loading page

An umbrella review and meta-analysis of the use of renin-angiotensin system drugs and COVID-19 outcomes: what do we know so far?
  • Amanj Kurdi,
  • Natalie Weir ,
  • Tanja Mueller
Amanj Kurdi
University of Strathclyde
Author Profile
Natalie Weir
Strathclyde Institute of Pharmacy and Biomedical Sciences
Author Profile
Tanja Mueller
Strathclyde Institute of Pharmacy and Biomedical Sciences
Author Profile


Aim To provide a comprehensive assessment of the effect of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor II blockers (ARBs) on COVID-19 related outcomes by summarising the currently available evidence. Methods This was an umbrella review of systematic reviews/meta-analysis conducted using Medline (OVID), Embase, Scopus, Cochrane library and medRxiv from inception to 1st February 2021. Systematic reviews with meta-analysis that evaluated the effect of ACEIs/ARBs on COVID-19 related clinical outcomes were eligible. Studies’ quality was appraised using the AMSTAR 2 Critical Appraisal Tool. Data were analysed using the random-effects modelling including several sub-group analyses. Heterogenicity was assessed using I2 statistic. The study protocol was registered in PROSPERO (CRD42021233398). Results Overall, 47 reviews were eligible for inclusion. Out of the nine COVID-19 outcomes evaluated, there was significant associations between ACEIs/ARBs use and each of death (OR=0.80, 95%CI=0.75-0.86; I2=51.9%), death/ICU admission as composite outcome (OR=0.86, 95%CI=0.80-0.92; I2=43.9%), severe COVID-19 (OR=0.86, 95%CI=0.78-0.95; I2=68%), and hospitalisation (OR=1.23, 95%CI=1.04-1.46; I2= 76.4%). The significant reduction in death/ICU admission, however, was higher among studies which presented adjusted measure of effects (OR=0.63, 95%CI=0.47-0.84) and were of moderate quality (OR=0.74, 95%CI=0.63-0.85). There was no evidence of any significant association between ACEIs, or ARBs and COVID-19 outcomes. Conclusions Collective evidence from observational studies indicate a good quality evidence on the significant association between ACEIs/ARBs use and reduction in death and death/ICU admission, but poor-quality evidence on both reducing severe COVID-19 and increasing hospitalisation. Our findings further support the current recommendations of not discontinuing ACEIs/ARBs therapy in patients with COVID-19.
12 May 2022Submitted to British Journal of Clinical Pharmacology
13 May 2022Assigned to Editor
13 May 2022Submission Checks Completed
20 May 2022Reviewer(s) Assigned
24 Jun 2022Review(s) Completed, Editorial Evaluation Pending
27 Jun 2022Editorial Decision: Revise Major