Does Immunosuppressive Therapy Increase Risk of COVID-19 in Patients with IMID?

Data so far suggests that patients with immune-mediated diseases (IMIDs) who are being treated with immunosuppressive therapies appear not to be at a heightened risk of becoming infected with the SARS-COV-2 virus, concluded panelists in a roundtable discussion at the virtual Interdisciplinary Autoimmune Summit (IAS) 2020 on July 10.

The panel included Joel M. Gelfand, MD, professor of dermatology and epidemiology at the University of Pennsylvania’s Perelman School of Medicine; Stephen B. Hanauer, MD, the Clifford Joseph Barborka professor of medicine and medical director of the Digestive Health Center at Northwestern University’s Feinberg School of Medicine; Leonard Calabrese, DO, professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and vice chair of the Department of Rheumatic and Immunologic Diseases; and Cassandra Calabrese, DO, associate staff physician at the Cleveland Clinic Foundation Department of Rheumatologic & Immunologic Disease.

While the panelists agreed that it may be best to stop immunomodulating therapies among patients with COVID-19 symptoms, they noted that much remains unknown about the virus, which complicates decision making on several fronts.

Dr Leonard Calabrese explained the work of the COVID-19 Global Rheumatology Alliance, which is “bringing together the global rheumatology community to curate and disseminate accurate and comprehensive knowledge to advance rheumatology care in the COVID-19 pandemic.”

He urged any physician with a patient with an IMID and COVID-19, “please go to the site and add your patient information.” The importance of maintaining and updating this database is critical, he emphasized.  

He further explained that both the American College of Rheumatology and the European League Against Rheumatism are developing guidelines. He described these as “living, breathing documents” to help practitioners in the ongoing treatment of patients with stable IMIDs in absence of COVID-19 who are being treated with immunosuppressing medications.

Dr Cassandra Calabrese told the IAS audience that a regularly updated chart from Johns Hopkins University on new cases of COVID-19 illustrates that “4 months into this pandemic it is clear the United States has become an outlier.” While other nations who had earlier and often severe outbreaks have seen their new cases decrease precipitously, the United States “is continuing to break records every day.” She stressed the importance of counseling patients to not be around anyone not in their immediate family without wearing a mask, to adhere to the 6-foot distancing rule, and to limit going out in public as much as possible. “We have a lot to learn here; masks and protective measures are most important,” she added.

Dr Stephen Hanauer noted that while corona viruses typically enter through the mouth, nose, and upper respiratory tract, the SARS-COV-2 virus “connects to ACE2 receptors, which are found in multiple organs, including the gastrointestinal tract.” This led to some investigations into the impact of COVID19 and its possible manifestations in the GI system.

Samples taken through the GI tract demonstrate that ACE2 receptor is present, as is the viral nuclear protein for COVID-19, he explained. “In some patients, the stool tests positive for the COVID-19, but that doesn’t mean the virus is actually infective. That remains to be demonstrated.” Dr Hanauer said that so far, the composite global experience with COVID-19 indicates that GI symptoms are mostly minor, such as diarrhea, nausea, and vomiting.

As in the field of rheumatology, Dr Hanauer explained, representatives of several gastroenterology organizations have begun to meet virtually on a weekly basis to discuss findings and experiences concerning the pandemic’s impact on their patients. One result of this collaboration is creation of the Secure IBD database, which allows gastroenterologists to enter information on patients with inflammatory bowel disease (IBD) and COVID-19. So far, he noted, the information supports what has been found in the rheumatology field: patients with IBD who are on therapies other than steroids have rates of COVID-19 infection comparable to the general population. Only the use of steroids, along with the comorbidities that affect all populations, increase risk for complications of COVID-19 in patients with IBD.

Dr Gelfand pointed out the many parallels in all these fields, reporting that dermatology associations have also created registries for patients with dermatological diseases and COVID-19. As with rheumatology and gastroenterology patients, he noted that the risk of infection and of complications resulting from COVID-19 appear primarily in patients with underlying comorbidities. He also noted that some patients with psoriasis who become infected with COVID-19 have reported flares in their skin disease, “perhaps associated with inflammatory processes secondary to the virus.”

Another distinction in the dermatology field, he said, is “our recommendations are a bit softer on stopping therapy with biologics or small molecules in patients who have become infected with COVID-19. We put our recommendations out a bit later than the other specialties, after it was found that biologics are not indicators of risk.”

Like his colleagues in rheumatology and gastroenterology, Dr Gelfand emphasized the importance of stressing public health safety measures with patients. “It’s really important for physicians to be involved in educating the public on these issues.”

Dr Gelfand also added that despite the level of the pandemic, some significant progress has been made. “This virus was sequenced within two weeks of the first report of it. We’re seeing progress in terms of clinical trials for possible treatment, which have shown that remdesivir and dexamethasone appear to be effective.”

For more coverage of IAS 2020 virtual, visit the newsroom.

–Rebecca Mashaw

Reference

Hanauer SB, Gelfand, JM, Calabrese C, Calabrese L. Roundtable: impact of COVID-19 on autoimmune diseases. Presented virtually at: Interdisciplinary Autoimmune Summit 2020; July 10, 2020.