COVID-19
Inhaled corticosteroids downregulate the SARS-CoV-2 receptor ACE2 in COPD through suppression of type I interferon

https://doi.org/10.1016/j.jaci.2020.09.034Get rights and content
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Background

The mechanisms underlying altered susceptibility and propensity to severe Coronavirus disease 2019 (COVID-19) disease in at-risk groups such as patients with chronic obstructive pulmonary disease (COPD) are poorly understood. Inhaled corticosteroids (ICSs) are widely used in COPD, but the extent to which these therapies protect or expose patients to risk of severe COVID-19 is unknown.

Objective

The aim of this study was to evaluate the effect of ICSs following pulmonary expression of the SARS-CoV-2 viral entry receptor angiotensin-converting enzyme-2 (ACE2).

Methods

We evaluated the effect of ICS administration on pulmonary ACE2 expression in vitro in human airway epithelial cell cultures and in vivo in mouse models of ICS administration. Mice deficient in the type I IFN-α/β receptor (Ifnar1−/−) and administration of exogenous IFN-β were used to study the functional role of type-I interferon signaling in ACE2 expression. We compared sputum ACE2 expression in patients with COPD stratified according to use or nonuse of ICS.

Results

ICS administration attenuated ACE2 expression in mice, an effect that was reversed by exogenous IFN-β administration, and Ifnar1−/− mice had reduced ACE2 expression, indicating that type I interferon contributes mechanistically to this effect. ICS administration attenuated expression of ACE2 in airway epithelial cell cultures from patients with COPD and in mice with elastase-induced COPD-like changes. Compared with ICS nonusers, patients with COPD who were taking ICSs also had reduced sputum expression of ACE2.

Conclusion

ICS therapies in COPD reduce expression of the SARS-CoV-2 entry receptor ACE2. This effect may thus contribute to altered susceptibility to COVID-19 in patients with COPD.

Key words

COPD
COVID-19
inhaled corticosteroids
viral infection

Abbreviations used

ACE2
Angiotensin-converting enzyme-2
BEC
Bronchial epithelial cell
BSG
Basigin
COPD
Chronic obstructive pulmonary disease
COVID-19
Coronavirus disease 2019
FP
Fluticasone propionate
GR
Glucocorticoid receptor
ICS
Inhaled corticosteroid
ISG
Interferon-stimulated gene
TMPRSS2
Transmembrane serine protease 2

Cited by (0)

Supported by a Wellcome Trust Clinical Research Training Fellowship (grant WT096382AIA [to A.S.]), a Wellcome Trust Seed Award in Science (grant 215275/Z/19/Z [to A.S.]), a British Society for Antimicrobial Chemotherapy COVID-19 grant (to A.S.) a National Institute for Health Research (NIHR) Senior Investigator Award (to S.L.J.), the NIHR Clinical Lecturer funding scheme (to P.M.) and funding from the Imperial College and NIHR Biomedical Research Centre scheme.

Disclosure of potential conflict of interest: S.L. Johnston has personally received consultancy fees from Myelo Therapeutics GmbH, Concert Pharmaceuticals, Bayer, Sanofi Pasteura, and Aviragen; in addition, he and his institution have received consultancy fees from Synairgen, Novarits, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, and Centocor. S.L. Johnston is also an inventor on patents related to the use of inhaled interferons for treatment of exacerbations of airway diseases. M.A. Calderazzo was employed by Chiesi Pharmaceuticals from January 2015 to November 2017. A. Singanayagam has received honoraria for speaking from AstraZeneca. The rest of the authors declare that they have no relevant conflicts of interest.