key: cord-303800-h3lvbldz
authors: Schultz, Brittney; Pearson, David R.; Mansh, Matthew
title: Reply to “Treatment considerations for patients with pemphigus during the COVID-19 pandemic”
date: 2020-09-04
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.07.132
sha: 
doc_id: 303800
cord_uid: h3lvbldz

nan

individual basis through shared decision-making. In particular, rituximab should be considered 43 for patients with severe disease and without active COVID-19 illness after discussion of specific 44 individual-level risks (age, comorbidities, occupation) and benefits of rituximab. We would also 45 consider rituximab for younger patients without comorbidities and with less severe disease. 46 First, rituximab is an effective and targeted therapy for pemphigus. We have limited data directly 47 comparing adverse events in those treated with rituximab versus other therapies but compared to 48 prednisone alone, individuals treated with rituximab plus short-term prednisone had decreased 49 cumulative exposure to prednisone and fewer adverse effects, 2 including known risk factors for Conversely, physicians should discuss that rituximab may reduce immune response to 63 vaccination, 5 which may decrease the ability of patients to effectively receive a COVID-19 64 vaccine. The response to vaccination appears to improve when given 6 months or more after 65 rituximab dosing. 5 Immune response to infection itself may similarly be blunted, theoretically 66 leading to risk of re-infection. 67 In summary, we agree with careful consideration of rituximab for patients during the COVID-19 68 pandemic. However, with an unknown peak of COVID-19, it may not be feasible or beneficial to 69 delay rituximab. On an individualized basis through shared decision making, dermatologists 70 should consider rituximab for select patients. Our approach is to discuss rituximab in patients 71 with severe disease, who might otherwise require high doses of prednisone or more broadly 72 immunosuppressive agents over an extended time period, and those with less severe disease but 73 fewer comorbidities and younger age. Rheumatologic dosing of rituximab, rather than 74 hematologic, can be considered to decrease healthcare exposures, and we would recommend 75 against maintenance dosing in stable patients where the risk of disease flare is deemed low. 2 76 Prior to rituximab, we recommend discussing vaccination concerns and general infection control 77 guidance, including social distancing, frequent hand-washing, and use of masks. 78 J o u r n a l P r e -p r o o f

Treatment considerations for patients 80 with pemphigus during the COVID-19 pandemic

First-line rituximab combined with short-82 term prednisone versus prednisone alone for the treatment of pemphigus

multicentre, parallel-group, open-label randomised trial

Risk Factors Associated with Clinical Outcomes

Hospitalized Patients in Wuhan, China. Clin Infect Dis

Mild course of Coronavirus disease 2019 and spontaneous 87 severe acute respiratory syndrome coronavirus 2 clearance in a patient with depleted peripheral 88 blood B-cells due to treatment with rituximab. Arthritis Rheumatol

Vaccines and Disease-Modifying Antirheumatic Drugs: Practical 90

Implications for the Rheumatologist

None.