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Updates from the Registries Preview: Immunomodulators and COVID

In this video preview, Drs Larry Green and Esther Freeman discuss the latest data regarding the use of immunomodulators during the COVID-19 pandemic.

Dr Freeman is an assistant professor of dermatology, director of Global Health Dermatology at Massachusetts General Hospital and Harvard Medical School, and a member of the AAD Ad Hoc Taskforce for COVID-19.

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 Green: Let me switch the topic a little bit and talk about...We have patients on immunomodulating therapy for people taking antibiotics for psoriasis, for atopic dermatitis, and other conditions like that. Do you think there’s any problems with immunomodulating therapy, any aspects of immunomodulation that you want to discuss that you think are applicable with COVID‑19 infection?

Dr Freeman: Yeah. This has been tricky from the very beginning. Early on, we were really worried that our patients, for example, on biologics, were going to end up at higher risk for COVID. That was our concern. People were very, very concerned about that.

I have to say, I’ve been reassured by the data that we’ve now seen several studies, both from the rheumatology literature and from the dermatology literature that don’t seem to suggest that our patients with biologics are necessarily getting any more severe COVID than other patients of similar age and profile. I’ll give you one example.

We talked a little bit about our collaboration between different COVID registries. We’ve been collaborating with PsoProtect, which is one of the COVID‑19 psoriasis‑specific registries. We collaborated with them and pooled some of our data from the AAD and ILDS registry.

This paper was recently published in the Journal of Allergy and Clinical Immunology just in October. It’s titled, “Factors Associated with Adverse COVID‑19 Outcomes in Patients with Psoriasis, Insights from a Global Registry‑Based Study.” In this study, evaluated 374 clinician‑reported patients from 25 different countries. Hospitalization was not more frequent in patients on biologics.

In fact, it was more frequent in patients on other immune modulators and other treatments than biologics. Different biologic classes were not seen to be different. That type of data has been seen in the rheumatology literature as well. I’ve been reassured. That being said, it’s still really tricky to figure out what to do with your individual patient.

My other hat is I’m the chair of the Clinical Guidelines Committee at the AAD. It’s important for people to recognize that when we normally produce guidelines at the AAD, it’s a very evidence‑based‑Driven process. We spend a lot of time evaluating the literature that’s out there. Very tricky when there’s no real literature to base those guidelines on.

When we produce this interim guidance, I want people to be aware that it’s very different than our much more robust, normal psoriasis guidelines, for example. The National Psoriasis Foundation, the NPF, has done a really nice job with producing some guidance around this. All of these guidelines from all these different groups are interim. We don’t have the data.

It’s a bit tricky when you’re faced with a patient. Certainly, I wouldn’t recommend rushing to take anyone off biologics. I, myself, have had patients where now we are in the middle, we’re month‑nine of COVID, and I want to start them on a biologic. That’s tricky.

You have to have an individual‑level discussion with your patient about their risks and benefits. As much as possible, explain to them what we do know, what we don’t know in terms of biologics and COVID‑19.

Dr Green: I agree. That’s makes the most sense. You still have the chronic disease state like atopic dermatitis or psoriasis. Having that and what COVID could do when you’re chronically inflamed and untreated versus treated, that’s a discussion, like you said, you have to have with the patient. Time will tell.

Eventually, we’ll see once we get patients who take biologics and then, unfortunately, do come down with COVID‑19 to see how they respond long‑term. Will then have chronic COVID? Will they have long‑COVID infection? How many of them do? How many of them don’t? We don’t know. You talked about evidence. We don’t have evidence. It’s early on.

Dr Freeman: We have evidence for the short term. We know, at least, you’re not more likely to end up in the hospital, which is good. You’re absolutely right, we don’t know what this means for you necessarily six months after you’ve gotten COVID.

Like you said, there’s so many different pieces of it. If you have someone who’s in such a horrible psoriasis flare that they’re going to become erythrodermic and end up in the emergency department, that’s not good. [laughs] It’s this balance of risk and benefits.

Dr Green: Right. No one wants to go to a hospital overrun with COVID because you have a flare of psoriasis. 

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