Cannabinoids as Emergent Therapy Against COVID-19

Title: Cannabinoids as Emergent Therapy Against COVID-19 Authors: J. McGrail, Lucía Martín-Banderas, Matilde Durán-Lobato Note: This is the accepted manuscript of the article published in Cannabis and Cannabinoid Research. This version has been peer-reviewed but has not undergone final editing, formatting, or typesetting by the publisher. For the final published version, please refer to: McGrail, J., Martín-Banderas, L., & Durán-Lobato, M. (2022). Cannabinoids as Emergent Therapy Against COVID-19. Cannabis and Cannabinoid Research, 7(5), 582– 590. https://doi.org/10.1089/can.2021.0147 For Peer Review Cannabis and Cannabinoid Research Cannabinoids as emergent therapy against COVID-19 Journal: Cannabis and Cannabinoid Research Manuscript ID CAN-2022-0018.R1 Manuscript Type: Mini-Review Date Submitted by the Author: n/a Complete List of Authors: McGrail, Joseph; Universidad de Sevilla, Farmacia y Tecnología Farmacéutica Martín-Banderas, Lucía; Universidad de Sevilla, Farmacia y Tecnología Farmacéutica Durán-Lobato, Matilde; Universidad de Sevilla, Farmacia y Tecnología Farmacéutica Keywords: Cytokine expression, Inflammation, T-cell proliferation, Cannabidiol, Tetrahydrocannabinol Manuscript Keywords (Search Terms): COVID-19, acute respiratory distress syndrome cannabinoid, cytokine storm, antiviral, cannabinoid Abstract: The Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Distress Syndrome Coronavirus 2 (SARS-Cov-2), was identified for the first time in late 2019 in China, resulting in a global pandemic of massive impact. Despite a fast development and implementation of vaccination strategies, and the scouting of several pharmacological treatments, alternative effective treatments are still needed. In this regard, cannabinoids represent a promising approach since they have been proven to exhibit several immunomodulatory, antiinflammatory and antiviral properties in COVID-19 disease models and related pathological conditions. This mini-review aims at providing a practical brief overview of the potential applications of cannabinoids so far identified for the treatment and prevention of COVID-19, finally considering key aspects related to their technological and clinical implementation. ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. For Peer Review 1 1Cannabinoids as emergent therapy against COVID-19 2 3Joseph McGraila, Lucía Martín-Banderasa, Matilde Durán-Lobatoa* 4 5aDpto. Farmacia y Tecnología Farmacéutica, Facultad de Farmacia. Universidad de 6Sevilla. C/Prof. García González nº2 41012, Sevilla, España. 7 8*Corresponding author 9Matilde Durán-Lobato 10 Dpto. Farmacia y Tecnología Farmacéutica, Facultad de Farmacia. Universidad de 11 Sevilla. C/Prof. García González nº2 41012, Sevilla, España. 12 E-mail address: [email protected] 13 Phone: +34 954556757 Page 6 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 2 14 15 ABSTRACT 16 The Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory 17 Distress Syndrome Coronavirus 2 (SARS-Cov-2), was identified for the first time in late 18 2019 in China, resulting in a global pandemic of massive impact. Despite a fast 19 development and implementation of vaccination strategies, and the scouting of several 20 pharmacological treatments, alternative effective treatments are still needed. In this 21 regard, cannabinoids represent a promising approach since they have been proven to 22 exhibit several immunomodulatory, anti-inflammatory and antiviral properties in COVID23 19 disease models and related pathological conditions. This mini-review aims at 24 providing a practical brief overview of the potential applications of cannabinoids so far 25 identified for the treatment and prevention of COVID-19, finally considering key aspects 26 related to their technological and clinical implementation 27 28 Keywords: COVID-19, acute respiratory distress syndrome, cytokine storm, antiviral, 29 cannabinoid Page 7 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 3 31 32 TABLE OF CONTENTS 33 1. Introduction 34 2. Potential applications of cannabinoids in COVID-19 35 2.1 Downregulation of ACE2 and TMPRSS2 (Prophylaxis) 36 2.2 PPAR-γ activation 37 2.3 Prevention of the Cytokine Storm and ARDS 38 2.4 Effects on COVID-19 models: blocking of SARS-Cov-2 replication and anti39 inflammatory effects 40 3. Conclusions and future prospects Page 8 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 4 42 43 1. INTRODUCTION 44 Coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory 45 Syndrome Coronavirus 2 (SARS-CoV-2), appeared in late 2019 in China, leading to a 46 global pandemic of massive impact1. Several treatments have been investigated, 47 including interferon-α and anti-viral drugs such as remdesivir2. Vaccines were designed 48 to fight off the virus, including novel formulations such as mRNA-based vaccines that 49 have been proven highly efficient and safe3. Notwithstanding, due to the scale of the 50 pandemic and the evolving characteristics of the virus, alternative and effective 51 treatments still need to be considered. 52 53 Cannabinoids have been explored as potential pharmaceutical treatments against a 54 wide range of pathologies including inflammatory diseases and cardiovascular 55 disorders4,5. Their effects are mainly due to the activation of CB1 and CB25. 56 Interestingly, specific CB2 activation was found to lead to a higher controlled release of 57 proinflammatory cytokines, useful in conditions that cause airway inflammation and 58 fibrosis, such as asthma4,6, and subsequently COVID-197. More specifically, 59 cannabinoids have been recently shown to alleviate the symptoms associated to 60 severe cases of COVID-19 through several mechanisms8–10 and have been attributed 61 with antiviral activity9–11. This mini-review aims at providing a practical brief overview of 62 the potential applications of cannabinoids so far identified for the treatment and 63 prevention of COVID-19, finally considering key aspects related to their technological 64 and clinical implementation. 65 Page 9 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 5 66 2. POTENTIAL APPLICATIONS OF CANNABINOIDS IN COVID-19 67 68 Recently identified pharmacological properties of cannabinoids with high interest in the 69 context of COVID-19 are summarized and discussed in the following sections. 70 71 2.1 Downregulation of ACE2 and TMPRSS2 (Prophylaxis) 72 73 The infection mechanism of SARS-CoV-2 involves the priming of spike (S) proteins by 74 host cell proteases, which leads to the fusion of the viral and cellular membranes. 75 Specifically, the process takes place upon interaction of the S protein with angiotensin76 converting enzyme 2 (ACE2) receptors and transmembrane serine proteases 77 (TMPRSS2)12. 78 79 In this context, a potential application of cannabidiol (CBD) as prophylaxis has been 80 considered. CBD has been reported to downregulate ACE2 and TMPRSS213. More 81 specifically, CBD reduced ACE2 expression in an alveolar epithelial cells (A549)8, 82 indicating a potential hampering effect on SARS-CoV-2 infection. Mouthwashes with 83 high concentrations of CBD were proposed as prophylaxis10. 84 85 2.2 PPAR-γ activation 86 87 Peroxisome proliferator-activated receptors (PPAR) are a large family of nuclear 88 receptors/transcription factors, which modify the transcription of target genes upon 89 activation14. Particularly, the activation of PPARγ leads to reduced pulmonary Page 10 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 6 90 inflammation, subsequently related to a faster recovery in viral respiratory infections 91 such as influenza15. Thus, PPARγ activation could be considered a potential 92 pharmacological target in severe cases of COVID-191. 93 94 Moreover, a significant number of patients surviving COVID-19 present unresolved 95 decreased lung capacity and pulmonary fibrosis10. Pulmonary fibrosis is categorised as 96 an alteration in fibroblast phenotypes causing a disproportionate accumulation of 97 extracellular matrix. Interestingly, in vitro experiments showed that the activation of 98 PPARγ in lung fibroblasts led to an inhibition of a proliferative response16. 99 100 CBD has been attributed with PPAR-γ agonist activity, potentially useful for limiting 101 excessive lung inflammation, decreasing in turn the mortality rate of COVID-19 and 102 associated sequelae. In fact, CBD led to reduced lung inflammation and a lower rate of 103 fibrosis in mice with induced allergic asthma4. 104 105 Furthermore, CBD has been described as a weak agonist10. Thus, CBD could prevent 106 secondary effects associated with full PPAR-g agonist, such as higher risk of 107 cardiovascular complications, including stroke and heart failure17. Thus, CBD would 108 represent an interesting approach against COVID-19 pulmonary inflammation and 109 fibrosis with minimized side effects. 110 111 2.3 Prevention of the Cytokine Storm and ARDS 112 Page 11 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 7 113 The cytokine storm is a disproportionate release of inflammatory cytokines as response 114 of the human body upon exposure to a biological or chemical agent18, and constitute a 115 key factor in the development of the acute respiratory distress syndrome (ARDS)9. 116 ARDS arises from excessive activation of the immune system and may result in 117 respiratory and multi-organ failure, leading to death. Importantly, COVID-19 disease 118 stems from the development of ARDS19. Several strategies involving the use of 119 cannabinoids as means of preventing and treating the cytokine storm, and therefore 120 ARDS, have been identified. 121 122 Downregulation of the expression of inflammation-related genes 123 124 Cannabinoids have been attributed with the capacity to downregulate the expression of 125 inflammation-related genes. The effect of several cannabis extracts on the expression 126 of genes encoding interleukins and pro-inflammatory cytokines with a significant role in 127 the development of ARDS and associated mortality of COVID-19 was evaluated in UV128 exposed artificial skin20. A correlation between Δ-9-tetrahydrocannabinol (Δ9-THC) 129 concentration and the downregulated expression of several genes was found (Figure 130 1). 131 132 Even though these effects should be confirmed in a SARS-CoV-2 inflammation tissue 133 model, the similarities in the mechanisms of inflammation and fibrosis with the assayed 134 tissue model20 support the potential usefulness of cannabinoids in this regard. 135 136 Increase of immunoregulatory cells Tregs and MSDC Page 12 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 14 281 applications. Finally, the translation of in vivo results in small animal models to humans 282 is conditioned by the dose of cannabinoid needed to reach the therapeutic target, 283 subsequently determining the dose of cannabinoid to be administered, as well as 284 interspecies differences. For instance, the active doses employed in the studies 285 referenced in this work ranged from 5 to 20 mg/Kg body weight in mice, which would 286 correspond to 0.4 – 1.62 mg/Kg body weight in humans, according to FDA criteria for 287 conversion into Human Equivalent Dose (HED). However, active doses of 288 cannabinoids assayed in recent clinical trials also range from 5 to 20 mg/Kg in humans. 289 In this context, the unfavourable physicochemical and biopharmaceutical properties of 290 cannabinoids must be considered. On one hand, the poor stability and solubility of 291 cannabinoids typically lead to inadequate bioavailability values. On the other hand, 292 cannabinoids unspecific biodistribution, along with their capacity to interact with several 293 receptors, the latter being widely distributed in the organism, frequently result in side 294 effects, even including psychotropic effects. Ultimately, only a limited fraction of the 295 dose employed is estimated to reach the therapeutic target, with a significant risk of 296 adverse effects. Of note, the recent clinical trial on CBD for COVID-19 patients 297 (NCT04467918) previously referenced employed an oral 300 mg/d dose of CBD (5 298 mg/Kg), resulting in no alteration of the clinical evolution of COVID-19 along with the 299 observation of mild and transient side effects, and leading to consider the need of 300 higher doses. 301 Overall, the issues related to cannabinoids unfavourable properties remain a common 302 challenge regardless of the disease of interest. Since increasing the administered dose 303 may not be the most convenient alternative, given the potential associated costs and 304 increased side effects, technological tools have been increasingly considered for a Page 19 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 15 305 wide range of applications. Initially, a local modality of administration is expected to 306 help minimize the extent of drug reaching off-side targets. Furthermore, advanced 307 technological tools, including microspheres and nanocarriers, with the capacity to 308 optimize cannabinoid delivery to the desired location, are enabling advances reaching 309 clinical evaluation and the therapeutic market. 310 In the specific case of COVID-19, pulmonary administration would be an especially 311 convenient alternative to be considered for cannabinoid-based therapies. In addition, 312 the success reported by cannabinoid-based drug delivery systems for several 313 syndromes offer a promising alternative to boost the clinical development in this arena. 314 Overall, cannabinoids offer a great pharmacological potential in the management of 315 COVID-19, but their successful implementation as actual treatment will rely on further 316 pharmacological evaluation along with the implementation of drug delivery tools. It is to 317 be hoped that the scientific evidence so far reported on cannabinoids effects along with 318 the possibilities offered by drug delivery systems will entice the development of 319 valuable therapies in this area. 320 321 ACKNOWLEDGEMENTS 322 M. Durán-Lobato acknowledges a postdoctoral contract granted by “VI Plan Propio” 323 from the University of Seville (USE-19533-Y). 324 325 CONFLICT OF INTEREST STATEMENT 326 The authors declare no conflict of interest. 327 Page 20 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 16 328 REFERENCES 329 1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 330 novel coronavirus in Wuhan, China. Lancet 2020;395(10223). 331 https://doi.org/10.1016/S0140-6736(20)30183-5. 332 2. 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Cannabidiol inhibits SARS-Cov-2 spike 444 (S) protein-induced cytotoxicity and inflammation through a PPARγ-dependent 445 TLR4/NLRP3/Caspase-1 signaling suppression in Caco-2 cell line. Phyther Res 446 2021;35(12):6893–903. https://doi.org/10.1002/ptr.7302. 447 34. Saraswat A, Vartak R, Patki M, Patel K. Cannabidiol Inhibits In Vitro Human 448 Liver Microsomal Metabolism of Remdesivir: A Promising Adjuvant for COVID449 19 Treatment . Cannabis Cannabinoid Res 2021;X(X):1–11. 450 https://doi.org/10.1089/can.2021.0109. 451 452 FIGURE LEGENDS Page 27 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 23 453 Figure 1. Graphic displaying analysis of global gene expression profiling of Artificial 454 Human 3D skin EpiDermFTTM exposed to Ultraviolet (UV) and treated with different C. 455 sativa extracts (15 µL of 60 mg/mL extract solutions in DMSO). Extracts 4, 6, 8, 13 and 456 14 highly downregulated genes such as pro inflammatory interleukins and cytokine, C457 C motif chemokines and C-X-C subfamily cytokines that play a role in ARDS. Extract 458 12 upregulated the genes and 15 did not modify gene expression. Reproduced from 459 Kovalchuk et al.20 Extracts composition in % of cannabinoids: extract 4 10.69% THC, 460 0.55% CBD, 0.10% CBGA, 0.05% CBN; extract 6 3.28% THC, 7.44% CBD, 1.07% 461 CBGA, 0.03% CBN; extract 8 10.34% THC, 0.10% CBD, 0.15% CGA, 0.02% CBN; 462 extract 12 13.74% THC, 0.57% CBD, 0.29% CBGA, 0.04% CBN; extract 13 12.24% 463 THC, 0.38% CBD, 0.12% CBGA, 0.04% CBN; extract 14 14.09% THC, 0.35% CBD, 464 0.07% CBGA, 0.11% CBN; extract 15 10.34% THC, 0.29% CBD, 0.07% CBGA, 0.11% 465 CBN. 466 467 Figure 2. Microscopy images from Masson´s trichome analysis of lung tissues 468 displayed that post intranasal administration of elevated dosage of Poly (I:C) led to 469 elevated devastation of the lung tissue, pulmonary oedema, hypertrophy and fibrosis, 470 while CBD treatment helped maintain the original) state, represented in control image 471 (Images on the left). Immunofluorescence analysis revealed that CBD contributed to 472 maintain normal Apelin levels compared to Poly (I:C) treated tissue, and reduced the 473 amount of IL-6, a pro-inflammatory cytokine (Images on the right) (Red: apelin; green: 474 IL-6; DAPI: cell nuclei). Dosing; control group: intranasal, once daily administration of 475 sterile saline for three consecutive days; Poly(I:C) group: intranasal, once daily 476 administration of Poly (I:C) (100 μg in 50 μL in sterile saline) for three consecutive days Page 28 of 34 ScholarOne Support phone: 434-964-4100 email: [email protected] Mary Ann Liebert, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60