If you follow enough trans women on Twitter, you might have seen a panic break out earlier this week over concerns that spironolactone, a testosterone blocker that many of us take as part of hormone replacement therapy that is also widely prescribed to the general population to treat hormonal acne, increases one’s risk for developing COVID-19. Thankfully, according to the medical experts VICE spoke with, there is absolutely no cause for concern.
The mess, like many before it, all began on Instagram. Ellen Marmur, a New York City dermatologist, posted a video to her feed on March 21 in which she recommends that her patients stop taking spironolactone, also called spiro. The potassium-sparing diuretic was initially developed in 1957 to treat hypertension and congestive heart failure.
“I would stop spironolactone,” Marmur says in the video. “It is not medically necessary for acne. I am only talking about my acne patients. I would stop the spironolactone until we know further.”
As Marmur explains in the video, her recommendation is based on her own research into spironolactone’s effect on angiotensin converting enzyme 2 (ACE2) receptors, which appear to serve as one possible entry point for SARS-CoV-2, the novel coronavirus that can cause COVID-19. This is not a recommendation shared by the American Academy of Dermatology, she notes at the top of the clip; she merely speaks for herself. A number of outlets ran with the recommendation shortly after Marmur posted the video to her Instagram account, which has nearly 16,000 followers at press time. Pop Sugar and RealSelf told readers that they might want to stop taking spiro as a precautionary measure against COVID-19. Neither site makes note of the key role spiro plays in trans healthcare, nor does Marmur in her Instagram video.
In the days that followed, an increasing number of trans people started sharing the RealSelf and Pop Sugar articles on social media, anxiously wondering whether a medication that many consider to be life-saving may actually be putting their lives at risk. The concern is more than valid. Trans healthcare and its impact on actual trans people has been woefully under-researched since its inception, leading many trans individuals to trust anecdotal information from other community members as much as if not more than the recommendations they get directly from providers. Given our constantly evolving understanding of the coronavirus pandemic, not to mention spiro’s negative reputation in many pockets of the community, we would have every reason to worry after reading RealSelf or Pop Sugar’s alarming and, frankly, irresponsible reporting.
VICE spoke with medical providers who oversee trans healthcare and other services at two LGBTQ community health centers, both of whom agreed that there is no reason to believe that taking spiro will make any individual, trans or cis, any more susceptible to COVID-19. “The data is still inconclusive regarding the role of ACE2 receptors and coronavirus susceptibility,” said Julie Thompson, Medical Director of Trans Health at Fenway Health in Boston. Asa Radix, Senior Director of Research and Education at Callen-Lorde Community Health Center in New York City, echoed Thompson’s sentiments: “I would not want someone to stop the medication based on no evidence.”
The argument that spiro might make one more vulnerable to the virus may appear to be scientifically sound at first, with many credible citations to back it up. But in the words of Cher Horowitz, it’s a full-on Monet: From far away it’s OK, but up close? It’s a big old mess. Marmur’s claim likely draws on a study from 2005 about how spiro increases the activity and expression of your cells’ ACE2 receptors, which, as discussed earlier, are believed to be key to the novel coronavirus’ replication process. (Radix was skeptical about this study during our interview, noting that it only involved 10 patients.) Using a kind of transitive logic, the people making the case against spiro then connect that study’s findings to current research into whether medications that affect ACE2 receptors might increase risk for COVID-19 infection. In other words, if A equals B and B equals C, then spiro might make you more susceptible to COVID-19.
The problem here is that no matter how scary that risk sounds, it’s still theoretical. Nobody has conclusively proven that taking spiro, or any other medication that affects our ACE2 receptors, will make us more likely to get infected. And given how long it would take to conduct a study and produce any credible evidence one way or the other, nobody will be able to conclusively prove it any time soon.
On March 17, the American Heart Association, the American College of Cardiology, and the Heart Failure Society of America released a joint statement addressing concerns about ACE2 receptor-interactant medications and COVID-19 risk, telling patients to continue taking ACE inhibitors and angiotensin-receptor blockers (ARBs) as prescribed. Radix of Callen-Lorde told VICE that trans people currently taking spiro should continue to do so, as well. Rather than worry about a theoretical risk, he recommended that we instead focus our attention on the very real health risks trans people will face in this pandemic.
“Trans people have always had inadequate healthcare and are generally discriminated against in our systems, all of which will continue,” he said. “Imagine if you were a trans person who’d had negative healthcare experiences, and you developed COVID-19. You’re probably sitting at home and worrying about whether you should even go to the emergency room. Those are the issues we should be concerned about: encouraging trans people to seek out healthcare if they need it.”
“That’s not theoretical. That’s real.”
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