.

This unlike antibiotics (not for viral infections) where you are supposed to
take exactly the recommended amount for recommended time, preventing
resistance.

------
jbattle
After a couple of asthmatic attacks after taking aspirin and ibuprofen I went
to an allergist and she told me that I have an allergic reaction to all
NSAIDs.

The syndrome is called 'NSAIDs-Exacerbated Respiratory Disease'.

I felt equally proud and ashamed that the medical establishment officially
diagnosed me as a NERD

[https://en.wikipedia.org/wiki/NSAID_hypersensitivity_reactio...](https://en.wikipedia.org/wiki/NSAID_hypersensitivity_reactions)

~~~
takeda
Sadly NERD doesn't refer to you, but to the disease ;P

~~~
silviogutierrez
Could argue diseased as a noun works (to refer to them, as “the diseased”)

------
zackmorris
I'm wondering if some of the downside of anti-inflammatories is that they
often lower fevers. A fever is the body's natural response to infection, to
raise the rate of chemical reactions and make more immune cells:

[https://www.sciencedaily.com/releases/2011/11/111101130200.h...](https://www.sciencedaily.com/releases/2011/11/111101130200.htm)

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869589/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869589/)

I also think that this is part of the mechanism that makes zinc effective
against viruses as a catalyst.

Generally, I think that it's good to keep fevers down for non-lethal
infections like the common cold, especially for children. Just beware that
aspirin may cause Reye's syndrome in the young:

[https://www.healthline.com/health/headache-reyes-
syndrome](https://www.healthline.com/health/headache-reyes-syndrome)

But for serious infections like Covid-19, maybe it would be better to maintain
a relatively safe temperature of say 101-102 F (38-39 C)? I'm honestly curious
to know what doctors think of this.

~~~
topkai22
Good summary, althoughI would be more forceful about aspirin- don't use it for
children under 12 without a medical professional recommending it. While Reyes
syndrome is rare, acetaminophen and ibuprofen are equally effective,
available, and do not carry the risk.

~~~
robocat
Taking too much acetaminophen (Paracetomol) is the most common cause of acute
liver failure in the United States.

There has been a huge PR push (in advertising etc) against Aspirin and for
other NSAIDs.

Of course, take care, but don’t be sucked in by marketing.

~~~
robocat
To add to that:

1\. High dose aspirin might have been implicated in causing higher death rates
from 1918 influenza:
[https://academic.oup.com/cid/article/49/9/1405/301441](https://academic.oup.com/cid/article/49/9/1405/301441)
(daily doses of 8 to 31.2 grams, are above the maximum safe dose)

2\. But low dose aspirin has been studied and effects are not apparent e.g.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737981/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737981/)

------
sgroppino
From the article: "ACE2 can also be increased by thiazolidinediones and
ibuprofen. These data suggest that ACE2 expression is increased in diabetes
and treatment with ACE inhibitors and ARBs increases ACE2 expression.
Consequently, the increased expression of ACE2 would facilitate infection with
COVID-19. We therefore hypothesise that diabetes and hypertension treatment
with ACE2-stimulating drugs increases the risk of developing severe and fatal
COVID-19."

~~~
chrismeller
Considering that lisinopril (Prinivil, Zestrel, etc, an ACE inhibitor) is,
according to any list I could find, easily in the top 10 meds prescribed in
the US (and by some top three or number one), this is something that should
definitely be more publicly known.

I’m not saying anyone should just stop taking their hypertension drugs, that’s
a horrible idea. But if you do suspect that you might have COVID-19, you
should probably call your doctor - there’s no shortage of other options.

One of those lists:
[https://www.medicinenet.com/top_drugs_prescribed_in_the_us/v...](https://www.medicinenet.com/top_drugs_prescribed_in_the_us/views.htm)

~~~
snapetom
ACE != ACE2.

ACE inhibitors have no effect on ACE2.

[https://www.nrcresearchpress.com/doi/10.1139/y02-021](https://www.nrcresearchpress.com/doi/10.1139/y02-021)

~~~
mikedilger
[https://www.researchgate.net/publication/26859747_Upregulati...](https://www.researchgate.net/publication/26859747_Upregulation_of_angiotensin-
converting_enzyme_ACE_2_in_hepatic_fibrosis_by_ACE_inhibitors)

"Upregulation of angiotensin-converting enzyme (ACE) 2 in hepatic fibrosis by
ACE inhibitors"

------
mlrtime
[https://www.theguardian.com/world/2020/mar/14/anti-
inflammat...](https://www.theguardian.com/world/2020/mar/14/anti-inflammatory-
drugs-may-aggravate-coronavirus-infection)

~~~
takeda
Was about to say this.

They advise is to use acetaminophen.

It really comes down how covid-19 kills people, whether it is by directly
attacking the body, or by triggering cytokine release syndrome (CRS).

In later case, medication that suppresses the immune system would be better,
but in former case it could make things worse.

~~~
zozbot234
> It really comes down how covid-19 kills people, whether it is by directly
> attacking the body, or by triggering cytokine release syndrome (CRS).

It seems to be both. Plausibly at least, CRS may be often involved in damage
to the respiratory system, but COVID-19 is not unlike SARS in that severe
forms can directly attack other parts of the body. So any treatment based on
lowering inflammation or any other part of the immune response will have to be
carefully tuned.

------
dmurray
Ibuprofen, along with paracetamol, is generally considered very safe. All over
the world they are prescribed for any kind of pain, fever, inflammation or
discomfort. Of course, there are some known side effects, but they are
generally considered minor.

Does it make sense that a virus would evolve to favour these conditions? Or is
it just an unfortunate coincidence? I guess it depends on whether the virus
being "worse" means it helps spread faster, or just compromises the host
faster - after all, the virus doesn't gain from killing its host. Also,
animals don't get treated with NSAIDs to the same degree, so if nCovid-19 came
from a non-human host that's another argument for it being coincidence.

~~~
throwawayy477
Ibuprofen is an anti-inflammation drug, which means it weakens somewhat your
immune system (which is responsible for the inflammation in the first place).
It makes sort of sense that taking such medication while infected with a virus
for which there is no treatment can be dangerous.

In related news, there have been cases of "severe" forms of Covid-19 among
young people with no antecedents, all of them having taken ibuprofen.

Please don't take ibuprofen.

~~~
sbuttgereit
This is precisely the sort of comment that not only makes social networking a
medium with nearly no real value, but actually dangerous.

The commentator comes here with some assumptions, perhaps some hearsay, and an
emotional attachment to their position and make the statement as though it's
fact.

In this comment, you know what's missing? Actual knowledge, actual reasoning,
and actual facts to back up the his/her claims. Perhaps worse, there are some
facts (Ibuprofen suppresses some immune system responses to infection) which
are used to draw unsubstantiated conclusions about the commentator's opinions
(Ibuprofen can cause severe forms of Covid-19 in young people).

From where did this "related news" come from? On what rational basis do you
draw the conclusion that an across-the-board recommendation not to take
Ibuprofen is warranted? How does that trump other factors that may be at play?

What I really worry about though is how many people will read the comment I'm
responding to and go on to post elsewhere, "in related news...", with a
similar air of self-certainly and casting of opinions as facts. In other
contexts of high emotion, people get lynched because of this sort of social
media posting, people may cause themselves harm because of this kind of
posting.

By the way, the commentator may actually be right... but there is nothing in
the comment to make me believe that his/her being right would be anything more
than coincidence.

I'll leave with the personal observation that this community is suppose to be
made up of "the smart ones"; which we ourselves so often confidently believe
to be true that we all too frequently think we should be able to engineer
society and solve all its ills. If there is any one ponder-able to take away
from reading Hacker News on regular basis, it's how decidedly average even
"the smart ones" can be on any given topic.

~~~
ohiovr
tylonol is safer than ibuprofen if you have covid19. But you don't have to
believe me as I read and don't make bibliographies in all of my posts.

But I will make an exception for you.
[https://amp.theguardian.com/world/2020/mar/14/anti-
inflammat...](https://amp.theguardian.com/world/2020/mar/14/anti-inflammatory-
drugs-may-aggravate-coronavirus-infection)

~~~
mathgeek
> But you don't have to believe me as I read and don't make bibliographies in
> all of my posts.

We certainly don't have to make them in all posts, but I think it's reasonable
to request that we make them in what are hopefully a small number of posts
wherein we offer medical advice.

~~~
ohiovr
No one should be accepting anything online as medical advice. It's like high
finance, if you base every purchase on what you read on Yahoo finance you are
going to lose your shirt. If you take health advice online you might die.
Nobody is giving advice here. We are having a discussion.

Read not to contradict and confute; nor to believe and take for granted; nor
to find talk and discourse; but to weigh and consider.

\- Bacon

------
lousken
why is this keep popping up???

[https://news.ycombinator.com/item?id=22582568](https://news.ycombinator.com/item?id=22582568)

[https://news.ycombinator.com/item?id=22576721](https://news.ycombinator.com/item?id=22576721)

stop spamming this

~~~
azinman2
Those other ones got flagged, but this is from the lancet which is a credible
source.

------
earthtourist
Any information on cough suppressants? Whether they're a good or bad for
people with COVID-19?

I've had my doctor recommend against cough suppressants in the past. But I've
had trouble sleeping with a bad cough, and so if cough suppressants make sleep
possible, it seems like a net-win. Is there any data yet?

~~~
nradov
Are you asking about dextromethorphan or some other cough suppressant? I don't
think there's any real evidence one way or the other yet.

~~~
earthtourist
Yes, dextromethorphan. Thanks.

------
bryanrasmussen
Ibuprofen is also used among people with arthritis and gout, gout is strongly
linked with diabetes.

------
SubiculumCode
Curious. Melatonin is anti-inflammatory. Would this pose a similar
(hypothetical) danger as NSAIDs?

------
happycube
Bettridge's law may be wrong here... sounds like the answer is "maybe"

~~~
geofft
But this isn't even the real headline. The real headline is "Are patients with
hypertension and diabetes mellitus at increased risk for COVID-19 infection?"
And it's not even a headline, it's a title of a medical note to other
researchers to advance a hypothesis. This isn't a news source, this is work in
progress in the early stages of the scientific method.

~~~
he0001
How do you follow up one these “articles”. I understand that it is a
hypothesis, but unfortunately these articles do create some nasty rumors,
where these tend to be treated as facts instead of just a hypothesis.

------
fatjokes
Morbidity aside, this must be an exciting time to be an epidemiologist.

