key: cord-0832132-wpay179x
authors: Zhao, Liang; Du, Hongyao; Alamgir, Mahin; Yang, Jing; Miao, Xiaoping; Jiang, Biling; Xia, Yuting; Lou, Yuchen; Wang, Yujue; Shen, Chen; Zhu, Jinjin; Chung, Wen-Hung; Li, Yan; Tao, Juan
title: Safety of biologics for psoriasis patients during the COVID-19 pandemic: the experience from Wuhan, China
date: 2021-02-12
journal: Eur J Dermatol
DOI: 10.1684/ejd.2020.3908
sha: 021d4f9e5eef67fb73c79ce000b6d313a0e0283a
doc_id: 832132
cord_uid: wpay179x

nan

Patients with psoriasis have an increased risk of systemic comorbidities, which may be associated with the develop-ment of severe manifestations of coronavirus disease 2019 (COVID-19) [1, 2] . However, the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection for the subset of psoriasis patients on biologic therapies remains unclear [3] . Continuing biologic therapy during the COVID-19 pandemic is an area of concern and inquiry for patients and providers [4, 5] . Wuhan, the epicentre of the outbreak in China, reported more than 50,000 confirmed cases of COVID-19. The local government enforced strict lockdown measures from January 23 rd to April 8 th , 2020. We set out to conduct a survey of psoriatic patients receiving biologic treatments in Wuhan City. Self-administered, online questionnaires were sent out to 118 registered psoriatic patients through smartphones (WeChat). In total, 107 patients completed the questionnaires (response rate: 90.7%) during March 2020, revealing 102 cases of psoriasis vulgaris (95.3%), three cases of erythrodermic psoriasis (2.8%), and two cases of pustular psoriasis (1.9%). The average age was 39.99 ± 1.29 years (range: 15-86 years) and there were 73 males (68.2%). Forty-three (40.2%) patients had underlying comorbidities, including 15 (14.0%) with psoriatic arthritis, 10 (9.3%) with hypertension, 16 (15.0%) with obesity (BMI >27.5 kg/m 2 ) [6], and five (4.7%) patients with diabetes. Additionally, 14 (13.1%) patients had at least two comorbidities. IL-17 inhibitors were used in 90 patients (84.1%) and TNF-␣ inhibitors were used in 17 patients (15.9%). The survey showed that none of the 107 patients with psoriasis were diagnosed with COVID-19, including 55 (51.4%) patients who were either local residents or had travelled to Wuhan after November 2019. Since the government of Wuhan City administered a comprehensive SARS-CoV-2 nucleic acid test on 11 million citizens in May 2020, we conducted telephone interviews for our patients in July 2020. One hundred and two patients completed this follow-up; 90 (88.2%) patients underwent the nucleic acid amplification test and 61 patients (59.8%) underwent the antibody test, all reported as negative. Two patients with psoriatic arthritis (table 1) developed fever during the COVID-19 pandemic. A 35-year-old woman with a history of tuberculosis , receiving adalimumab (80 mg monthly) injections, was hospitalized in an isolation ward and became afebrile after treatment with antibiotics. The second was a 37-year-old man on secukinumab therapy (300 mg monthly), who received antibiotic treatment as an outpatient, and recovered. Four patients (3.7%) had a history of close contact with a COVID-19 patient, but none of these patients developed any COVID-19 symptoms. Notably, a 16-year-old girl on secukinumab therapy (150 mg monthly), whose mother and grandparents had confirmed COVID-19 infection, had negative serologic and radiologic screening tests. We subsequently learned that she was in the habit of wearing a facemask even around family members, and washed her hands frequently. We also analysed the possible reasons why the patients in our study did not contract COVID-19. Firstly, the majority of patients (99 cases, 92.5%) were younger than 60 years of age. Secondly, most patients (64 cases, 59.8%) did not have underlying comorbidities. Also, many patients rigorously followed infection control guidelines. Moreover, in our cohort, IL-17 inhibitors, which have been reported to be comparatively less immunosuppressive [7], were prescribed more often than TNF-␣ 

Tuberculosis (TB) has always represented a concern in the setting of systemic treatment for psoriasis, mainly with biologic therapy. Currently, latent tuberculosis infection (LTBI) treatment is mandatory in all patients starting biologic therapy [1] . Data suggest a variable risk of TB reactivation in patients with LTBI depending on the mechanism of action of treatment, even for agents within the same class [1] . Moreover, toxicity associated with LTBI treatment is considerable [2] . Isoniazid remains the first line for LTBI treatment and is associated with hepatotoxicity, with hepatitis rates of 0.5-1.0% and mortality in 0.05-0.1% of cases [2] . Alternatively, rifampin may be prescribed, but the several possible drug interactions and risk of resistance often limit its use [2] . Recent data suggests that novel biologics acting in the IL-23/IL-17 axis are not associated with TB reactivation and may be considered for patients in whom isoniazid or rifampin treatment is contraindicated or not tolerated [1, 3] . We report two cases with moderate to severe psoriasis and LTBI (table 1), in whom isoniazid or rifampin treatment was contraindicated or not tolerated [4] . Both patients were treated with secukinumab with an excellent, maintained clinical response, and showed no evidence of TB reactivation after two years of follow-up.

With the advent of biologics, the risk of TB has been highlighted, namely with TNF-␣ inhibitors [1, 5] . TB is caused by Mycobacterium tuberculosis, which is an intracellular pathogen that elicits a Th1 response. TNF-␣ is a key molecule that directly promotes an effective Th1 response. In contrast, IL-17A plays a protective role in the host defence at epithelial and mucosal barriers, serving as an important mediator for the clearance of extracellular pathogens [1] . An in vitro study examined the effect of TNF-␣ antibody, adalimumab and secukinumab, on dormant Mycobacterium tuberculosis H37Rv using a novel human three-dimensional microgranuloma model [5] . The results with adalimumab were indicative of mycobacterial reactivation, while, secukinumab treatment was

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