Should Biologics for Psoriasis Be Interrupted in the Era of COVID-19?

TAKE-HOME MESSAGE

• There are currently no data on the susceptibility of patients on biologics for psoriasis to the COVID-19 infection. Existing studies of infection rates in biologic groups compared with placebo demonstrate an increased rate of infections (up to 7%) associated with TNF-alpha inhibitors except etanercept, for which no increased risk was found. Ustekinumab was associated with a small overall increase in infections, although not respiratory tract infections. IL-23 blockers increased infections by up to 9% but did not consistently cause higher rates of respiratory tract infections. IL-17 blockers showed up to an 11% increase in overall infections, including respiratory tract infections with secukinumab but not ixekizumab or brodalumab.

• Overall, respiratory infection rates in patients on psoriasis biologics were comparable with rates in patients on placebo in most studies. The benefit of discontinuing these medications should be weighed with the risk of loss of response when treatments are reinitiated.

– Margaret Hammond, MD

Written by

 

 

Mark G Lebwohl MD

Written by

 

 

Ryan Rivera-Oyola MD

We have received hundreds of emails from patients and physicians asking whether biologic therapies should be discontinued in view of the current coronavirus pandemic. Several professional and patient organizations (including the American Academy of Dermatology and the National Psoriasis Foundation) have issued positions asking that biologic therapies not be discontinued except in patients with active infection.

The COVID-19 virus is new, and so we do not have specific data on what drugs render patients more susceptible to infection or more likely to develop severe infection. A few weeks ago, we would never have considered most of these drugs to be immunosuppressive, and that has not changed. Some of our biologic therapies, like dupilumab or omalizumab, are also approved to treat asthma, which is associated with atopic dermatitis and occurs in some patients with chronic urticaria. It could be detrimental to patients to stop treatments that prevent asthma, which can be an exacerbating factor in patients with COVID-19 pneumonia. Although we don't have data on coronavirus, it is helpful to know that, in pivotal trials, there was not a marked increase in viral or upper respiratory infections in patients on biologic therapies for psoriasis or atopic dermatitis. Moreover, patients who are born with deficiencies in IL-17 or in p40 (the target of ustekinumab) develop monilial infections and salmonella and mycobacterial infections, respectively, not viral infections.

When we have more data from this pandemic, we will probably be able to address this issue more accurately; but, for now, we have to apply common sense to the data we already have. Based on these data, this letter recommends that patients continue biologic therapies, especially antibodies to IL-17 and IL-23.

Abstract 

With daily media warnings of a looming pandemic, physicians are understandably concerned about immunosuppressive or immunomodulating effects that might render patients on biologic therapies more susceptible to COVID-19 infection. At this early stage, we do not have specific data about susceptibility to the virus, but we have data on infectious complications for biologic therapies from their pivotal trials for psoriasis.

Journal of the American Academy of Dermatology

Should Biologics for Psoriasis Be Interrupted in the Era of COVID-19?

J Am Acad Dermatol 2020 Mar 18;[EPub Ahead of Print], M Lebwohl, R Rivera-Oyola, DF Murrell 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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