key: cord-0764574-jinst062
authors: Krueger, James G.; Murrell, Dedee F.; Garcet, Sandra; Navrazhina, Kristina; Lee, Patricia C.; Muscianisi, Elisa; Blauvelt, Andrew
title: Secukinumab lowers expression of ACE2 in affected skin of patients with psoriasis
date: 2020-09-28
journal: J Allergy Clin Immunol
DOI: 10.1016/j.jaci.2020.09.021
sha: b42abaa6cf8611c671608b83641e76ec4ee6a1d6
doc_id: 764574
cord_uid: jinst062

Capsule summary (33 of 35 words; 2 of 2 sentences): Secukinumab reduced the inflammation and the expression of ACE2, which encodes the SARS-CoV-2 receptor, in plaques of patients with psoriasis. Reductions in ACE2 expression with secukinumab significantly correlated with reductions in disease activity.

Secukinumab lowers expression of ACE2 in affected skin of patients with psoriasis

To the Editor:

Current guidance recommends that patients with psoriasis who are diagnosed with coronavirus disease 2019 (COVID-19) discontinue biologic therapy until they recover. 1 However, no evidence supports discontinuation of biologic therapy because of potential risk of infection, and whether biologic therapies increase the risk of COVID-19 infection in patients with psoriasis is not clear. [1] [2] [3] [4] Data from randomized studies showed that rates of respiratory infections with biologics were comparable to those seen with placebo. 5 Recently, however, Damiani et al reported that patients with psoriasis who were receiving biologic therapy were at higher risk of testing positive for COVID-19 (P <.0001). 6 Interestingly, these patients appeared to be protected from requiring intensive care and from death, with rates of both these measures being similar to those seen in the general population. 6 It was recently demonstrated that angiotensin-converting enzyme 2 (ACE2) is the main receptor used for entry by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 7 ; however, little is known about the impact of biologic therapy on ACE2 expression in the skin of patients with psoriasis. To better understand this, we explored the effect of secukinumab treatment on levels of ACE2 mRNA expression in the skin of patients enrolled in the ObePso-S study (ClinicalTrials.gov identifier NCT03055494). 8 ObePso-S was a randomized (2:1), double-blind, phase 4 trial investigating the effects of secukinumab on the levels of systemic inflammatory markers and the modulation of gene expression in fat, blood, and skin of patients with moderate-to-severe plaque psoriasis. Patients were treated with secukinumab, 300 mg (n 5 54), or placebo (n 5 28) for 12 weeks (the placebo-controlled period) and then rolled over to the open-label phase, during which they received secukinumab, 300 mg, every 4 weeks through week 52. A control group of healthy volunteers (n 5 17) was included. The study was conducted in accordance with the principles of the Declaration of Helsinki, and all patients provided written informed consent. Lesional and nonlesional 6-mm punch skin biopsies were performed at baseline, week 12, and week 52. ACE2 expression levels were assessed in the lesional and nonlesional biopsy samples by using mRNA quantification at baseline and at week 12 (see the Methods section of this article's Online Repository at www.jacionline.org). RNA expression was analyzed by using a mixed-effects model, with tissue type (lesional vs nonlesional) and time point (baseline vs week 12) as fixed effects and random effect for the patients. Least square means by group and fold change (FC) were also calculated. Hypotheses were tested by using multiple t tests for repeated samples. Correlations with clinical and biologic markers were assessed by using the Pearson method. ACE2 protein expression was detected by immunohistochemistry performed on frozen optimal cutting temperature compound-embedded samples (see the Methods section of the Online Repository).

Baseline patient characteristics are shown in Table E1 (in this article's Online Repository at www.jacionline.org). When assessed at baseline, ACE2 expression in patients with psoriasis was significantly upregulated in lesional skin compared with in nonlesional skin (FC 5 2.03; P <.001) and the skin of healthy patients (FC 5 1.8; P < .001); no significant difference in ACE2 expression was observed between nonlesional skin and the skin of healthy patients (Fig 1, A) . When assessed by treatment group, ACE2 expression was significantly upregulated in lesional versus in nonlesional skin of patients in the placebo and secukinumab groups at baseline (P < .001) (Fig 1, A) , which suggested that inflammation could be influencing ACE2 expression. To further investigate this, we assessed the correlation between ACE2 and interleukin 17A (IL-17A) expression in lesional skin at baseline and found significant correlation between expression of these genes (r 5 0.33; P < .005). Given that detection levels of IL-17A expression in skin were low, we also assessed the correlation between ACE2 and IL-17C at baseline. ACE2 expression significantly correlated with IL-17C expression (r 5 0.57; P <.001) (Fig  1, B) . We then examined the effect of treatment on ACE2 expression and found that inhibiting IL-17A-mediated inflammation with secukinumab treatment led to a significant downregulation of ACE2 expression at week 12 (FC 5 22.17; P < .001) (Fig 1,  A) ; no significant downregulation of ACE2 expression was observed with placebo (Fig 1, A) . We also examined the correlation between ACE2 expression and disease severity (using Psoriasis Area Severity Index [PASI] scores). Although ACE2 expression did not correlate with PASI scores at baseline (Fig 1,  C) , changes from baseline in ACE2 expression significantly correlated with changes from baseline in PASI scores at week 12 (Fig 1,  D) . These observations were consistent with clinical outcomes in these patients; at week 12, patients treated with secukinumab had substantial decreases in their PASI scores compared with those patients who received placebo (see Table E1 ).

We then assessed ACE2 protein expression in the skin and found that it was largely restricted to epithelial cells (keratinocytes) and substantially upregulated in the epidermis of psoriasis lesions, especially in basal keratinocytes (Fig 2) . Treatment with secukinumab not only reduced overall ACE2 protein expression in lesional epidermis, but also reduced basal layer expression in both lesional and unaffected skin biopsy samples. This reduced expression in unaffected skin might be due to the elevated levels of circulating IL-17 in patients with psoriasis leading to increased ACE2 expression in background skin, thus affecting expression in other types of epithelial cells.

Overall, our analysis showed that IL-17-mediated inflammation in patients with psoriasis is associated with increased ACE2 expression in skin plaques. Given that IL-17 exerts its proinflammatory effect systemically, it can be hypothesized that the skin may provide a model epithelium for inflammatory responses that can occur in other organs. 9 If IL-17-mediated inflammation increases ACE2 expression in other epithelia, untreated inflammatory diseases might lead to an increased risk or severity of COVID-19 infection. Importantly, secukinumab treatment lowered ACE2 expression to levels similar to those seen in nonlesional skin, which could prove to be advantageous in patients with psoriasis who are at risk for SARS-CoV-2 infection; however, additional studies are needed to determine whether similar findings are observed in other organs. Although further studies are warranted, our findings add new information on the relationship between IL-17-related inflammation and expression levels of the SARS-CoV-2 receptor/ACE2 in peripheral tissues. This information is 1 factor to consider in management of T-cell-mediated inflammatory diseases during the COVID-19 pandemic.

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There is a strong upregulation of ACE2 expression in the basal keratinocytes of lesional psoriasis skin. B, ACE2 expression is largely restricted to epithelial cells (keratinocytes). C, Treatment with secukinumab reduces overall ACE2 protein expression in the lesional epidermis and decreases basal layer expression in both lesional and nonlesional skin (C and D). E, Negative control demonstrates that the secondary antibody does not produce background staining. F, CD3 staining of baseline lesional skin is shown to demonstrate that a specific antibody to another target does not stain the epidermis. Scale bar 5 100 mm

Harshlight: a ''corrective make-up'' program for microarray chips

A model-based background adjustment for oligonucleotide expression arrays

biotinylated secondary antibody at room temperature for 30 minutes (Vector Laboratories, Burlingame, Calif), and developed with the chromogen 3-amino-9-ethylcarbazole

The authors thank Karen Chinchilla, PhD, of ArticulateScience LLC, Hamilton, NJ, for providing medical writing support and editorial support, which was funded by Novartis Pharmaceuticals Corporation, East Hanover, NJ, in accordance with Good Publication Practice (GPP3) guidelines (http:// www.ismpp.org/gpp3).James G. Krueger 

RNA was extracted, followed by hybridization to Affymetrix Human U133Plus 2.0 gene arrays (Affymetrix, Santa Clara, Calif), as previously described, by using probes 222257_s_at and 219962_at. E1 Quality control of the microarray chips was carried out with standard quality control metrics and the R software package microarray quality control. Images were scrutinized for spatial artifacts by using Harshlight. E2 Expression measures were obtained with the GCRMA algorithm. E3 A batch effect, corresponding to the hybridization date, was detected by using principal component analysis and adjusted with the ComBat function from the R software package sva.

Immunohistochemistry was performed on frozen optimal cutting temperature compound-embedded samples. Samples were fixed in acetone, blocked in 10% normal serum, incubated overnight in primary antibody at 48C,