In the second installment, Dr Green and Dr Gelfand discuss the impact of the COVID-19 pandemic and how they are managing patients with psoriasis.
Dr Gelfand is a professor of dermatology and epidemiology, vice chair of clinical research and medical director of the dermatology clinical studies unit, and the director of the psoriasis and phototherapy treatment center at the University of Pennsylvania Perelman School of Medicine.
Dr Green is the section editor of The Dermatologist’s Psoriasis Center of Excellence, clinical professor of dermatology at George Washington University School of Medicine in Washington, DC, and on the National Psoriasis Foundation Medical Board.
Dr Larry Green: Welcome back. We have Dr Joel Gelfand here to discuss his take on managing psoriasis during the COVID-19 pandemic. So, let’s open up with what everyone’s dealing with these days.
I’ve had...I’m sure you have. Everyone who treats psoriasis, every dermatologist, has had multiple patients talk to us and call us and patients who are taking biologics or have severe psoriasis asking us what’s best to do.
And there’s been information put out by the National Psoriasis Foundation Medical Board. The AAD has something. But I’d like to hear from you, who’s, has a lot of work with inflammation and psoriasis, on what you think an untreated patient’s risk who has severe psoriasis is for COVID-19 versus a treated patient. And then, the treated patient’s risk for biologics as a separate patient who’s treated with biologics who’s doing well as a separate issue from the untreated versus the treated patient. So, let’s start there. Let’s start.
Dr Joel Gelfand: Yeah.
Dr Green: You know, people have asked me, “I’d like to go off my biologic because I’d rather have severe psoriasis than taking a potentially immunosuppressive medication.” What would be your response?
Dr Gelfand: Yeah, so the way I’ve thought about this, it’s a very much individual patient-level decision, shared decision-making. And, and I agree with the guidance come out from the AAD, as well from the International Psoriasis Council board, which I’m a member of their board of directors.
And essentially what we’ve advocated for is a discussion with patients about the risks and benefits and the uncertainties that we’re dealing with the era of a COVID-19 pandemic. Certainly, one of our goals is to avoid patients having a flare of their psoriasis that would require them to seek urgent medical attention.
That’s probably the biggest risk that could happen to a patient, is that because their disease and their skin gets so bad that they have to go to the office for management or have to go to the emergency room for management, and then they become infected with COVID-19 and have a really bad outcome because of that.
So, I think, you know, first and foremost, our goal is to try and help people maintain good control of their disease. Then I decide with my patients as such. You know, for patients who are older, you know, a 70-year-old patient who has underlying lung disease, you know, if my records show that their initial indication for their biologic was more moderate disease, they never were hospitalized for it. They were never erythrodermic. Their disease was, you know, not so terrible for them, uh, objectively. If their disease is under really good control, we have a choice. We can essentially delay their next injection and then restart it as soon as they see signs of their disease coming back.
That might be a conservative approach to take with a patient who’s very anxious about this environment. But certainly, what we don’t want to do is have patients just, you know, stopping their drugs, their therapies, without appreciating the risk of their disease coming back.
So, on the other hand, I have patients who have serious health problems, you know, bad congestive heart failure, bad COPD, but their psoriasis is so horrible we know that if they were to come off their biologic that their disease will return and they’re going to need urgent medical management that themselves put them at risk that point in time COVID-19 infection.
So, you know, generally speaking, patients who have an underlying indication of very severe psoriasis, who are well-controlled, probably should stay on their biologic.
Those whose underlying indication is more mild, moderate disease, less likely to flare and cause problems for them. Well, if those people have serious underlying health problems, they may want to consider delaying their next shot. And hopefully, by then we’ll have more information. Maybe we’ll have more data to know what the impact of these therapies may be on outcomes related to COVID-19.
Dr Green: Right, right. And I’ve always, I’ve, one other thing I’ve mentioned to patients is that if, it’s, of course, if they can stay on their biologics, if they don’t have other comorbidities, stay on your biologics.
But if they think they’re exposed to someone or they know someone who knows someone and they’re a little worried, then, by all means, it can’t hurt to stop for a few weeks just to make sure you’re not infected. It’s just a few weeks. You can go back on your biologic and not miss that much of a beat because a lot of your psoriasis won’t come back.
Dr Gelfand: It’s the advantage we have as dermatologists in that the patients and us will know when their disease is back, unlike a patient, say, with psoriatic arthritis. And you don’t know if their pain is from inflammatory arthritis or from osteoarthritis, fibromyalgia, gout attack, what have you? We can at least assess and figure out, “OK, yeah, you need to restart your medication.”
Dr Green: Right, yeah, that’s certainly one advantage we have with a skin disease. So, let me ask a much tougher question, is how would you distinguish among biologics as which would be potentially a safer biologic to be using in regards to risks for COVID-19 infection?
Dr Gelfand: Yeah, so I think this is a very hard question to answer at this point in time. I mean we know that IL-17s and IL-23s, which have some amazing safety profile under normal conditions, although we also know that those pathways are important for mucosal immunity and those therapies are generally associated with higher rates of upper respiratory tract infections as compared to placebo. And, of course, you know, SARS-CoV-2 is an upper respiratory tract infection. Now the difference between the treating groups and the placebo group is pretty small. We’re talking about differences of about 1%, 2%, over a period of 12 weeks or so. But it’s certainly cause for concern based on the importance of these pathways for mucosal immunity. Of course, we know with TNF inhibitors, they have warnings related to more serious infections, reactivation of tuberculosis. There’s some concern there, theoretically, as well.
Now on the flip side of the coin, there’s some papers that have shown that people with severe COVID-19 infection, that they had elevations in cytokines like interleukin-17 and TNF. And so, you know, it’s possible that something on these therapies might prevent people from having serious lung damage.
So, you know, essentially this shows you how much uncertainty there is. And that’s why it’s important to have it be an individual decision between the patient and the prescribing clinician. Because many patients, accept this uncertainty and recognize the importance of being on their therapy. And, other patients will be uncomfortable with the uncertainty or they recognize that the disease was really not so bad that they need to be on this medication still at this time.
Dr Green: Yeah, so we’re back to the beginning where we started when we talked about COVID-19. It really is, like you said, shared decision-making is the best way, and we’re there the people in private practice, like myself and you, who treat these patients with severe psoriasis are there to help and help make the best choice for that person.
Dr Gelfand: That’s exactly right. And the other thing that we’ve done, at least in my health system, we’re fortunate we have telemedicine set up on-demand for patients. So, they come down with symptoms, they could call our health system.
They can then get counseled and be told, “Yes, your symptoms are serious enough you need to be tested,” where to go for testing, about whether or not they need to go to the emergency room, things of that nature.
So, I think it’s important that all of our patients, you know, have a plan and know who the doctors they’ll contact if they have symptoms, know how to do social distancing, and understand what symptoms to be looking out for so they know when to seek medical attention.
Dr Green: Very good. Well, thank you, Joel. It’s a, been a pleasure speaking with you and talking with you about cardiovascular disease and comorbidities in psoriasis as well as talking a little bit about COVID-19 infection. I hope everyone’s enjoyed this podcast. And please let us know your thoughts or questions. There is a feedback box on the web page, which you can use to get in contact with us.
With that, Joel, I look forward to seeing you whenever we’re free to get together again and talk in a group with dermatologists. It’s always a fun time to talk with you and get your opinion and just enjoy, spending some time with you and, and everyone else. And look forward to getting together with everyone else at some point soon.
Dr Gelfand: Yes, absolutely, Larry. Good, good to talk.