Disease Management and Patient Care Recommendations During the COVID-19 Pandemic

A few short weeks ago, The Dermatologist reviewed IL-23 biologics and their role in the long-term management of psoriatic disease.¹ Around the time of publication, the number of cases of coronavirus disease (COVID-19) in the United States began to grow exponentially, jumping from 1215 reported cases on March 11 to 10,442 just 1 week later.² Now, at the time of publication in early April 2020, the United States has surpassed more than 400,000 reported cases and 13,000 deaths to become the new global epicenter of COVID-19.

Dermatology practices across the country are fielding calls from patients with psoriasis and psoriatic arthritis looking for guidance on managing their disease during the pandemic.

What to Do With Biologics
A recent op-ed in The Washington Post by Kevin Brennan, member of the national advocacy board of the Arthritis Foundation with psoriatic arthritis, detailed his fears surrounding severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and his biologic therapy.³ He questioned “Should I stop taking my medicine and brace for a painful and crippling flare for fear that my weakened immune system could threaten my life? Or is it already too late for my immune system to rebound to fight the coronavirus?”³ Mr Brennan is not alone in asking these questions. As Bashyam and Feldman noted in the March 2020 issue of The Dermatologist,⁴ many patients with psoriasis or psoriatic arthritis want to know if their biologic should be stopped in light of the pandemic. Further, in a reader survey sent digitally on March 15, 2020, 62.1% of respondents indicated that their patients have asked if they too should stop their biologic therapy.

To assist its membership during the pandemic, the American Academy of Dermatology (AAD) released an interim guidance statement on March 18 on the use of biologics at this time.⁵ Two days later, the National Psoriasis Foundation (NPF) shared similar recommendations as advised by its medical board regarding patient care.⁶ In short, both statements stress that patients should not stop biologic therapy without consulting their physicians. A summary of the recommendations is listed in the Table.^5-9

Identifying Risk of Severe COVID-19
Despite having an immune-mediated disease, there is no current conclusive evidence that patients with psoriasis or psoriatic arthritis (without comorbidities and who are not receiving immunosuppressive therapy) have any additional risk of contracting a SARS-CoV-2 infection compared with a healthy person.⁶ However, psoriasis is increasingly recognized as a systemic inflammatory disorder connected to a number of comorbid diseases, such as:

• Cardiovascular disease and major adverse cardiovascular events;
• Metabolic syndrome, including obesity, hypertension, insulin resistance, and dyslipidemia;
• Inflammatory bowel disease;
• Hepatic disease;
• Renal disease; 
• Chronic obstructive pulmonary disease; and
• Malignancy.^10-12

Notably, the common comorbidities of psoriasis are also considered serious underlying medical conditions that may elevate the risk of severe illness from COVID-19 for persons of any age.¹³ As previously mentioned, when dermatologists evaluate biologic therapy in patients, they should consider the individual patient’s medical history, as any of these comorbidities may require a second thought when examined alongside other patient factors.

The potential safety issues with immunomodulatory therapies have been discussed in major academic journals over the past few weeks.^14-17 Lebwohl et al¹⁴ extrapolated infection rates from the pivotal trials of biologics approved to treat psoriasis. In a comparison of biologic agents vs placebo, rates of upper respiratory infection and nasopharyngitis were comparable. For tumor necrosis factor (TNF) blockers, overall infections and upper respiratory infections are increased by up to 7%, but TNF blockers do come with a black box warning regarding infection. While they did recognize the limitations of their comparison, the authors concluded that the available data could be useful in informing physician decisions.

Aside from biologic use, the best course of action for patients with psoriatic disease is to follow normal Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) recommendations for protecting against COVID-19. These include washing hands frequently; using good respiratory hygiene (ie, covering coughs and sneezes with a disposable tissue or shoulder/elbow); not touching the eyes, nose, and face; and staying a minimum of 6 feet away from others outside of the home. Dermatologists should inform their patients with psoriatic disease of these protection recommendations. Physicians are in a unique position to model physical distancing to their patients by implementing telemedicine into their practice.

More study exploring the relationship of psoriatic disease, infection risk, and SARS-CoV-2 is still needed. In the meantime, understanding the recommendations by the AAD and NPF along with staying updated with the latest information from the CDC and WHO is critical to making informed decisions in patient care.

References
1. Mateja L. Options with IL-23 inhibitors for the patient with psoriasis. The Dermatologist. 2020;28(3):27,34. Accessed March 23, 2020. https://www.the-dermatologist.com/article/npf0320

2. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): cases in the US. Updated March 31, 2020. Accessed March 31, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

3. Brennan K. Some people worry we’re overreacting to coronavirus. I worry about dying on a ventilator. Washington Post. March 12, 2020. Accessed March 23, 2020. https://www.washingtonpost.com/opinions/2020/03/12/some-people-worry-were-overreacting-coronavirus-i-worry-about-dying-ventilator/

4. Bashyam AM, Feldman SR. Dermatology and the COVID-19 pandemic. The Dermatologist. 2020;28(3):8. Accessed March 23, 2020. https://www.the-dermatologist.com/article/dermatology-and-covid-19-pandemic

5. American Academy of Dermatology. Guidance on the use of biologic agents during COVID-19 outbreak. March 18, 2020. Accessed March 23, 2020. https://assets.ctfassets.net/1ny4yoiyrqia/PicgNuD0IpYd9MSOwab47/07b614658aff5fc6ccc4c0bd910509a3/Biologics_and_COVID_19_FINAL_V2.pdf

6. National Psoriasis Foundation. Coronavirus concerns?: NPF Medical Board COVID-19 recommendations for patients with psoriatic disease. March 20, 2020. Accessed March 23, 2020. https://www.psoriasis.org/advance/coronavirus

7. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): discontinuation of in-home isolation for immunocompromised persons with COVID-19 (interim guidance). Updated March 16, 2020. Accessed March 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ending-isolation.html

8. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): disposition of non-hospitalized patients with COVID-19. Updated March 16, 2020. Accessed March 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html

9. Menter A, Strober BE, Kaplan DH. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029-1072. doi:10.1016/j.jaad.2018.11.057

10. Takeshita J, Grewal S, Langan SM, et al. Psoraisis and comorbid diseases. J Am Acad Dermatol. 2017;76(3):377-390. doi:10.1016/j.jaad.2016.07.064

11. National Psoriasis Foundation. Comorbidities associated with psoriatic disease. Accessed March 24, 2020. https://www.psoriasis.org/about-psoriasis/related-conditions

12. Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073-1113. doi:10.1016/j.jaad.2018.11.058

13. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): underlying conditions. Updated March 22, 2020. Accessed March 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/underlying-conditions.html

14. Lebwohl M, Rivera-Oyola R, Murrell DF. Should biologics for psoriasis be interrupted in the era of COVID-19? J Am Acad Dermatol. Published online March 18, 2020.

15. Shanshal M. Is the coronavirus (COVID-19) pandemic an indication to temporarily modify dermatological management plans? J Drugs Dermatol. 2020;19(4):436. 

16. Shah P, Zampella JG. Use of systemtic immunomodulatory therapies during the coronavirus disease 2019 (COVID-19) pandemic. J Am Acad Dermatol. Published online March 23, 2020. doi:10.1016/j.jaad.2020.03.056

17. Price KN, Frew JW, Hsiao JL, Shi VY. COVID-19 and immunomodulator/immunosuppressant use in dermatology. J Am Acad Dermatol. Published online March 20, 2020. doi:10.1016/j.jaad.2020.03.046