Letter to Editor

Can anti-TNFα Antibodies Affect SARS-CoV-2 Disease Outcomes?

Dear Editor,

The novel coronavirus (COVID-19) that first appeared in December 2019, subsequently named severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is rapidly spreading as a global pandemic. Following infection by SARS-CoV-2, systemic inflammatory response mediated by the release of large amounts of mediators including IL-6, IL-1b, TNFα and IL-2R in severe infected patients. ^1,2

It has been reported that severe COVID-19 infected patients had significantly higher serum levels of TNF than non-severe infected patients. ²

In a case series study treatment of severe COVID-19 patients with infliximab (IFX), an anti-TNF antibody showed a rapid and temporary decrease in pro-inflammatory mediators such as IL-6 and other inflammatory markers (lactate dehydrogenase and C-reactive protein) along with clinical improvement in 6 of 7 infected patients. Lymphocyte count also increased in 5 patients after IFX treatment which was initially below (before IFX treatment). Moreover, 35% overall mortality at a similar stage of hospitalization was also observed in the 17 patients of the control group. ³ In a study a man about 70 years old that treated with IFX (5 mg/kg) every 8 weeks and azathioprine for refractory ulcerative colitis infected with SARS-CoV-2, the symptoms of pneumonia were not observed on his chest computed tomography (CT). Also, some symptoms of this patient resolved within a few days without special treatment. But his wife, who was younger than that was not received immunosuppressive drugs, developed SARS-CoV-2 induced pneumonia. ⁴

The results of a study showed that from 530 rheumatoid arthritis patients that treated with anti TNF agents (53.7%), 39.3% with other biologic disease-modifying drugs (bDMARDs) and treated with JAK inhibitors (7%) only 3 patients with mild COVID-19 were confirmed that managed at home without any complication in respiratory tract. ⁵

In conclusion, TNF may exert pathogenic effects in coronavirus disease by augmenting the expression of angiotensin-converting enzyme 2 (ACE2) or by augmenting lymphopenia. Anti-TNF antibody by modulating of immune system and expression of ACE2 can useful for SARS-CoV-2 disease. But more clinical trials of anti-TNFα therapy for SARS-CoV-2 disease were suggested.

Ethical Issues

Not applicable.

Conflict of Interest

The author declares no conflicts of interest in this study.

References

1. Cameron MJ, Bermejo-Martin JF, Danesh A, Muller MP, Kelvin DJ. Human immunopathogenesis of severe acute respiratory syndrome (SARS). Virus Res 2008; 133(1):13-9. doi: 10.1016/j.virusres.2007.02.014 [Crossref]
2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395(10223):497-506. doi: 10.1016/s0140-6736(20)30183-5 [Crossref]
3. Stallmach A, Kortgen A, Gonnert F, Coldewey SM, Reuken P, Bauer M. Infliximab against severe COVID-19-induced cytokine storm syndrome with organ failure-a cautionary case series. Crit Care 2020; 24(1):444. doi: 10.1186/s13054-020-03158-0 [Crossref]
4. Kunisaki R, Tsukiji J, Kudo M. Potential inhibition of COVID-19-driven pneumonia by immunosuppressive therapy and anti-TNFα antibodies: a case report. J Crohns Colitis 2020; 14(12):1786-7. doi: 10.1093/ecco-jcc/jjaa105 [Crossref]
5. Favalli EG, Ingegnoli F, Cimaz R, Caporali R. What is the true incidence of COVID-19 in patients with rheumatic diseases?. Ann Rheum Dis 2021; 80(2):e18. doi: 10.1136/annrheumdis-2020-217615 [Crossref]