expert roundtables

Patient Immune Status and Psoriasis Treatment in the COVID-19 Era

by Steven R. Feldman, MD, PhD; Joel M. Gelfand, MD, MSCE; and Alice B. Gottlieb, MD, PhD

Overview

Although data are limited, outcomes for patients with psoriasis who become infected with SARS-CoV-2 seem to be driven by age and the previously identified underlying comorbidities, not necessarily psoriasis or treatments for psoriasis. Still, much remains unknown, and the COVID-19 pandemic continues to impact patient care in profound ways.

Q:

What is your approach to systemic treatments for psoriasis during the COVID-19 pandemic, and how is COVID-19 impacting patient care?

Joel M. Gelfand, MD, MSCE

Professor of Dermatology and Epidemiology
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA

“A review of known benefits of treatment, along with acknowledgment that there is some uncertainty related to the COVID-19 pandemic, should guide decision making. A patient’s individual circumstances and preferences should also be discussed.”

Joel M. Gelfand, MD, MSCE

I cochair the National Psoriasis Foundation’s COVID-19 Task Force, which Dr Feldman is on as well. It is a multidisciplinary group of 18 dermatologists, rheumatologists, infectious disease doctors, critical care doctors, epidemiologists, and other specialists. We have reviewed more than 150 papers regarding the pandemic that are relevant to the psoriatic disease communities. When it comes to treatments for psoriasis, the best we can tell so far is that the major drivers of negative outcomes in patients with psoriasis and infection with the novel coronavirus (SARS-CoV-2) are age and underlying comorbidities, not necessarily psoriasis or the treatments patients may be taking for psoriasis or psoriatic arthritis. In general, I believe that a review of known benefits of treatment, along with acknowledgment that there is some uncertainty related to the COVID-19 pandemic, should guide decision making. A patient’s individual circumstances and preferences should also be discussed. There is some uncertainty, as the existing data are not ideal, but, to the best of our knowledge, patients on therapy seem to have the same course as one would expect if they were not on these systemic therapies.

One of the analytic challenges with SARS-CoV-2 is that, traditionally, respiratory tract infections have been considered more of a nuisance; they were not studied in clinical trials using precise, consistent terminology to ensure that categories are certain (eg, viral infection vs allergic phenomenon), which could mask safety signals. The current model of COVID-19 illness is that upfront immunosuppression might increase the risk of infection dissemination or, conversely, may help modulate the overactive immune response and prevent serious illness from the infection.

Patients should be aware that psoriasis may flare during the pandemic due to therapy withdrawal. We also know that viral infections trigger the immune system and that COVID-19 infection may aggravate underlying psoriasis.

In terms of COVID-19’s impact on care, one aspect that I found surprising was that, in the midst of our risk mitigation efforts, while we had a reduced physical presence in the clinic, insurance companies began to require a wet signature for biologic prescriptions.

Steven R. Feldman, MD, PhD

Professor of Dermatology, Pathology, and Social Sciences & Health Policy
Wake Forest School of Medicine
Winston-Salem, NC 

One of the challenges that we are facing now is the same one that we had been facing long before COVID-19: that patients may be concerned about the risk(s) of their medication, in general, even though these agents are exceptionally safe and the benefit to risk ratio is exceptionally good.

Steven R. Feldman, MD, PhD

One of the challenges that we are facing now is the same one that we had been facing long before COVID-19: that patients may be concerned about the risk(s) of their medication, in general, even though these agents are exceptionally safe and the benefit to risk ratio is exceptionally good. Since the emergence of COVID-19, many patients have been worried about starting or even continuing their medicine. The extent to which patients have been stopping their medication on their own during the pandemic has arisen as a question in the literature. I would suspect that the overall proportion of patients with psoriasis who stop their therapy against our advice during the pandemic is low, perhaps around 5%; however, it is difficult to know whether a patient has stopped treatment unless they report a problem (ie, uncontrolled psoriasis). Some of our patients using some of the newer psoriasis treatments have stopped their medication for as long as 6 months without reporting a problem.

I personally believe that many of the important COVID-19–related questions do not yet have good answers. We do not yet have well-designed, placebo-controlled, randomized trials to answer key questions. Even for what might be considered a “no brainer” (ie, stopping the immunomodulatory therapy in a person with active COVID-19 infection), we do not know whether suddenly stopping a cytokine inhibitor is the best thing to do in all cases, when the big problem with severe COVID-19 is the cytokine storm.

Alice B. Gottlieb, MD, PhD

Clinical Professor and Medical Director
Department of Dermatology
Mount Sinai Beth Israel
Kimberly and Eric J. Waldman Department of Dermatology
Icahn School of Medicine at Mount Sinai
New York, NY 

“I generally agree with the points raised here by my colleagues. I would be reluctant to prescribe immunosuppressive therapy in patients with psoriasis who are symptomatic with COVID-19 or have an unusual fever or respiratory symptoms.”

Alice B. Gottlieb, MD, PhD

I generally agree with the points raised here by my colleagues. I would be reluctant to prescribe immunosuppressive therapy in patients with psoriasis who are symptomatic with COVID-19 or have an unusual fever or respiratory symptoms. It is not a good idea to give a patient with an active serious infection any immunosuppressant. This is applicable not only to COVID-19 but also to other serious infections. All of the package inserts for these systemic agents that we use to treat psoriasis communicate the risk of serious infection (ie, clinically important chronic or acute infection), recommending discontinuation until the infection resolves.

Regarding the impact of COVID-19 on patient care, I have seen cases of dramatically worsening psoriasis in patients who, because of COVID-19, did not come into the office or did not get their treatments. When one talks about treating to target, the target has certainly deteriorated during the COVID-19 era. I think that a safe future hinges on the availability of an effective vaccine.

References

Amerio P, Prignano F, Giuliani F, Gualdi G. COVID-19 and psoriasis: should we fear for patients treated with biologics? Dermatol Ther. 2020;e13434. doi:10.1111/dth.13434

Brownstone ND, Thibodeaux QG, Reddy VD, et al. Novel coronavirus disease (COVID-19) and biologic therapy in psoriasis: infection risk and patient counseling in uncertain times.  Dermatol Ther (Heidelb). 2020;10:339-349. doi:10.1007/s13555-020-00377-9

Brownstone ND, Thibodeaux QG, Reddy VD, et al. Novel coronavirus disease (COVID-19) and biologic therapy for psoriasis: successful recovery in two patients after infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Dermatol Ther (Heidelb). 2020;10(4):881-885. doi:10.1007/s13555-020-00394-8

Di Lernia V. Reply: “Biologics for psoriasis during COVID-19 outbreak”. J Am Acad Dermatol. 2020;82(6):e217-e218. doi:10.1016/j.jaad.2020.04.004

Gelfand JM, Armstrong AW, Bell S. National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: version 1. J Am Acad Dermatol. 2020;S0190-9622(20)32544-5. doi:10.1016/j.jaad.2020.09.001

Gisondi P, Zaza G, Del Giglio M, Rossi M, Iacono V, Girolomoni G. Risk of hospitalization and death from COVID-19 infection in patients with chronic plaque psoriasis receiving a biologic treatment and renal transplant recipients in maintenance immunosuppressive treatment. J Am Acad Dermatol. 2020;83(1):285-287. doi:10.1016/j.jaad.2020.04.085

Holcomb ZE, Santillan MR, Morss-Walton PC, et al. Risk of COVID-19 in dermatologic patients receiving long-term immunomodulatory therapy. J Am Acad Dermatol. 2020;83(4):1215-1218. doi:10.1016/j.jaad.2020.06.999

Lebwohl M, Rivera-Oyola R, Murrell DF. Should biologics for psoriasis be interrupted in the era of COVID-19? J Am Acad Dermatol. 2020;82(5):1217-1218. doi:10.1016/j.jaad.2020.03.031

National Psoriasis Foundation. COVID-19 Task Force guidance statements. Accessed September 11, 2020. https://www.psoriasis.org/covid-19-task-force-guidance-statements/

Syed MN, Shin DB, Wan MT, Winthrop KL, Gelfand JM. The risk of respiratory tract infections in patients with psoriasis treated with interleukin 23 pathway-inhibiting biologics: a meta-estimate of pivotal trials relevant to decision making during the COVID-19 pandemic. J Am Acad Dermatol. 2020;S0190-9622(20)32115-0. doi:10.1016/j.jaad.2020.06.1014

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