FXR inhibition may protect from SARS-CoV-2 infection by reducing ACE2

Preventing SARS-CoV-2 infection by modulating viral host receptors, such as angiotensin-converting enzyme 2 (ACE2)(1), could represent a new chemoprophylactic approach for COVID-19 that complements vaccination(2,3). However, the mechanisms that control the expression of ACE2 remain unclear. Here we show that the farnesoid X receptor (FXR) is a direct regulator of ACE2 transcription in several tissues affected by COVID-19, including the gastrointestinal and respiratory systems. We then use the over-the-counter compound z-guggulsterone and the off-patent drug ursodeoxycholic acid (UDCA) to reduce FXR signalling and downregulate ACE2 in human lung, cholangiocyte and intestinal organoids and in the corresponding tissues in mice and hamsters. We show that the UDCA-mediated downregulation of ACE2 reduces susceptibility to SARS-CoV-2 infection in vitro, in vivo and in human lungs and livers perfused ex situ. Furthermore, we reveal that UDCA reduces the expression of ACE2 in the nasal epithelium in humans. Finally, we identify a correlation between UDCA treatment and positive clinical outcomes after SARS-CoV-2 infection using retrospective registry data, and confirm these findings in an independent validation cohort of recipients of liver transplants. In conclusion, we show that FXR has a role in controlling ACE2 expression and provide evidence that modulation of this pathway could be beneficial for reducing SARS-CoV-2 infection, paving the way for future clinical trials.

Automated summary

Modulating the expression of angiotensin-converting enzyme 2 (ACE2) through farnesoid X receptor (FXR) can reduce susceptibility to SARS-CoV-2 infection, as shown in various tissues and organoids in vitro, in vivo, and ex vivo. The use of z-guggulsterone and ursodeoxycholic acid (UDCA) can downregulate ACE2 and decrease viral infection, including in the nasal epithelium. Clinical data also indicate positive outcomes with UDCA treatment in SARS-CoV-2 infection. These findings suggest that targeting the FXR-ACE2 pathway could be a potential strategy for preventing COVID-19.