key: cord-0846832-1vyne9sj
authors: Elston, Dirk M.
title: COVID and Biologics
date: 2020-09-11
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.09.010
sha: e2059ffbcc34a15e45e4c777f5c4913239fda6df
doc_id: 846832
cord_uid: 1vyne9sj

nan

In this issue of the JAAD, the National Psoriasis Foundation provides guidelines regarding the use of immunomodulating agents for psoriasis during the COVID pandemic.

While there are still many unanswered questions, these guidelines together with guidance issued by the American Academy of Dermatology (AAD) provide a practical framework for dermatologists and their patients to aid with therapeutic decisions during the pandemic. The guidelines emphasize shared decision making as well as attention to Centers for Disease Control recommendations for risk assessment, social distancing, and personal protection including wearing of masks and hand hygiene.

While there have been reports of poor COVID-related outcomes among patients with psoriasis, this is strongly correlated with comorbidities and the guidelines note that most existing data suggest that treatments for psoriasis and psoriatic arthritis do not meaningfully alter either risk of acquiring SARS-CoV-2 infection or COVID-19 outcomes. Consistent with guidance issued by the AAD, the guidelines recommend that patients who are not infected continue their biologic or oral treatments in most cases. Other published data indicate that nonadherence to psoriasis treatment during the pandemic is associated not only with the aggravation of psoriasis but also perceived stress and symptoms of anxiety and depression 1 emphasizing the important role of patient education and communication.

Cytokines upregulated in psoriasis are also upregulated in COVID-19 infection. While the guidelines caution against chronic systemic corticosteroid use for the treatment of psoriasis and published data suggest that glucocorticoid exposure of more than10 mg/day is associated with a higher odds of hospitalization, anti-TNF therapy has been associated with decreased odds of hospitalization among patients with rheumatologic disease. 2 Some data suggest that anti-IL-1 J o u r n a l P r e -p r o o f and anti-IL-6 therapy may have benefits in regard to the cytokine storm in severe COVID infection and baricitinib has both antiviral and anti-inflammatory properties. 3 While chronic prednisone therapy for psoriatic arthritis is discouraged, recent data suggest that intravenous dexamethasone plus standard care improves outcomes for hospitalized COVID-19 patients with moderate or severe adult respiratory distress syndrome compared with standard care alone. 4 A meta-analysis of clinical trials of critically ill patients with suggests that systemic corticosteroids are associated with lower 28-day all-cause mortality. 5 The guidelines acknowledge recent data and note that systemic corticosteroids for the management of COVID-19 inpatients should not be withheld because of concern about psoriatic flares.

It should be noted that all guidelines are intended as living documents that evolve as additional information emerges. Recommendations are based on the best currently available data. We hope that readers will find it helpful in counseling their patients.

Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry

Recommendations for coronavirus infection in rheumatic diseases treated with biologic therapy

Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19: The CoDEX Randomized Clinical Trial

Epub ahead of print

WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group