Some believe that ACE-Is should be used in all patients, save those with preexisting hypertension, to treat COVID-19.  ACE-Is may increase the expression of ACE2 which may play a role in reducing cellular inflammation.  However, this claim is unsubstantiated as little evidence shows that ACE-Is increase ACE2 receptor mRNA or protein expression.  

Michigan State University

Because ACE and ACE2 are structurally similar, it was thought that existing ACE inhibitor (ACE-I) drugs could be used as a COVID-19 treatment by inhibiting ACE2 activity.  However, because the enzymatic binding sites of ACE and ACE2 are different, ACE-Is do not affect ACE2 activity.  Additionally, COVID-19 patients who took ACE-I drugs were more likely to experience more severe symptoms and had a higher mortality rate than those that didn't take them.  It is thought that ACE inhibition in the RAS may exacerbate the vulnerability of patients with hypertension, diabetes mellitus, or cardiovascular disease to SARS-CoV-2 infection or COVID-19 symptoms.

Using ACE Inhibitors (ACE-Is) to Treat or Prevent COVID-19

McLachlan, C. S. (2020). The angiotensin-converting enzyme 2 (ACE2) receptor in the prevention and treatment of COVID-19 are distinctly different paradigms. Clinical Hypertension, 26(1), 1-3.
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-020-00147-x

The angiotensin-converting enzyme 2
(ACE2) receptor in the prevention and
treatment of COVID-19 are distinctly
different paradigms

Some believe that ACE-I/ARB use is harmful in treating SARS-CoV-2 infections because they increase the expression of ACE2, allowing the virus more opportunity to enter host cells.  

"Harmful" ACE-I/ARB Hypothesis in Treating SARS-CoV-2 Infection

Some believe that ACE-I/ARB use is beneficial in treating SARS-CoV-2 infections beneficial because the relative amount of Ang II is decreased.  While ACE2 expression may increase, the anti-inflammatory and anti-oxidant properties of Ang II could be helpful in mitigating or preventing acute lung injury.  

"Beneficial" ACE-I/ARB Hypothesis in Treating SARS-CoV-2 Infection

A retrospective longitudinal cohort study at a French university hospital was conducted to test the "harmful" and "beneficial" ACE-I/ARB hypotheses.  59 biomarkers were screened for in severe COVID-19 patients during their hospital stay, and these data were used to assess the association between chronic ACE-I/ARB use and kidney, lung, heart, and liver dysfunctions and inflammation.  It was concluded that this cohort was at an increase risk for acute kidney injury (AKI), and the observed increased in urea nitrogen was associated with the development of acute respiratory failure.    

Chronic ACE-I/ARB Use Is Associated with Acute Kidney Injury (AKI) in Severe COVID-19 Patients

Rationale in Using ACE Inhibitors (ACE-Is) to Treat or Prevent COVID-19

Professional societies, including journals such as The New England Journal. of Medicine, have released statements saying that ACE-Is, as well as ARBs, should not be discontinued in hypertensive COVID-19 patients.  They claim that these drugs are crucial for limiting Ang II formation and restoring levels to a healthy quantity.  

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