Dampening of the respiratory cytokine storm is promoted by inhaled budesonide in patients with early COVID-19
Jonathan R Baker, Mahdi Mahdi, Dan V Nicolau Jr, Sanjay Ramakrishnan, Peter J Barnes, Jodie L Simpson, Steven P Cass, Richard Ek Russell, Louise E Donnelly, Professor Mona Bafadhel
doi:10.1101/2021.10.26.21265512
Vaccinations against SARS-CoV-2 are effective in COVID-19. However, with limited vaccine access, vaccine hesitancy and variant breakthroughs, there is still a need for effective and safe early treatments. Two community-based clinical trials of the inhaled corticosteroid, budesonide, have recently been published showing and improvement in patients with COVID-19 treated early with budesonide 1,2 . To understand mechanistically how budesonide was beneficial, inflammatory mediators were assessed in the nasal mucosa of patients recruited to the Steroids in COVID (STOIC 1 ) trial and a cohort of SARS-CoV-2 negative individuals. Here we show that in early COVID-19, elevation in viral response proteins and Th1 and Th2 inflammation occurs. Longitudinal sampling in the natural course of COVID-19 showed persistently high interferon levels and elevated concentrations of the eosinophil chemokine, CCL11. In patients who deteriorate, the initial nasal mucosal signal is characterised by a marked suppression of the early inflammatory response, with reduced concentrations of interferon and inflammatory cytokines, but elevated eosinophil chemokines. Systemic inflammation remained altered in COVID-19 patients, implying that even after symptom resolution, changes in immunological mediators do not resolve. Budesonide treatment decreased IL-33 and IFN-γ, implying a reduction in epithelial damage and dampening of the interferon response. Budesonide treatment also increased CCL17 concentrations, suggesting an improved T-cell response; and significantly alters inflammatory pathways giving further insight into how this treatment can accelerate patient recovery. . This finding has now been replicated in a large Phase 3 efficacy trial 2 , but has yet to attract global adoption. The mechanism for how ICS can improve early COVID-19 infection is however currently unknown. Here, we report the nasal mucosal inflammatory response in patients with early COVID-19 disease and examine the evolution of inflammation in the natural course of COVID-19. We also identify how inflammation in the airway can predict illness severity and investigate the effect of inhaled budesonide upon the respiratory mucosa in early COVID-19 disease. Finally, we show using network analysis how inhaled budesonide can resolve the exaggerated inflammatory response seen in early COVID-19 infection and promote resolution to health.
Methods
Study design and participants STOIC was a randomised, open-label, parallel group, phase 2 clinical intervention trial. Participants aged 18 and over with early COVID-19 symptoms (defined as new onset of cough and/or fever and/or anosmia for less than 7 days) were randomised to receive usual care (UC), namely as required anti-pyretics, or inhaled budesonide (BUD) at a dose of 800μg twice a day plus usual care (see supplement figure S1 ). Participants were seen at home at randomisation day 0 (visit 1), day 7 (visit 2), and day 14 (visit 3) by a research nurse to obtain consent, provide inhalers and collect nasal absorption samples and nasopharyngeal swabs which were self-performed. At day 28 (visit 4), whole
Nasal mucosal sampling Nasal mucosal sampling was self-performed by all participants as previously described
37 . Briefly, samples of the nasal mucosal lining fluid were collected by placing a Nasosorption™ FX•I device (Hunt Developments UK Ltd) consisting of a synthetic absorptive matrix strip against the inferior turbinate for a duration of 1 minute. The sample was then eluted in 500 μL of PBS, 1% bovine serum albumin (BSA) (w/v), 1% Triton X-100 (v/v), and 0.05% sodium azide (w/v) (Sigma-Aldrich, UK) and stored at -80°C.
Isolation of serum
References
Bafadhel, Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers, Am J Respir Crit Care Med,
doi:10.1164/rccm.201104-0597OCBlondel, Guillaume, Lambiotte, Lefebvre, Fast unfolding of communities in large networks, Journal of Statistical Mechanics: Theory and Experiment,
doi:10.1088/1742-5468/2008/10/p10008Bloom, Risk of adverse outcomes in patients with underlying respiratory conditions admitted to hospital with COVID-19: a national, multicentre prospective cohort study using the ISARIC WHO Clinical Characterisation Protocol UK, Lancet Respir Med,
doi:10.1016/S2213-2600(21)00013-8Chua, COVID-19 severity correlates with airway epithelium-immune cell interactions identified by single-cell analysis, Nature Biotechnology,
doi:10.1038/s41587-020-0602-4Finney, Inhaled corticosteroids downregulate the SARS-CoV-2 receptor ACE2 in COPD through suppression of type I interferon, The Journal of allergy and clinical immunology,
doi:10.1016/j.jaci.2020.09.034Guo-Parke, Linden, Weldon, Kidney, Taggart, Mechanisms of Virus-Induced Airway Immunity Dysfunction in the Pathogenesis of COPD Disease, Progression, and Exacerbation, Frontiers in Immunology,
doi:10.3389/fimmu.2020.01205Hadjadj, Impaired type I interferon activity and inflammatory responses in severe COVID-19 patients, Science,
doi:10.1126/science.abc6027Han, Profiling serum cytokines in COVID-19 patients reveals IL-6 and IL-10 are disease severity predictors, Emerging Microbes & Infections,
doi:10.1080/22221751.2020.1770129Hoffmann, SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor, Cell,
doi:10.1016/j.cell.2020.02.052Leist, Schäfer, Martinez, Cell and animal models of SARS-CoV-2 pathogenesis and immunity, Disease Models & Mechanisms,
doi:10.1242/dmm.046581Marchenko, Pastur, Распределение собственных значений в некоторых ансамблях случайных матриц
Mason, Thoughts on the alveolar phase of COVID-19, American Journal of Physiology-Lung Cellular and Molecular Physiology,
doi:10.1152/ajplung.00126.2020Milne, Inhaled corticosteroids downregulate SARS-CoV-2-related genes in COPD: results from a randomised controlled trial, Eur Respir J,
doi:10.1183/13993003.00130-2021Morton, Distinct clinical and immunological profiles of patients with evidence of SARS-CoV-2 infection in sub-Saharan Africa, Nature communications,
doi:10.1038/s41467-021-23267-wMurira, Lamarre, Type-I Interferon Responses: From Friend to Foe in the Battle against Chronic Viral Infection, Frontiers in Immunology,
doi:10.3389/fimmu.2016.00609Papi, Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations, Am J Respir Crit Care Med,
doi:10.1164/rccm.200506-859OCPeluso, Long-term SARS-CoV-2-specific immune and inflammatory responses in individuals recovering from COVID-19 with and without post-acute symptoms, Cell Rep,
doi:10.1016/j.celrep.2021.109518Ramakrishnan, Inhaled budesonide in the treatment of early COVID-19 (STOIC): a phase 2, open-label, randomised controlled trial, Lancet Respir Med,
doi:10.1016/s2213-2600(21)00160-0Rogliani, Lauro, Di Daniele, Chetta, Calzetta, Reduced risk of COVID-19 hospitalization in asthmatic and COPD patients: a benefit of inhaled corticosteroids?, Expert Rev Respir Med,
doi:10.1080/17476348.2021.1850275Rouse, Sehrawat, Immunity and immunopathology to viruses: what decides the outcome?, Nature Reviews Immunology,
doi:10.1038/nri2802Scheller, Chalaris, Garbers, Rose-John, ADAM17: a molecular switch to control inflammation and tissue regeneration, Trends in Immunology,
doi:10.1016/j.it.2011.05.005Thwaites, Inflammatory profiles across the spectrum of disease reveal a distinct role for GM-CSF in severe COVID-19, Sci Immunol,
doi:10.1126/sciimmunol.abg9873Vareille, Kieninger, Edwards, Regamey, The airway epithelium: soldier in the fight against respiratory viruses, Clin Microbiol Rev,
doi:10.1128/CMR.00014-10Yamaya, Nishimura, Nadine, Kubo, Nagatomi, Formoterol and budesonide inhibit rhinovirus infection and cytokine production in primary cultures of human tracheal epithelial cells, Respir Investig,
doi:10.1016/j.resinv.2014.03.004Yu, Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial, Lancet,
doi:10.1016/S0140-6736(21)01744-XZhou, Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study, Lancet,
doi:10.1016/S0140-6736(20)30566-3{ 'institution': [{'name': 'medRxiv'}],
'indexed': {'date-parts': [[2022, 3, 31]], 'date-time': '2022-03-31T12:47:50Z', 'timestamp': 1648730870091},
'posted': {'date-parts': [[2021, 10, 27]]},
'group-title': 'Infectious Diseases (except HIV/AIDS)',
'reference-count': 41,
'publisher': 'Cold Spring Harbor Laboratory',
'content-domain': {'domain': [], 'crossmark-restriction': False},
'accepted': {'date-parts': [[2021, 10, 27]]},
'abstract': '<jats:title>Summary</jats:title><jats:p>Vaccinations against SARS-CoV-2 are effective in '
'COVID-19. However, with limited vaccine access, vaccine hesitancy and variant breakthroughs, '
'there is still a need for effective and safe early treatments. Two community-based clinical '
'trials of the inhaled corticosteroid, budesonide, have recently been published showing and '
'improvement in patients with COVID-19 treated early with budesonide<jats:sup>1,2</jats:sup>. '
'To understand mechanistically how budesonide was beneficial, inflammatory mediators were '
'assessed in the nasal mucosa of patients recruited to the Steroids in COVID '
'(STOIC<jats:sup>1</jats:sup>) trial and a cohort of SARS-CoV-2 negative individuals. Here we '
'show that in early COVID-19, elevation in viral response proteins and Th1 and Th2 '
'inflammation occurs. Longitudinal sampling in the natural course of COVID-19 showed '
'persistently high interferon levels and elevated concentrations of the eosinophil chemokine, '
'CCL11. In patients who deteriorate, the initial nasal mucosal signal is characterised by a '
'marked suppression of the early inflammatory response, with reduced concentrations of '
'interferon and inflammatory cytokines, but elevated eosinophil chemokines. Systemic '
'inflammation remained altered in COVID-19 patients, implying that even after symptom '
'resolution, changes in immunological mediators do not resolve. Budesonide treatment decreased '
'IL-33 and IFN-γ, implying a reduction in epithelial damage and dampening of the interferon '
'response. Budesonide treatment also increased CCL17 concentrations, suggesting an improved '
'T-cell response; and significantly alters inflammatory pathways giving further insight into '
'how this treatment can accelerate patient recovery.</jats:p><jats:sec><jats:title>Abstract '
'Figure</jats:title><jats:fig id="ufig1" position="float" fig-type="figure" '
'orientation="portrait"><jats:graphic xmlns:xlink="http://www.w3.org/1999/xlink" '
'xlink:href="21265512v1_ufig1" position="float" orientation="portrait" '
'/></jats:fig></jats:sec>',
'DOI': '10.1101/2021.10.26.21265512',
'type': 'posted-content',
'created': { 'date-parts': [[2021, 10, 29]],
'date-time': '2021-10-29T14:55:17Z',
'timestamp': 1635519317000},
'source': 'Crossref',
'is-referenced-by-count': 0,
'title': 'Dampening of the respiratory cytokine storm is promoted by inhaled budesonide in patients with '
'early COVID-19',
'prefix': '10.1101',
'author': [ {'given': 'Jonathan R', 'family': 'Baker', 'sequence': 'first', 'affiliation': []},
{'given': 'Mahdi', 'family': 'Mahdi', 'sequence': 'additional', 'affiliation': []},
{ 'suffix': 'Jr.',
'given': 'Dan V',
'family': 'Nicolau',
'sequence': 'additional',
'affiliation': []},
{ 'ORCID': 'http://orcid.org/0000-0002-3003-7918',
'authenticated-orcid': False,
'given': 'Sanjay',
'family': 'Ramakrishnan',
'sequence': 'additional',
'affiliation': []},
{ 'ORCID': 'http://orcid.org/0000-0002-5122-4018',
'authenticated-orcid': False,
'given': 'Peter J',
'family': 'Barnes',
'sequence': 'additional',
'affiliation': []},
{'given': 'Jodie L', 'family': 'Simpson', 'sequence': 'additional', 'affiliation': []},
{ 'ORCID': 'http://orcid.org/0000-0002-7032-6239',
'authenticated-orcid': False,
'given': 'Steven P',
'family': 'Cass',
'sequence': 'additional',
'affiliation': []},
{ 'ORCID': 'http://orcid.org/0000-0002-3890-7201',
'authenticated-orcid': False,
'given': 'Richard EK',
'family': 'Russell',
'sequence': 'additional',
'affiliation': []},
{'given': 'Louise E', 'family': 'Donnelly', 'sequence': 'additional', 'affiliation': []},
{ 'ORCID': 'http://orcid.org/0000-0002-9993-2478',
'authenticated-orcid': False,
'given': 'Mona',
'family': 'Bafadhel',
'sequence': 'additional',
'affiliation': []}],
'member': '246',
'reference': [ { 'key': '2021102907550968000_2021.10.26.21265512v1.1',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/s22132600(21)00160-0'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.2',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/S0140-6736(21)01744-X'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.3',
'doi-asserted-by': 'publisher',
'DOI': '10.1242/dmm.046581'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.4',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/j.celrep.2021.109518'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.5',
'doi-asserted-by': 'publisher',
'DOI': '10.1371/journal.ppat.1009759'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.6',
'doi-asserted-by': 'publisher',
'DOI': '10.1038/nri2802'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.7',
'doi-asserted-by': 'publisher',
'DOI': '10.1183/09031936.01.00228701'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.8',
'doi-asserted-by': 'publisher',
'DOI': '10.3389/fimmu.2020.01205'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.9',
'doi-asserted-by': 'publisher',
'DOI': '10.1097/01.mcp.0000146781.11092.0d'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.10',
'doi-asserted-by': 'publisher',
'DOI': '10.1164/rccm.200506-859OC'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.11',
'doi-asserted-by': 'publisher',
'DOI': '10.1164/rccm.201104-0597OC'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.12',
'doi-asserted-by': 'publisher',
'DOI': '10.1183/13993003.00547-2020'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.13',
'doi-asserted-by': 'publisher',
'DOI': '10.1080/17476348.2021.1850275'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.14',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/S2213-2600(21)00013-8'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.15',
'doi-asserted-by': 'publisher',
'DOI': '10.1038/s41467-021-23267-w'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.16',
'doi-asserted-by': 'publisher',
'DOI': '10.1038/s41586-020-2588-y'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.17',
'doi-asserted-by': 'publisher',
'DOI': '10.1038/s41591-020-0901-9'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.18',
'doi-asserted-by': 'publisher',
'DOI': '10.1038/s41587-020-0602-4'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.19',
'doi-asserted-by': 'publisher',
'DOI': '10.1080/22221751.2020.1770129'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.20',
'doi-asserted-by': 'publisher',
'DOI': '10.1152/ajplung.00126.2020'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.21',
'doi-asserted-by': 'publisher',
'DOI': '10.1128/CMR.00014-10'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.22',
'doi-asserted-by': 'publisher',
'DOI': '10.1126/science.abc6027'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.23',
'doi-asserted-by': 'publisher',
'DOI': '10.1067/mai.2000.105712'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.24',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/S0140-6736(20)30566-3'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.25',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/S2213-2600(17)30217-5'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.26',
'doi-asserted-by': 'publisher',
'DOI': '10.5603/ARM.a2021.0040'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.27',
'doi-asserted-by': 'publisher',
'DOI': '10.1136/thoraxjnl-2020-216256'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.28',
'doi-asserted-by': 'publisher',
'DOI': '10.1038/s41591-021-01292-y'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.29',
'doi-asserted-by': 'publisher',
'DOI': '10.3389/fimmu.2018.02061'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.30',
'doi-asserted-by': 'publisher',
'DOI': '10.3389/fimmu.2016.00609'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.31',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/j.cell.2020.02.052'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.32',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/j.jaci.2020.09.034'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.33',
'doi-asserted-by': 'publisher',
'DOI': '10.1183/13993003.001302021'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.34',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/j.resinv.2014.03.004'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.35',
'doi-asserted-by': 'publisher',
'DOI': '10.3390/ph3030514'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.36',
'doi-asserted-by': 'publisher',
'DOI': '10.1016/j.it.2011.05.005'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.37',
'doi-asserted-by': 'publisher',
'DOI': '10.3791/56413'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.38',
'doi-asserted-by': 'publisher',
'DOI': '10.1126/sciimmunol.abg9873'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.39',
'doi-asserted-by': 'publisher',
'DOI': '10.1038/s41591-020-1051-9'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.40',
'first-page': '507',
'article-title': 'Распределение собственных значений в некоторых ансамблях случайных '
'матриц” [Distribution of eigenvalues for some sets of random matrices]',
'volume': '72',
'year': '1967',
'journal-title': 'Mat. Sb'},
{ 'key': '2021102907550968000_2021.10.26.21265512v1.41',
'doi-asserted-by': 'publisher',
'DOI': '10.1088/1742-5468/2008/10/p10008'}],
'container-title': [],
'original-title': [],
'link': [ { 'URL': 'https://syndication.highwire.org/content/doi/10.1101/2021.10.26.21265512',
'content-type': 'unspecified',
'content-version': 'vor',
'intended-application': 'similarity-checking'}],
'deposited': { 'date-parts': [[2021, 10, 29]],
'date-time': '2021-10-29T14:55:21Z',
'timestamp': 1635519321000},
'score': 1,
'resource': {'primary': {'URL': 'http://medrxiv.org/lookup/doi/10.1101/2021.10.26.21265512'}},
'subtitle': [],
'short-title': [],
'issued': {'date-parts': [[2021, 10, 27]]},
'references-count': 41,
'URL': 'http://dx.doi.org/10.1101/2021.10.26.21265512',
'relation': {},
'subject': [],
'published': {'date-parts': [[2021, 10, 27]]},
'subtype': 'preprint'}
