We have previously shown that elevated cytokine release of IL-a/b, IL-6, MIP-1b, RANTES and TNF-a induced by highly pathogenic avian H5N1 influenza A virus was significantly reduced by application of the proteasome inhibitor VL-01 in vivo 32. The underlying mechanism of this inhibitory effect of proteasome inhibitors is supposed to be mediated largely by the inhibition of one of the most prominent cellular transcription pathways, NF-kB. The inhibition of the nuclear translocation of the transcription factor NF-kB by proteasome inhibitors has been described 33-35. It is mediated via the inhibition of the proteasomal degradation of the cytosolic inhibitor IkBa, this way keeping NF-kB sequestered by IkBa in the cytosol and thereby inhibiting the otherwise induced translocation of NF-kB to the nucleus where it would initiate the transcription of multiple pro-inflammatory proteins, such as cytokines, chemokines, adhesion molecules and growth factors (see Figure 1). Activation of the NF-kB pathway has been described for very different signal-receptor bindings, including binding of LPS to TLR4, binding of cytokines like IL-1 and TNFa to their respective receptors, or recognition of RNA viruses by Toll-like receptors, TLR7/8. Importantly, all these different signaling pathways join into a common downstream signaling sequence of phosphorylation of the cytosolic inhibitor IkBa which triggers its ubiquitination and proteasomal degradation resulting in release and translocation of NF-kB into the nucleus 35 (see Figure 1). These data suggest that interfering at these late stages (i.e. phosphorylation, ubiquitination, and/or proteasomal degradation of IkBa) of the pathway will inhibit NF-kB activation, irrespectively of the initial triggering signal. We could demonstrate the inhibitory effect of proteasome inhibitors on nuclear translocation NF-kB in various cell types such as human macrophages after stimulation with TNFa in vitro. Without stimulation of the NF-kB pathway, p65/p50 (p65 FITC stained) is sequestered in the cytosol by its inhibitor IkB. Following stimulation by TNFa, NF-kB translocates to the nucleus (shown by coinciding p65 staining and nucleus staining by DAPI). NF-kB nuclear translocation after TNFa stimulation was inhibited by application of the proteasome inhibitor VL-01 showing p65 staining in the cytosol and only few cells with p65 positive nucleus (Figure 2).
The influence of VL-01 on the pro-inflammatory cytokine and chemokine response in vivo was demonstrated in a H5N1 influenza virus mouse model. A strong cytokine and chemokine response was induced in Balb/c mice intranasally infected with avian H5N1 virus A/mallard/Bavaria/1/2006 (7x102 pfu, i.e. 10-fold MLD50). Mice were treated i.v. either with 25 mg/kg VL-01 or solvent (mock) two hours prior to virus infection. Serum samples for cytokine analysis were collected at different time points after infection. While some cytokines/chemokines such as TNFa, MIP-1b, and RANTES peaked very early after H5N1 infection (12 hrs), others, i.e. KC (neutrophil-activating protein-3) and IL-6, peaked later at 72 hrs after infection (Fig. 3). Treatment with proteasome inhibitor significantly inhibited the release of IL-1, IL-6, TNFa, MIP-1 and CXCL1 at the peak time-points in Balb/c mice after infection with the highly pathogenic avian H5N1 influenza A virus (Fig. 3). Importantly, proteasome inhibition significantly decreased the release for all, early and late cytokines and chemokines, and resulted in significantly increased survival of mice after infection with the highly pathogenic avian H5N1 influenza A virus 32.
In order to investigate whether the inhibition of cytokine and chemokine release by inhibition of the nuclear translocation of NF-kB is a general mechanism, an acute lung injury (ALI) mouse model with LPS challenge was used. This model provides a rapid and strong systemic induction of pro-inflammatory cytokines and chemokines. Balb/c mice were treated i.v. with 25 mg/kg VL-01, followed by i.p. application of 20 µg LPS. Serum samples for cytokine analysis were collected before (-4hrs) LPS treatment (control) and after LPS treatment (1.5 and 3 hrs). Again distinct release patterns were found for different cytokines/chemokines, with TNFa, IL-1b, MIP-1a and MIP-1b peaking already 1.5 hrs after LPS challenge, followed by others, such as IL-6, RANTES, IL-12p40 and KC peaking 3 hrs after LPS stimulus (Fig. 4). Importantly, treatment of mice with proteasome inhibitor significantly reduced release of the whole panel of pro-inflammatory cytokines and chemokines. Taken together, these data generated in different models demonstrate the principal potency of proteasome inhibitors to interfere with the pro-inflammatory effects, by inhibiting the translocation of NF-kB to the nucleus.
As a second line of evidence for the potential role of the NF-kB pathway in acute respiratory viral infection DeDiego et al. have demonstrated, that the inhibition of NF-kB-mediated inflammation in SARS-CoV infected mice significantly decreased the expression of pro-inflammatory cytokines including TNFa, IL-6 and chemokines including CCL-2, CCL-5, CXCL-1, CXCL-2, CXCL-10, correlating with increased survival. In their study four different NF-kB inhibitors, with different mechanism of inhibition, i.e. CAPE, resveratrol, Bay11-7082, and parthenolide, were used. All four inhibitors were shown to inhibit NF-kB activity, and to decrease the expression levels of pro-inflammatory cytokines and chemokines, without affecting viral titers or cell viability 36.
Moreover, Acetylsalicylic acid (ASA) and other salicylates – in contrast to pure (COX) cyclooxygenase inhibitors, such as indomethacin – are well-known inhibitors of NF-κB activation by acting as specific inhibitors of IKK2 – a kinase essential for phosphorylating IkB 37. Furthermore, D,L-lysine-acetylsalicylate∙glycine (LASAG) a water-soluble salt of ASA (licensed as Aspirin i.v.®) was shown to decrease activation of promoter constructs of NF-κB-dependent genes for IL-6 and IL-8 and to improve the time to alleviation of influenza symptoms in hospitalized patients in a phase II clinical trial 38. The well-known analgesic, antipyretic, anti-thrombotic, anti-inflammatory, and antiviral effects of ASA have led to initiation at least 8 clinical studies investigating the effects of ASA in COVID-19 according to clinicaltrials.gov 39.
The concept of a central role of NF-kB pathway in critical stage SARS-CoC-2 infected patients is supported by two recently published studies showing pronounced clinical effect in critical COVID-19 patients by Bruton tyrosine kinase (BTK) inhibitors, correlating with significantly decrease in inflammatory parameters (C-reactive protein and IL-6), normalized lymphopenia, and improved oxygenation 40,41. Bruton tyrosine kinase is known to be involved in TLR7/8-induced TNFa transcription via NF-κB recruitment at the stage of phosphorylation of p65 42.
Finally, support for the role of NF-kB pathway in critical stage COVID-19 patients is provided by recent results from the RECOVERY trial. Dexamethasone was found to significantly reduce death in patients with severe respiratory complications of COVID-19 requiring ventilation by up to one third 43. Dexamethasone – a broadly used glucocorticoid anti-inflammatory drug – is assumed to mediate its anti-inflammatory activity at least partially via downregulation of the NF-kB activity 44, probably by suppression of NF-kB expression 45 and/or increased expression of IkB in the cytoplasm 46.
All these data collectively strongly indicate that inhibition of the NF-kB signal pathway may be a promising target to control SARS-CoV-2 induced excessive immune activation associated with systemic cytokine and chemokine release, capillary leakage and multi-organ tissue damage (Figure 1).