Angiotensin II Receptor Blockers (ARBs Antihypertensive Agents) Increase Replication of SARS-CoV-2 in Vero E6 Cells

Abstract

Several comorbidities, including hypertension, have been associated with an increased risk of developing severe disease during SARS-CoV-2 infection. Angiotensin II receptor blockers (ARBs) are currently some of the most widely-used drugs to control blood pressure by acting on the angiotensin II type 1 receptor (AT1R). ARBs have been reported to trigger the modulation of the angiotensin I converting enzyme 2 (ACE2), the receptor used by the virus to penetrate susceptible cells, raising concern that such treatments may promote virus capture and increase their viral load in patients receiving ARBs therapy. In this in vitro study, we reviewed the effect of ARBs on ACE2 and AT1R expression and investigated whether treatment of permissive ACE2+/AT1R+ Vero E6 cells with ARBs alters SARS-CoV-2 replication in vitro in an angiotensin II-free system. After treating the cells with the ARBs, we observed an approximate 50% relative increase in SARS-CoV-2 production in infected Vero E6 cells that correlates with the ARBs-induced up-regulation of ACE2 expression. From this data, we believe that the use of ARBs in hypertensive patients infected by SARS-CoV-2 should be carefully evaluated.

Renin-angiotensin system blockade on angiotensin-converting enzyme 2 and TMPRSS2 in human type II pneumocytes

“…Regarding RAS blockade and ACE2 expression we found that smokers under RAS blockade exhibited a slightly enhanced amount of ACE2-expressing type II pneumocytes compared to never smokers. Supporting our results, recently it has been shown that ARBs increased SARS-CoV-2 replication in Vero E6 cells that correlated with the ARBs-induced up-regulation of ACE2 expression [45] . In contrast, in a study by Lee et al [8] using a small sample size of patients taking ACEIs, upper respiratory tract ciliary ACE2 expression was slightly decreased compared to matched controls.…”

“…We found that older smokers and former smokers comprised the largest percentage of subjects exhibiting higher ACE2 protein content. In agreement, higher ACE2 expression in smokers compared to never smokers have been reported [17] , [43] , [44] , [45] . In contrast, other reports have shown that current smokers and never smokers have similar levels of bronchial epithelial cell mRNA ACE2 [46] and ACE2 protein in both bronchial and alveolar epithelial cells [47] as well as nasal ciliary cells [9] .…”

Angiotensin II Type I Receptor (AT1R): The Gate towards COVID-19-Associated Diseases

“…As its name suggests, this type of medication works by blocking the Ang II receptor, given its role in promoting the constriction of blood vessels and in increasing blood pressure [ 113 , 114 ]. Since these receptors are found in the heart, blood vessels, kidneys, and intestine [ 115 , 116 ], blocking their action helps in lowering blood pressure and preventing kidney and heart damage [ 117 ]. In addition, blocking AT1R may reduce acute lung injury and the response of inflammatory mediators [ 62 ].…”

“…Azilsartan, eprosartan, irbesartan, and telmisartan induced a higher expression of ACE2 in Vero E6 cells than in untreated cells, which also have increased expression of AT1R, the binding of which to these blocking molecules was reduced. Interestingly, there are significant differences in the ability of ARBs to induce the overexpression of ACE2 once bound to AT1R, since some drugs at 7 µM (e.g., telmisartan) led to higher ACE2 increase than others when used at higher concentration (e.g., irbesartan at 60 µM) [ 117 ]. It is also known that following Ang II binding, AT1R triggers ACE2 cleavage and shedding, dependent on the p38–MAPK pathway, resulting in reduced cell surface expression [ 136 , 137 ].…”

“…Results indicated that Vero E6 cells previously treated with ARBs for 72 h exhibit relative increases in ACE2 expression and SARS-CoV-2 production. Interestingly, scientists commented that Vero E6 cells were treated with ARBs without adding Ang II, which has been reported as a biomarker of severe COVID-19 [ 117 ]. In addition, increased SARS-CoV-2 production found in Vero E6 cells was not observed in the preliminary investigations recently performed on two human cell lines—namely, Caco-2 (intestinal epithelia origin) and Calu-3 (lung epithelia origin).…”