Iloprost May Be Useful in the Treatment of COVID-19 Vasculopathy

Prostacyclin receptor agonist iloprost may be a useful adjunctive treatment for coronavirus disease 2019 (COVID-19) vasculopathy, according to a report published in Lancet Rheumatology.¹

Previous studies have indicated low-dose systemic iloprost in the treatment of patients with autoimmune peripheral vasculopathy.² To evaluate the effectiveness of iloprost therapy in reducing endothelial dysfunction and systemic inflammation in COVID-19 vasculopathy, it was added to standard treatment in patients with COVID-19.

A total of 3 patients (all men; age range, 44-62 years) were admitted to the hospital with severe COVID-19 (defined as acute onset of bilateral lung infiltrates) and hypoxemia. All patients tested positive for severe acute respiratory syndrome coronavirus 2. Two patients presented with digital ischemia; all 3 received supportive oxygen treatment. Based on clinical diagnoses and persistent oxygen requirement, patients received a 5-day intravenous infusion of iloprost (0.5 mg/kg/min).

Following continuous treatment with iloprost, patients showed sustained clinical improvement in digital ischemia and cardiovascular and respiratory parameters, decreasing oxygen requirements, and increasing Pa0₂:FiO₂ ratio. It was noted that none of the patients required mechanical ventilation or had any serious adverse events. Any complications, including mild rebound tachycardia, observed upon iloprost cessation were resolved before patients were discharged from the hospital.

Overall, the authors of this report concluded, “Although larger controlled studies are needed to confirm our observations and despite the limitations inherent to small case series, based on the pharmacological effects of iloprost in analogous pathological states and its [favorable] safety profile, we suggest that iloprost might be a useful adjunctive treatment in COVID-19.”

To get further insight, we spoke with the lead author of this case report, Carine J. Moezinia, MBBS, department of rheumatology at Royal Free Hospital in London, United Kingdom and the Hospital for Special Surgery, New York City, New York.

Can you tell us more about the recent case series you published on iloprost treatment for COVID-19 vasculopathy?

Our rheumatology department became very actively involved in caring for patients with acute COVID-19, as [we were working closely with] the acute COVID-19 wards. One thing we were struck by is how certain features of COVID-19 resembled the connective tissue diseases that we deal with, particularly the multiorgan involvement and vasculopathy. We tried using iloprost because of its known beneficial effects on vascular health, pulmonary vascular disease, and generally good safety profile.

How does iloprost compare with the multitude of drugs being considered for the treatment of COVID-19-related symptoms?

As far as we are aware, this is the only therapy that specifically targets the vascular health in patients with COVID-19. [Iloprost treatment] is likely to synergize with antiviral as well as immunomodulatory treatments.

Is there any further research being conducted to evaluate the safety and efficacy of iloprost in COVID-19 vasculopathy?

Currently, the UK is experiencing a COVID-19 “honeymoon period” with very few cases; however, it might be possible to perform a cohort study of iloprost in other countries [with patients] in flare, where this cost-effective and safe therapy might reduce the need for progression to the [intensive care unit (ICU)] or other adverse outcomes.

References

1. Moezinia CJ, Ji-Xu A, Azari A, Horlick S, Denton C, Stratton R. Iloprost for COVID-19-related vasculopathy [published online July 10, 2020]. Lancet Rheumatol. doi:10.1016/S2665-9913(20)30232-0
2. Hughes M, Ong VH, Anderson ME, et al. Consensus best practice pathway of the UK Scleroderma Study Group: digital vasculopathy in systemic sclerosis. Rheumatology. 2015;54(11):2015-2024.