Clinical considerations for managing dermatology patients on systemic immunosuppressive and/or biologic therapy during COVID-19 pandemic
Background: Managing patients treated with systemic immunosuppressive and/or biologic therapy (SIBT) during the coronavirus disease 2019 (COVID-19) pandemic is a challenge. Objective: To develop a preliminary evidence-based approach for clinicians managing these patients under the threat of COVID-19. Methods: Literature review of clinical data and practice guidelines describing upper respiratory infections (URIs) in patient on SIBT. Results: Some anti-tumor necrosis factor medications are associated with increased URI in treatment of psoriasis but not in treatment of pyoderma gangrenosum or hidradenitis suppurativa. There is an increase in URIs for tofacitinib. URIs are increased for secukinumab compared to placebo, but not for the other anti-IL-17 biologics. Biologics targeting IL-12, IL-23, IL-4/13 and IgE have not been found to increase the risk of URIs. Incomplete data exists for rituximab, azathioprine, cyclosporine, and methotrexate. Limitations: Lack of SIBT-specific data on COVID-19, therefore we translate data from other similar viral infections and rely on expert opinion. Conclusion: Rates of URIs associated with SIBT were fairly comparable to placebo prior to the COVID-19 outbreak. Discontinuation of SIBT may result in disease exacerbation (requiring medical attention) and/or loss of therapeutic response upon reintroduction of therapy. Decisions to change SIBT should be done after patient-doctor discussion. An evidence-based decision pathway algorithm is proposed.