SARS Covid-19 as an Immunothrombotic Disease and the Potential Benefits of a New Estrogen-Free Contraceptive Containing Drospirenone

Review Article

Thromb Haemost Res. 2021; 5(1): 1052.

SARS Covid-19 as an Immunothrombotic Disease and the Potential Benefits of a New Estrogen-Free Contraceptive Containing Drospirenone

Regidor PA¹* and Colli E²

1Exeltis Europe, Ismaning, Germany

2Exeltis HealthCare Madrid, C/ Manuel Pombo Angulo 28, Spain

*Corresponding author: Pedro-Antonio Regidor,Exeltis Europe, Ismaning, Adalperostr. 84 85737 Ismaning Germany

Received: December 07, 2020; Accepted: December 28, 2020; Published: January 04, 2021

Abstract

Newly research associate the severity of Covid-19 with obesity and the rise in prothrombotic markers like D-Dimers. As Covid-19 is considered an immunothrombotic disease, the potential benefits of estrogen-free contraceptives like drospirenone are discussed.

Adding estrogens in contraception may rise the cardiovascular risk in Covid-19 and Long Covid patients.

Introduction

SARS-CoV-2 is a member of the family of viruses called Coronaviridae, which includes the virus strains SARS-CoV and Mers-CoV and is characterized by a positive-sense single-stranded RNA genome and a protein coat with protruding glycoproteins (peplomeres) that cause the distinctive corona-like appearance when imaged by electron microscopy [1,2]. Infections with SARS-Cov-2 may lead to systemic inflammatory responses associated with the activation of multiple coagulation processes [3]. Although they are part of the standard host defense mechanisms, they may result in Disseminated Intravascular Coagulation (DIC) and, consequently, critical illness [4,5].

Specific components of microorganisms can bind to patternrecognizing receptors of immune cells, thereby stimulating the expression of gene products like, for example, Tissue Factor (TF) produced by cells of the monocyte-macrophage lineage [6-8]. The usual inflammatory response of the host also leads to the synthesis of various further pro-inflammatory cytokines with pleiotropic effects, including the initiation of coagulation processes that may result in massive coagulopathy if not appropriately controlled. In order to describe and quantify the degree of coagulation, diagnostic criteria for overt DIC and a Sepsis-Induced Coagulopathy (SIC) score have been developed and validated by the ISTH (International Society of Thrombosis and Haemostasis) [9-11]. SIC is characterized by pronounced changes in coagulation that may continuously progress towards the more severe DIC disease pattern if the primary etiology of sepsis is not rectified [10-12].

Infections with pathogens like viruses, bacteria, or fungi may lead to complex reactions of the innate immune system, finally resulting in so-called immune-thrombosis or thrombo-inflammation. The term describes a pathologic process that is characterized by subsequent activation of coagulation and thrombin generation in response to an inflammatory trigger and, vice versa, the promotion of inflammatory processes by thrombotic events. Both processes are intertwined by a variety of molecular signaling pathways between the components of both systems [13-15].

The progression from normal hemostatic processes to excessive coagulation that finally leads to DIC and may result in multiorgan failure is a subject of intense research. Several procoagulant pathways are activated during inflammation. Polyphosphate groups of microbial origin may activate platelets, mast cells, and Factor XII (FXII), an essential component of the coagulatory response [16,17]. The complement system of the immune system is additionally involved in the activation of coagulation. Furthermore, neutrophils stimulated by microbes or pro-inflammatory compounds release nuclear material (DNA, histones, and other constituents), which forms so-called Neutrophil Extracellular Traps (NETs) that play a role in anti-microbial defense, but may also activate pro-thrombotic pathways leading to thrombin formation [8,18]. Hence, molecular mechanisms triggered by pathogens represent essential factors in the complex interactions between immune response and thrombotic processes in sepsis [8,19]. Additionally, activation of vascular endothelial cells by injury and specific inflammatory cytokines also leads to pro-thrombotic changes [8,20].

Infection with SARS-CoV2 may lead to significant inflammatory responses as measured by an increase in IL-6, C-reactive protein, fibrinogen, and erythrocyte sedimentation rate [21]. Since the virus primarily attaches to ACE2 receptors, activation and damage of affected endothelial cells may lead to the above-described prothrombotic changes. Accordingly, enhanced plasma concentrations of pro-inflammatory cytokines have been found in Covid-19 patients with the need for intensive care compared to non-ICU patients in early reports of COVID-19 patients [22]. These inflammatory conditions may lead to subsequent activation of the coagulation response as measured by increased D-Dimers levels, a characteristic parameter for pro-coagulatory conditions. Elevated D-Dimers concentrations have been linked to increased mortality of Covid-19 patients, and both septic patients and those developing DIC conditions are at a higher risk for a fatal course of the disease. Although the mechanisms leading to coagulation during SARS-CoV-2 infection have not been elucidated yet, they instead seem to relate to the host’s inflammatory response instead of distinct viral pathogenic factors. In contrast to RNA-stranded viruses associated with hemorrhagic fever like Ebola, infections with SARS-CoV-2 do not result in excessive bleeding [3]. Data from Wuhan support the view that Covid-19- related coagulopathy instead results from the inflammatory host response that leads to exaggerated thrombotic processes through the abovedescribed thrombo-inflammatory interrelations of different host signaling pathways.

Activated neutrophils and immunogenic platelets generate organ damage and a systemic thrombogenic phase in patients with SARS Covid-19. Recent data of Nicolai et al. [23] define Covid-19 as a dysregulated immunothrombosis.

Moreover, they reported peripheral blood coagulation tests and histopathological signs of microvascular thrombosis in affected organs, which reflects that plasmatic coagulation is distorted towards a procoagulant state correlating with disease severity. They exposed that platelets, neutrophils, and the coagulation cascade determine the ? gravity of the illness, and therefore these elements might be useful pharmacological targets in Covid-19. Additionally, prophylactic anticoagulation and accurate monitoring for thrombotic complications are an essential duty in treating Covid-19 patients.

Table 1 shows the immunothrombotic evidence of Covid-19 [24].