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EADV 2020 | SARS-CoV-2 (COVID-19) Pandemic and Psoriasis Management

Other 2020

A report from the 29th Congress of the European Academy of Dermatology and Venereology


The SARS-CoV-2 (COVID-19) pandemic has had a sweeping global impact on all facets of medicine and has fundamentally changed the way we monitor and treat patients. This has raised serious safety questions in psoriasis management, specifically regarding systemic and biologic medications. The EADV speakers confronted this critical issue by reviewing the evolving international data.

Giovanni Damiani, MD, of Milan, Italy reviewed the pathophysiology of COVID-19 infection, including the resulting immune cytokine storm which increases risk of severe complications and mortality. In an Italian multicenter case-control study reviewing teledermatology and in-person visits of 1193 psoriasis patients from February 21 (first confirmed case) to April 9, 2020, only 1.8% in total were affected by the virus, with 1.4% (n = 17) quarantined at home and only 0.4% (n = 5) hospitalized. Importantly, no patients died. Key confounders included obesity and/or smoking in most patients. Though patients under biologics and small molecules demonstrated higher risk of infection and hospitalization, there was no increased risk of ICU admission or death. No patients under apremilast treatment were infected. Dr. Damiani hypothesized that immunosuppressives may provide a protective effect against the cytokine storm and resulting COVID-19 morbidity and mortality.1

Anne-Claire Fougerousse, MD, of Saint Mandé, France reviewed results from a French multicenter, cross-sectional study of 1418 adult psoriasis patients receiving systemic or biologic treatment (SBT) from April 27 to May 7, 2020. 330 patients were on systemic therapy (mostly methotrexate) and 1005 on biologic therapy. 25% of patients had a risk factor for severe infection (including obesity), and 22% patients on systemic and 14% on biologic stopped therapy during the pandemic. Of the 54 patients who contracted COVID-19, only 5 required hospitalization, 2 required ICU admission, and no patients died; notably 60% (n = 3) were obese, including both patients admitted to the ICU. Importantly, there was no observed significant difference in COVID-19 cases when comparing initiation versus maintenance therapy, suggesting that initiating SBT for severe psoriasis during the pandemic may be safe after careful consideration.2

Phyllis Spuls, MD, PhD, of Amstelveen, Netherlands summarized results from the PSOPROTECT registry of 374 COVID-19 cases in psoriasis patients under SBT. Though 93% of patients fully recovered, 21% were hospitalized at some point and 2% died. Increased hospitalization was significantly associated with older age (odds ratio 1.59 per 10 years), male sex (OR 2.51), non-white ethnicity (OR 3.15), and comorbid chronic lung disease (OR 3.87). Hospitalization occurred more in systemics than biologics (OR 2.84), and there was no significant difference between biologic classes.3 Other studies have shown similar results, including Italian studies and the large SECURE-IBD registry of 3500+ patients.1,4,5 In this registry, hospitalization rate was higher for conventional systemic vs biologics, and death occurred more frequently in systemic corticosteroids (9%) and methotrexate (5%, though n = 1) than biologics (roughly 0.5% for both anti-TNF, anti-IL12/23).5

In accordance with all early data, the EADV has released Task Force Recommendations. In summary: in patients with active infection: conventional systemics, JAK inhibitors, and biologics should be stopped until more data has been collected. In uninfected/healthy patients, IL-17, IL-23, apremilast, and acitretin are likely safe to initiate and continue, and physicians should consider switching from other therapies to these safer alternatives.6

Section Pearls:

  • Though COVID-19 infection rates appear higher in psoriasis patients on biologic or small molecule therapy, immunosuppressive treatments may be protective against the subsequent inflammatory cytokine storm (and therefore severe infection) in COVID-19.
  • Patients who are initiating systemic and biologic therapy during the pandemic do not seem to be at significantly higher risk for infection than those patients on maintenance therapy.
  • Non-biologic systemic therapies convey increased risk of severe complications when compared to biologics. Apremilast, acitretin, and IL-17/IL-23 inhibitors appear safest.
References

 


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