key: cord-0252459-a1gn602y authors: Hajjar, Roy; Chan, Gabriel title: Anti-tumor necrosis factor agents and COVID-19: A word of caution date: 2020-08-29 journal: J Clin Transl Res DOI: nan sha: 76dd6ac762ef80fc949515e0797e832675d74fd2 doc_id: 252459 cord_uid: a1gn602y nan infectious complications has also been shown in patients with autoimmune arthritis receiving anti-TNF-α agents [11] . In older patients with a severe COVID-19 infection, the safety profile leaves even less margin for error. Some reports have suggested a tolerable adverse event profile in the elderly with inflammatory bowel and articular diseases [12] [13] [14] , while others have found a higher rate of opportunistic infections and treatment failure with IBD cases [15, 16] . The indication of anti-TNF-α treatment in the present pandemic would target pulmonary inflammation and mortality. The previous literature concerning both acute lung injury and acute respiratory distress syndrome feature higher local and systemic levels of TNF-α and have been associated with worse outcomes [17] . Similar to the current COVID-19 pandemic, this suggests a possible role of TNF inhibitors in the treatment of acute pulmonary inflammation. However, previous reports have not shown favorable effects on the survival of TNF blockade in patients with septic shock and ALI [17, 18] . It is nonetheless worth noting that emerging data on the use of anti-TNF agents in patients with COVID-19 included the description of a case where infliximab was initiated in a 54-yearold female patient for a severe episode of ulcerative colitis [19] . She specifically received two doses of infliximab 10 mg/kg, while being reported as having a concomitant infection with COVID-19 that was qualified as mild [19] . The patient had an uneventful recovery [19] . In their cohort of 40 patients with IBD, the authors reported two deaths (5%) due to acute respiratory distress syndrome in patients aged 77 and 86 years, and who were treated with mesalamine with or without methotrexate [19] . A complementary element to note with the reported fatality rate is the fact that most patients were described to have interrupted their immunomodulator or biologic maintenance therapy upon the diagnosis of a COVID-19 infection [19] . This adds an additional challenge to the proper interpretation of the safety of anti-TNF use during an active episode of COVID-19 and its potential effect on complications' occurrence. Although the initiation of an anti-TNF agent in a patient with a mild case of COVID-19 seems safe and potentially beneficial, it remains important to note that more cases are required to properly assess which patients might benefit from its use as a therapeutic agent for COVID -19. With no experience with this novel virus, TNF blockade, although mechanistically promising, may harbor serious risks in fragile older patients. We endorse the hypothesis stipulating that this therapy might prevent severe complications of systemic inflammation in COVID-19 infections, but further investigation into the evolution of COVID-19 infections in IBD patients already treated with anti-TNF agents could provide valuable insight into the benefits of suppressing the TNF-α cascade. Caution should, however, be used in projecting any outcomes observed in patients on maintenance therapy to initiating antibody treatment in a naïve but COVID-19 afflicted patients. 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The authors have no conflicts of interest to disclose.