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LETTER TO THE EDITOR

Comment on “Colchicine may not be effective in COVID-19 infection;

it may even be harmful?”

Senol Kobak1

Received: 16 May 2020 / Revised: 16 May 2020 / Accepted: 9 June 2020 # International League of Associations for Rheumatology (ILAR) 2020

Dear Editor

We read with great interest the report by Cure et al. which spec-ulated that colchicine may not be effective in COVID-19 infec-tion [1]. The main argument of the authors is that colchicine may have not increased the intracellular pH enough and cannot pre-vent the binding of the virus to the target angiotensin converting enzyme 2(ACE2) receptors. Also, they suggest that colchicine may increase the risk of acute respiratory distress syndrome(ARDS) and disseminated intravascular coagulation(DIC) which may occur during COVID-19 infection. We have not agreed with the authors at these points. Fırst, the colchicine and anti-malarial drugs both may increase the intracel-lular pH by different mechanisms. There are no studies investi-gating the intracellular concentration of colchicine in corona in-fection, while such data exist regarding chloroquine [2]. So, this view is only an author’s hypothesis that is not based on scientific data. Second, there is no any data supporting Cure et al. that colchicine increases the risk of ARDS and DIC in COVID-19 patients. On the contrary, we hypothesize that colchicine may protect rheumatic patients from COVID-19 or perhaps cause them to pass in a milder form of disease. COVID-19 is not only a viral infection, it is an autoinflammatory/autoimmune process that develops as a result of immune system dysfunction, cytokine release syndrome, and hemophagocytic lymphohistiocytosis [3]. It acts by binding to ACE2 receptors in target organs such as lung alveolar type 2 cells [4]. When COVID-19 is passed into the cell via ACE2, activation of NLRP3 inflammasome is triggered by immunological mechanisms. The presence of high NLRP3-induced pro-inflammatory cytokines (IL-1, IL-1beta) in the sera of COVID-19 patients supports this hypothesis [5]. Colchicine is an anti-inflammatory agent that inhibit the microtubule

polymerization on the cytoskeleton. Microtubules play an impor-tant role in cell migration, signal transduction and gene expres-sion [6]. Colchicine act on NLRP3 inflammasome resulting in inhibition of important signaling pathways involving intracellular secretion of cytokines and chemokines. It is estimated that one of the important pathogenic mechanisms of COVID-19 is through activation of NLRP3 inflammasome [7]. Considering the mech-anism of action of colchicine, it would make rationale use in patients with COVID-19 infection [8]. Therefore, at the present time, four randomized studies regarding colchicine in COVID-19 patients have been ongoing. ClinicalTrials.gov Identifier: N C T 0 4 3 2 2 6 8 2 , N C T 0 4 3 2 6 7 9 0 , N C T 0 4 3 2 2 5 6 5 , NCT04328480).

Recently, we reported COVID-19 infection in a patient with FMF under treatment with colchicine [9]. The patient was PCR positive for COVID-19 and have only mild symp-toms of disease (such as myalgia, arthralgia). On radiologic investigation, thorax CT was normal. The patient was treated according to accepted protocol,(hydroxychloroquine, azitromycine, and oseltamivir) in our country. Colchicine was also continued. Markedly regression in patients com-plaints after treatment were seen and control COVID-19 PCR test was negative. Although we cannot draw any defin-itive conclusion from our observation, we hypothesize that colchicine may prevent of severe form of disease. Prospective, randomized, placebo-controlled studies are need-ed in this regard.

Compliance with ethical standards

Conflict of interest The author declared not any conflict of interest of any financial support.

References

1. Cure CM, Kucuk A, Cure E (2020) Colchicine may not be effective in COVID-19 infection; it may even be harmful? Clin Rheumatol 39: 2101–2102.https://doi.org/10.1007/s10067-020-05144-x

* Senol Kobak

senolkobak@yahoo.com

1 Department of Internal Medicine and Rheumatology, Liv Hospital,

Istinye University Faculty of Medicine, Canan sokak No. 5 Ulus, Istanbul, Turkey

https://doi.org/10.1007/s10067-020-05233-x

/ Published online: 20 June 2020 Clinical Rheumatology (2020) 39:2487–2488

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2. Vincent MJ, Bergeron E, Benjannet S, Erickson BR, Rollin PE, Ksiazek TG, Seidah NG, Nichol ST (2005) Chloroquine is a potent inhibitor of SARS coronavirus infection and spread. Virol J 2:69 3. Caso F, Costa L, Ruscitti P, Navarini L, Del Puente A, Giacomelli R

et al (2020) Could Sars-coronavirus-2 trigger autoimmune and/or autoinflammatory mechanisms in genetically predisposed subjects? Autoimmun Rev 19(5):102524

4. Li W, Moore MJ, Vasilieva N, Sui J, Wong SK, Berne MA, Somasundaran M, Sullivan JL, Luzuriaga K, Greenough TC, Choe H, Farzan M (2003) Angiotensin-converting enzyme 2 is a function-al receptor for the SARS coronavirus. Nature 426(6965):450–454 5. Cookson BGT, Brennan MA (2001) Pro-inflammatory programmed

cell death. Trends Microbiol 9:113–114

6. Levy M, Spino M, Read SE (1991) Colchicine: a state-of-the-art review. Pharmacotherapy. 11(3):196–211

7. Chen I-Y, Moriyama M, Chang M-F, Ichinohe T (2019) Severe acute respiratory syndrome Coronavirus Viroporin 3a activates the NLRP3 inflammasome. Front Microbiol 10(JAN):50

8. Deftereos SG, Siasos G, Giannopoulos G, Vrachatis DA, Angelidis C, Giotaki SG, et al. (2020) The Greek study in the effects of colchi-cine in COvid-19 complications prevention (GRECCO-19 study): rationale and study design. Hellenic J Cardiol. S1109– 9666(20)30061–0

9. Kobak S (2020) Covid-19 infection in a patient with FMF: does the colchicine have protective effect. Ann Rheum Dis.https://doi.org/10. 1136/annrheumdis-2020-217882annrheumdis-2020-217882

Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institujurisdic-tional affiliations.

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