In this first video of our Coping During COVID series, Joel M. Gelfand, MD, MSCE, senior advisor of the Interdisciplinary Autoimmune Summit and cochair of the National Psoriasis Foundation (NPF) COVID-19 Task Force, discusses how to approach treatment with biologics in patients with psoriasis, citing the current literature, recommendations from the NPF and American Academy of Dermatology, and his own recent clinical experience.
Dr Gelfand is professor of dermatology and of epidemiology; vice chair of clinical research and medical director, Clinical Studies Unit; director, Psoriasis and Phototherapy Treatment Center; and senior scholar, Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, PA.
Read the NPF COVID-19 Task Force guidance on the National Psoriasis Foundation website.
Read the transcript:
Well, you know, the first question that people ask me is having psoriasis is that put them at higher risk of developing either infection with SARS-CoV-2 and having worse outcomes with COVID-19 illness, is there any relation to having disease and these type of pandemic issues.
And interestingly, there was a paper that came out recently out of the United Kingdom were they were able to follow everyone in the country, basically millions of people through their primary care physicians databases, and they actually found higher rates of mortality in people with psoriasis and other autoimmune diseases, including lupus and rheumatoid arthritis. And so from that trial, that study I should say, you know, we don't know for sure this is psoriasis that puts people at higher risk of having infection with COVID-19 and having worse outcomes from it, or is the fact that they were just lumped in with other diseases like lupus and RA, which may have worse prognoses. So, we just don't know the answer for sure.
What we do know is that people psoriasis have a number of comorbidities that make them more prone to worse outcomes with COVID illness. Okay, so, diabetes, obesity, BMI over 30—these kinds of things that are already identified by the CDC as predisposing people to worse outcomes from coronavirus infection. Cardiovascular disease is another one that can put people at higher risk. And so for our patients with psoriasis, if they’re otherwise completely healthy, then they probably have the same background risk as anyone else would have. But they have these major comorbidities or they’re older—they’re in their 50s, 60s, 70s, et cetera—that certainly puts them a higher risk for having bad outcomes from COVID-19.
Now in terms of our treatments, you know, this has been an area that we’re all learning together, if you will. Certainly, a lot more therapies target the immune system, and because of that, there is theoretical concern it can make people more prone to infection or potentially worse outcomes from this virus. The good news is that so far the data that’s come out has been largely reassuring. People on biologics or systemic agents for psoriasis generally seem to have the same course of illness that you would expect for a person, you know, of their own background, age, and other risk factors for outcomes. So, probably what drives the risk of COVID-19 is your underlying age and major health problems, not necessarily the treatments for psoriasis that you’re on.
Some studies actually been even more reassuring. There was one report in the rheumatology literature of mainly rheumatoid arthritis patients, and those on TNF inhibitors had a substantially lower rate of bad outcomes from COVID-19 illness compared to those rheumatoid arthritis or other rheumatic diseases getting other treatments. Now, again, we don’t want to read too much into this type of data because these are essentially spontaneous case reports than being analyzed in mass, if you will, but at least the best we could say is that virtually all the literature to date tends to be reassuring when it comes to psoriasis therapies not promoting a worse outcome for patients with COVID-19.
I think during the pandemic it’s really important that we as dermatologists, you know, deal with each patient’s individual concerns, okay. You know, so, for me, generally speaking, I encourage most of my patients to stay on their treatments for psoriasis, because we know that a stressful time can make people’s psoriasis worse. We know our treatments aren’t cures, and when people stop them eventually disease comes back. And what many of us are seeing the clinical community now is that our patients who stopped their biologics or other therapies for psoriasis early in the pandemic are now contacting to us with flares in their disease. And so, you know, it’s hard enough for people to deal with all these changes we’ve got to put up with in our daily lives related to the COVID-19 pandemic. It's nice to take the burden of psoriasis off the table.
Now that being said, you know, for some my patients, they have specific, special concerns. One patient, a young person who’s done brilliantly well on her biologic; skin’s completely clear. But she lives at home with her family, and there’s multiple generations in the household, and so this particular person was concerned about staying on their biologic because they’re worried it might make them more prone to getting infected. That's a theoretical concern; we have no data to say that's certainly the case. And so in her case, we talked about the risks and benefits of continuing treatment, and I explained to her like, “well, if you really want to go off of it, let’s just watch your skin, and if you see any signs of it coming back, we should discuss going back on it.” Which, we know some of our patients will have a prolonged remission in their disease, especially when they’re on the IL-23 pathway drugs. And so we don't always know for certain which of our patients has to stay on the therapy, you know, for years and years and which patients may be able to get away with a holiday off treatment for 6 months or a year.
The AAD had put out some guidance earlier on that’s still out there, and certainly, you know, we may want to revisit for some patients who may have softer indications for systemic therapies and may have underlying health problems of concern, right. So, if you have someone who’s, say, 75 years old with bad lung disease and was on a systemic agent for their psoriasis, but the disease wasn’t really that bad at baseline, well, it may be worthwhile saying, “why don’t you delay your next shot and let’s see if you have any evidence of recurrence,” because maybe they’re in a long-term remission and therefore for that individual, maybe the uncertainty of the therapy may outweigh the benefits if their skin is truly clear anyway and they can remain clear when they come off their treatment. But for most people, that’s not going to be the situation. Most people on these agents need to be on them, and then the concern becomes “well, if I stop their biologic, they may lose response to it, may be running out of treatment options,” because even though we have so many great options for treatment of moderate to severe disease, that, you know, there’s only three basic classes we have available. And I certainly had plenty of patients who have done well on a number of different biologics but are very mature in their treatment pattern, and they may be on their last biologic now, and if they won’t respond to that, they have no more options. And so clinicians really have to think about that carefully, you know. A patient who has a lot of underlying health problems, who’s significantly older, more mild disease as your indication and maybe they’ve only been on one systemic therapy—well, that person maybe has more leeway to say, “alright, if you want to come off of it, that's probably OK.” But a person who’s maybe a little bit younger, has severe underlying disease, has been through two or three treatments already, you know, these are people we want to be careful about stopping a therapy for hypothetical concerns because that could certainly do harm to them. They could have, you know, progression of their disease causing all sorts of problems and challenges for a patient, but then they also may not respond to their biologic.
So I cochair the National Psoriasis Foundation’s Task Force on COVID-19, and so I encourage my colleagues to keep an eye on their website, which we update as needed as new information comes out, and we are in a process of going through more formal Delphi-like exercise to provide some standing recommendations to people that will change as the evidence evolves. But generally speaking, you know, our recommendations are that for most people with psoriatic arthritis or psoriasis, that they likely should stay on their therapy. Really, it's an individual decision between patient-doctor, but for most people are the proven benefits of therapy will outweigh the theoretical concerns.