Perspectives on the Management of Plaque Psoriasis - Episode 15
Experts reflect on the treatment of patients with plaque psoriasis during the COVID-19 pandemic.
Christopher G. Bunick, MD, PhD: In the final segment, we’re going to talk about what’s on everybody’s mind, because hopefully we’re moving out of the pandemic. We’re 2 years in to this COVID-19 pandemic. Given that we’re in this era of the COVID-19 pandemic, it’s important that we address some questions regarding psoriasis biologics and their safe use during COVID-19 and with available vaccines. This is a pressing issue on many patients’ as well as health care providers’ minds, and they would love to hear from experts like you.
What’s the real story behind psoriasis, biologics, vaccines, and COVID-19? I’m going to leave this open to all 3 of you. I’m going to go through some questions, and I’d love everybody to jump in and give their opinions. The first and most important question that we need to help our viewers with is, what are the National Psoriasis Foundation [NPF] and AAD [American Academy of Dermatology] recommendations for the use of biologics in the COVID-19 pandemic?
Mark G. Lebwohl, MD: I’m on the committee that looks at this, so I’ll start. First, in cases of active infection, the package inserts, the companies that make the drugs, and the AAD and NPF have said to stop the drugs. There’s no information that stopping the drugs helps patients. It’s even been suggested that being on the drugs is protective against some of the cytokine storm that ends up destroying the lungs later on. But the recommendations are to stop the drug with active infection.
In terms of staying on the drug during the pandemic and the worry that it might make you more susceptible to infection, that’s been proven false. In addition, with patients on biologics, in many cases—the example is most clear with the TNF [tumor necrosis factor] blockers—several studies have shown that patients being treated with TNF blockers had a better outcome than patients not on TNF blockers. The bottom line is that they’re encouraging no one to discontinue their treatments, except during active infection. We can discuss vaccination afterward, but that’s the answer to your question.
Christopher G. Bunick, MD, PhD: Would anyone else like to comment on that?
Helen Torok, MD: That’s what I tell my patients. They’re all nervous. “You’re suppressing me.” No, I’m not. I’m going to prevent you from getting sicker. That’s what I tell them. I just keep them on it.
Christopher G. Bunick, MD, PhD: If your patient says, “Doctor, I tested positive for COVID-19,” do you tell them to skip their doses? Or do you tell them that the data suggest there may be a protective effect against the cytokine storm and to stay on it?
Helen Torok, MD: Their doctors have already said to stop it. They’ve already talked to their family doctors, their internists, so we don’t often hear that because they stop it automatically for them.
Mark G. Lebwohl, MD: That’s absolutely right. In fact, the data that show it’s protective were in a setting where patients were told, “If you have active infection, stop it.” The ones who had been on TNF blockers did better, but that doesn’t mean they were on it during the infection.
Jashin Wu, MD: I was part of a study presented in April 2021. It’s a large study using Symphony Health data, so we had over 167,000 patients with psoriasis. We looked at patients in the different biologic classes and the rates of COVID-19 infection. In these patients with psoriasis, we found that those on a TNF inhibitor had lower odds of contracting COVID-19. This is under consideration for publication soon. But it’s important to note that these patients shouldn’t necessarily stop a biologic just because they’re worried about having a COVID-19 infection. It’s something that may improve the risk of contracting or may even improve the risk of hospitalization or death if they’re on one of these biologics.
Christopher G. Bunick, MD, PhD: Can one of you speak to the available data that demonstrate the safety of biologics in patients with psoriasis who contract COVID-19? You’ve mentioned there are some studies out there. Are there any specifics that you could share?
Mark G. Lebwohl, MD: There’s a study from NYU [New York University] in New York—I think it was a study from Italy—where they looked at a number of cases and the odds of ending up in the hospital, on ventilators, dying, and so on. There are several studies that show a benefit to TNF blockade.
Christopher G. Bunick, MD, PhD: Excellent. Are you aware of any contraindications to COVID-19 vaccination and the use of psoriasis biologics? A lot of patients with psoriasis may come in and look to us or dermatology health care providers and say, “Doctor, should I get my vaccine? Is it safe to get my vaccine?” But also, “When should I get my vaccine? I’m due for my shot next week. When do I time my vaccine with my psoriasis biologic?”
Mark G. Lebwohl, MD: There’s no evidence that blocking the IL-23/IL-17 pathway interferes with response to vaccinations. The recommendations from the National Psoriasis Foundation; SPIN [Skin Inflammation & Psoriasis International Network], which is an international organization; and the American College of Rheumatology are fairly similar. They differ a little. Some of them say that with a drug like an IL-23 blocker, if you’re giving it every 3 months, aim for the 6-week period in the middle. But the NPF says to not impact your vaccination at all. The data support the NPF point of view.
As for the TNF blockers, the data for the flu and pneumococcal vaccines show that there’s a slight reduction in antibody response to the antigens against which you were vaccinated. However, it’s an adequate response. The NPF doesn’t recommend changing your course of therapy for those. With methotrexate, there’s some evidence that if you hold the dose for 2 weeks after vaccination, you get a better response. Some recommend holding it for a week before or holding it 1 or 2 weeks after. The NPF’s initial guideline said that it doesn’t impact it much at all. With JAK inhibitors, the recommendation by some organizations is to hold it for at least a week after the vaccination. With ustekinumab, there’s no recommendation to hold it at all. I think we covered all the drugs.
Christopher G. Bunick, MD, PhD: With regard to vaccination, because we now have the initial vaccination and boosters, I’m assuming that it’s the same for boosters—that there should be no contraindication to getting that booster for those who wish to get it.
Mark G. Lebwohl, MD: Correct. At worst, some of the drugs may have a little suppression of the response, but we want patients to get them.
Transcript edited for clarity.