Immunosuppressive Psoriatic Drugs Don't Increase Risks for COVID-19 Complications

Patients with psoriasis who are administered immunosuppressive drug therapies are not at an increased risk for severe complications related to coronavirus disease 2019 (COVID-19), according to an opinion piece published in the American Journal of Clinical Dermatology.

Patients with immune-mediated diseases, including psoriasis, atopic dermatitis, and hidradenitis suppurativa, often manage their conditions with biologic and non-biologic drugs known to suppress the immune system.

Those who receive immunosuppressive medications are known to have an increased risk or duration of infections caused by adenovirus, influenza, norovirus, rhinovirus, or respiratory syncytial virus. However, this doesn’t seem to be the case with virial infections caused by the coronavirus family, such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and MERS coronavirus (MERS-CoV).

“Similarly to SARS-CoV and MERS-CoV, immunosuppressed status…has not been found to be a risk factor for an adverse outcome, such as death or admission to an intensive care unit, in patients with COVID- 19 compared with the general population,” noted the authors.

For most patients who are positive for COVID-19, the primary immune response can clear the virus on its own. However, a subset of patients may have an overactive secondary immune response that lead to inflammatory-induced lung injury pneumonitis, acute respiratory distress syndrome, respiratory failure, shock, organ failure, and potentially death.

“This exaggerated response is considered a “cytokine storm” similar to that of secondary hemophagocytic histiocytosis, which leads to an hyperinflammation state, with unremitting fever, cytopenias, hyperferritinemia, and pulmonary involvement (including acute respiratory distress syndrome) in 50% of cases,” noted the authors.

The cytokine profile for COVID-19 is characterized by a high level of several cytokines likely produced by inflammatory cytokines. Elevated levels of interleukin (IL)- 6, IL-10 and tumor necrosis factor (TNF)-α appear during infection and decline upon recovery.

As a result, immunosuppressive drugs that manage the levels of these cytokines have the potential to control “cytokine storms” caused by the virus for patients with immune-mediated diseases.

Most dermatology societies recommend patients with immune-mediated diseases discontinue or postpone immunosuppressive or biologic therapy in the event of a COVID-19 diagnosis until recovery.

“However, the decision to stop or withhold treatment is left to the joint consideration of the patient and physician, pondering the risk/benefit on a case-by-case basis depending on the risk of SARS-CoV-2 infection,” said the authors. There is also no available evidence that supports discontinuation of treatment solely based on risk of infection.

Additionally, corticosteroid treatments are not recommended for patients with COVID-19 unless indicated to prevent the exacerbation of asthma, chronic obstructive pulmonary disease, or septic shock as they might exacerbate COVID-19 associated lung injury, which has occurred in the past for patients infected with other coronaviruses.

Patients with immune-mediated diseases have an increased risk for developing conditions such as obesity, cardiovascular disease, chronic lung disease, and asthma. These comorbidities in combination with being over 60 years of age can worsen the prognosis of COVID-19 infection and bring cause to interrupt treatment

“In the future, SARS-Cov-2 vaccination will most likely be added to the immunization recommendations for patients receiving immunosuppressive or biologic treatment for dermatologic indications, including psoriasis, atopic dermatitis, and hidradenitis suppurativa,” said the authors.

Reference

Torres T, Puig L. Managing cutaneous immune‐mediated diseases during the COVID‐19 pandemic. J. Clin. Dermatol. Published online April 10, 2020: doi: 10.1007/s40257-020-00514-2