Experts Opinion on the Use of Biologic Agents in Psoriatic Patients during COVID

Gang Wang*, Heng Gu*, Min Zheng, Yi Zhao, Jun Gu, Hong-Zhong Jin, Xiao-Ming Liu,Yu-Ling Shi, Qing Sun

1Department of Dermatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, China; 2Hospital for Skin Diseases (Institute of Dermatology), Chinese Academy of Medical Sciences, Nanjing, Jiangsu 210042, China; 3Department of Dermatology, The Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang 310009, China; 4Department of Dermatology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China;5Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200000, China;6Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; 7Department of Dermatology, The University of Hong Kong-Shenzhen Hospital,Shenzhen, Guangdong 518053, China; 8Department of Dermatology, Shanghai Skin Diseases Hospital, Shanghai 200443, China;9Department of Dermatology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, China.

Abstract The coronavirus disease 2019(COVID-19)outbreak affects the use of biologics for psoriatic patients,in the way that the consequential immunosuppression potentially alters a patient's susceptibility to the virus or deteriorate the condition if the patient is infected or even change the prognosis of infection.Therefore, authors reviewed currently available recommendations from international psoriasis academic organizations and specialists,and summarized them with the specific situation in China.We are trying to provide guidance to the use of biologics for psoriatic patients in the following contexts:patients on biologic therapy,patients being considered for biologic therapy initiation,patients with low-risk or high-risk of SARS-CoV-2 coronavirus infection,patients tested negative or positive for the nucleic acid testing of virus.

Keywords: psoriasis, biologic agents, COVID-19, SARS-CoV-2

Introduction

In the treatment of psoriasis, biologic agents exert immunosuppression via relevant targets, pathways and mechanisms, which theoretically may alter the patient's susceptibility to COVID-19 (pathogene is SARS-CoV-2),deteriorate the condition or even change the disease prognosis.During H1N1 outbreak, psoriatic patients on immunosuppressant or biologic agents were reported to contract H1N1 or even died from the infection.1This fact justifies the current concern of dermatologists and patients about the use of biologics; therefore, administration of biologics should be more precautious during the pandemic.So far, no guidance on the use of biologics during COVID-19 outbreak has been issued by any authority or specialist organization.We reviewed currently available recommendations from the American Academy of Dermatology, International Psoriasis Council, and Skin Inflammation & Psoriasis International Network, and took them together with the specific situation in China in order to provide guidances on the use of biologics for psoriatic patients.

Strategies to different status of patients with psoriasis

Psoriatic patients on biologic therapy

If psoriatic patients are confirmed of COVID-19 infection or present suspected symptoms such as fever and cough,they are suggested to discontinue the use of biologics and seek for COVID-19 screening,diagnosis,and treatment at specialized hospitals.1-4During the timeout,treatment for psoriasis may shift to topical agents or other nonimmunosuppressant therapies.Therapeutic protocol and resumption of biologics should be reassessed and planned after full recovery from the infection.

Psoriatic patients on biologic therapy who are not infected by COVID-19

No evidence suggests these patients should discontinue the use of biologics.1-4Dermatologists should analyze the patient's condition on a case-by-case basis and weigh the benefit versus risk of continuing biologics, according to patient's age, disease severity, underlying disease, contact history or risk of exposure to the SARS-CoV-2,before they decide if biologics should be continued.Evidence shows that, the factors that may drive a patient contracting COVID-19 to severe case include: age ＞60 years old,cigarette smoking, respiratory disease, cardiovascular disease,severe hypertension,liver disease,kidney disease,diabetes,malignant tumors,and so on.Therefore,patients with these high risks, if report contact history or risk of infection,are suggested to discontinue or postpone the use of biologics.1-4Moreover,those patients who are deprived of biologics supply due to traffic and logistics issue,should be assessed by a dermatologist before they re-start biologics,including if another induction therapy is needed or maintenance treatment should be continued.5

Patients who are considering biologics initiation

These patients should be assessed by a dermatologist on the basis of their risk of infection and overall health.

Psoriatic patients with the above-mentioned high risks should postpone their initiation and resort to nonimmunosuppressant therapies1-4; patients with low risks or those living in areas where the virus is effectively contained,may use biologics as normal if it is required by the condition.1,5

In conclusion, the above opinion is drafted based on the specialist agreement on the current understanding of COVID-19 pandemic and may subject to updates or amendments as new knowledge and evidence emerge.

Acknowledgment

The authors thank Ms.Pauline Pei for her assistance in the preparation of the manuscript.