No Interruption of Biological Treatment in the Era of COVID-19: More Considerations

Dear Editor,

We have read with great interest many papers and research letters or editorials recently published in many journals of great impact concerning if to go on or not treating psoriasis (PsO) patients with biologicals during the COVID-19 pandemic.

We think that in this peculiar time, characterized by COVID-19 spread, dermatologists treating with biologics in their clinical practice, should have common therapeutics aims, according to biological safety data from the literature and to personal experience (real life data). We do agree with Lebwohl et al., that there is a difference of risk of infections which differs among the many biologicals in use for the treatment of PsO and that most of the infections refer to upper respiratory tracts rather than to lung infections [1].

Next to known acquired data about the safety of biologicals, there is another important consideration concerning biologic treatment in PsO patients and which we have reported in a recently published manuscript [2]: the late and most serious  stages of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections, are characterized by the so-called “cytokines storm”: an impressive release of proinflammatory and inflammatory cytokines (mainly IL-1, IL-6, Il-12, TGF-beta and chemokines) which have proven to be lethal for some individuals [3]. 

PsO is a chronic inflammatory disease and patients in treatment with biologicals are affected by the most  severe clinical  forms and some of them are also affected by psoriatic arthritis; the interruption of the treatment for a long time due to the COVID-19 pandemic could worsen the symptoms and/or induce pharmaco-resistance [4].

Moreover, according to our very last experience, among the PsO patients treated with targeted therapy in our Departments, two patients had a close contact with COVID-19 positive patients (without clinical manifestations) and both of them were swab negative, the swab was performed twice. The first patient was on treatment with etenarcept for eight years and the second one with adalimumab biosimilar (switched from adalimumab originator) for six years.

In conclusion, we think that in line with the current data from the literature and real life, considering pros and cons if to interrupt or not biological treatment in PsO patients, we have not, up to now, robust data to interrupt therapy.

References

1. Lebwohl M, Riviera-Oyola R, Murrel DF. Should biologics for psoriasis be interrupted in the era of COVID-19? J Am Acad Dermatol (2020).
2. Amerio P, Prignano F, Giuliani F et al. COVID-19 and psoriasis: should we fear for patients treated with biologics? Dermatol Ther (2020).
3. Mehta PM, McAuley DF, Brown M, et Al. COVID-19: consider cytokine storm syndromes and immunosuppression. [published online ahead of print] Lancet (2020).
4. Brezinski EA, Armstrong AW. Off-label biologic regimens in psoriasis: a systematic review of efficacy and safety of dose escalation, reduction, and interrupted biologic therapy. PloS One 7 (2012): e33486.