COMMENTARY:
At the start of the COVID-19 epidemic in New York City, many of our patients with psoriasis as well as our colleagues were concerned that biologic therapies might increase susceptibility to COVID-19 infections or make those infections worse.
An early review of pivotal trials looking at susceptibility to viral respiratory infections calmed some of those fears, as numbers were small and in the case of many psoriasis drugs, not much higher than the placebo rate of viral infections or even lower for some of our biologic therapies.1 Moreover, individuals born with defects in the IL-17 pathway (which is blocked by secukinumab, ixekizumab and brodalumab) have increases in monilial infections, not viral infections.2 Those born with defects in p40 (which is blocked by ustekinumab) suffer from salmonella and mycobacterial infections, not viral infections.3 The report by Haberman, et al., is based on small numbers, but supports the safety of biologic therapies, pointing out that baseline use of biologics in COVID-19-infected patients with immune-mediated inflammatory diseases was not associated with worse outcomes.4
There is certainly reason for concern in patients with psoriasis who are infected with COVID-19. Our patients have many of the risk factors associated with poor outcomes in individuals infected with this coronavirus. Patients with psoriasis are more likely to suffer from hypertension, diabetes, and obesity – all risk factors for worse outcomes from COVID-19. Nonetheless, in contrast to biologic therapies, patients treated with oral steroids, hydroxychloroquine, and methotrexate were more likely to require hospitalization. And, the two patients with the most severe outcomes were not treated with long-term biologic therapies.
While it is reassuring that a signal was not found implicating biologic therapies in worse COVID-19 infection, this study was based on only 86 patients with immune-mediated inflammatory diseases. Much more data will be needed to establish the safety of these drugs in the setting of COVID-19 infection. Moreover, the drugs should not be lumped together. TNF blockers may have different outcomes than drugs that block IL-17 or IL-23 or IL-12 and IL-23. In the meantime, most of the patient and professional organizations such as the National Psoriasis Foundation, the American Academy of Dermatology, and the International Eczema Council have come out with similar statements advocating continuation of biologic therapies in uninfected patients but discontinuing the therapies according to the package insert in patients who are actively infected.:
Mark Lebwohl COVID-19
Mark Lebwohl, MD
Mt Sinai
New York, New York, United States
PUBLICATION:
Covid-19 in Immune-Mediated Inflammatory Diseases — Case Series from New York. A. Chen, R. Castillo, S. Adhikari, D. Hudesma. Letter to the editor. NEJM. April 29, 2020. DOI: 10.1056/NEJMc2009567
COMMENTARY:
At the start of the COVID-19 epidemic in New York City, many of our patients with psoriasis as well as our colleagues were concerned that biologic therapies might increase susceptibility to COVID-19 infections or make those infections worse.
An early review of pivotal trials looking at susceptibility to viral respiratory infections calmed some of those fears, as numbers were small and in the case of many psoriasis drugs, not much higher than the placebo rate of viral infections or even lower for some of our biologic therapies.1 Moreover, individuals born with defects in the IL-17 pathway (which is blocked by secukinumab, ixekizumab and brodalumab) have increases in monilial infections, not viral infections.2 Those born with defects in p40 (which is blocked by ustekinumab) suffer from salmonella and mycobacterial infections, not viral infections.3 The report by Haberman, et al., is based on small numbers, but supports the safety of biologic therapies, pointing out that baseline use of biologics in COVID-19-infected patients with immune-mediated inflammatory diseases was not associated with worse outcomes.4
There is certainly reason for concern in patients with psoriasis who are infected with COVID-19. Our patients have many of the risk factors associated with poor outcomes in individuals infected with this coronavirus. Patients with psoriasis are more likely to suffer from hypertension, diabetes, and obesity – all risk factors for worse outcomes from COVID-19. Nonetheless, in contrast to biologic therapies, patients treated with oral steroids, hydroxychloroquine, and methotrexate were more likely to require hospitalization. And, the two patients with the most severe outcomes were not treated with long-term biologic therapies.
While it is reassuring that a signal was not found implicating biologic therapies in worse COVID-19 infection, this study was based on only 86 patients with immune-mediated inflammatory diseases. Much more data will be needed to establish the safety of these drugs in the setting of COVID-19 infection. Moreover, the drugs should not be lumped together. TNF blockers may have different outcomes than drugs that block IL-17 or IL-23 or IL-12 and IL-23. In the meantime, most of the patient and professional organizations such as the National Psoriasis Foundation, the American Academy of Dermatology, and the International Eczema Council have come out with similar statements advocating continuation of biologic therapies in uninfected patients but discontinuing the therapies according to the package insert in patients who are actively infected.:
REFERENCES
- Lebwohl M, Rivera-Oyola R, Murrell DF. Should biologics for psoriasis be interrupted in the era of COVID-19?. J Am Acad Dermatol. 2020;82(5):1217‐1218
- Puel A, Cypowyj S, Bustamante J, et al. Chronic mucocutaneous candidiasis in humans with inborn errors of interleukin-17 immunity. Science. 2011;332(6025):65‐68.
- Fieschi C, Allez M, Casanova JL. High risk of infectious disease caused by salmonellae and mycobacteria infections in patients with Crohn disease treated with anti-interleukin-12 antibody. Clin Infect Dis. 2005;40(9):1381.
- Fieschi C, Allez M, Casanova JL. High risk of infectious disease caused by salmonellae and mycobacteria infections in patients with Crohn disease treated with anti-interleukin-12 antibody. Clin Infect Dis. 2005;40(9):1381.
Disclaimer: Views expressed in this commentary are those of the author and do not necessarily represent the position of the International Psoriasis Council or its Board of Directors.Categories
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