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Treatment discontinuation and rate of disease transmission in psoriasis patients receiving biologic therapy during the COVID-19 pandemic: A Canadian multicenter retrospective study

      To the Editor: Limited data are available to guide use of biologics for moderate to severe plaque psoriasis in the current coronavirus disease 2019 (COVID-19) health care landscape.
      • Warren R.B.
      • Gooderham M.
      • Burge R.
      • et al.
      Comparison of cumulative clinical benefits of biologics for the treatment of psoriasis over 16 weeks: results from a network meta-analysis.
      ,
      • Kim H.J.
      • Lebwohl M.G.
      Biologics and psoriasis: the beat goes on.
      We aimed to further understand the rate of patient-driven biologic discontinuation in moderate to severe psoriasis because of concerns regarding COVID-19 complications. Furthermore, our goal was to add to the limited but increasing body of literature on whether biologic use should be considered a risk factor for greater susceptibility to COVID-19.
      After research ethics approval, a multicenter retrospective study was undertaken of all patients from 2 tertiary academic hospitals affiliated with the University of Toronto, Canada, and a community practice in Hamilton, Canada. Inclusion criteria were patients aged 18 years or older with moderate to severe psoriasis who received at least 1 dose of a biologic before February 1, 2020. Data were retrospectively obtained from Patient Support Program case managers of all major suppliers of biologic agents for psoriasis. February 1, 2020, was the starting point of data collection (5 documented COVID-19 cases and 0 deaths in Canada) and patients were followed up until June 1, 2020 (91,703 cumulative cases and 7594 deaths).
      Johns Hopkins Coronavirus Resource Center
      COVID-19 case tracker.
      As of February 1, 2020, there were 2095 patients receiving biologic therapy for psoriasis who met inclusion criteria. Total number of patients who temporarily discontinued their biologic at any point during the 4-month period because of COVID-19–related concerns was 23 (1.1%) (Table I). Of the 23 patients who temporarily discontinued their biologic, 7 did so in February, 11 in March, 3 in April, and 2 in May. This corresponded to a total of 17 (0.81%), 18 (0.86%), and 18 (0.86%) patients discontinuing treatment at each of April 1, May 1, and June 1, 2020 timepoints, respectively. Biologic discontinuation by class included tumor necrosis factor α inhibitors (8/749, 1.07%), interleukin 12 and 23 inhibitors (5/371, 1.35%), interleukin 17 inhibitors (4/482, 0.83%), and interleukin 23 inhibitors (6/493, 1.22%) (Table II). Mean duration of biologic treatment before discontinuation was 50.6 ± 35.7 months. Five patients who temporarily discontinued their biologic elected to restart the same biologic before June 1 compared with 18 who remained without treatment. All patients who restarted their biologic (5/5, 100%) did so because of a flare of their psoriasis. Of the 23 patients who temporarily discontinued treatment, 14 (60.9%) were men, mean age was 56.4 ± 12.6 years, and 1 (4.3%) also had psoriatic arthritis. Of the 2095 patients in our cohort (2072 [98.9%] of whom continued to receive a biologic throughout the entire follow-up period), 0 had a confirmed positive diagnosis of COVID-19. All patients who developed COVID-19–related symptoms received testing, results of which were negative. Of the 16 new biologic treatment initiations between April 1 and June 1, 2020, the majority were interleukin 17 inhibitors (n = 13, 81.2%), followed by tumor necrosis factor α inhibitors (n = 2, 12.5%) and interleukin 23 inhibitors (n = 1, 6.2%).
      Table IDemographics of psoriasis patients who temporarily discontinued biologic treatment because of coronavirus disease 2019 concerns
      Discontinuation month, 2020BiologicSexAge, yearsDiagnosisDuration, monthsRestart before June 1
      FebruaryAdalimumabMan56Ps78Yes
      AdalimumabMan70Ps90No
      AdalimumabMan43Ps88No
      GuselkumabMan56Ps19No
      GuselkumabMan67Ps23No
      InfliximabMan63Ps133No
      UstekinumabMan45Ps43No
      MarchAdalimumabMan46Ps92No
      AdalimumabWoman65Ps + PsA83No
      AdalimumabWoman65Ps43Yes
      GuselkumabWoman64Ps24No
      GuselkumabMan48Ps17No
      GuselkumabWoman69Ps22No
      IxekizumabWoman66Ps26Yes
      IxekizumabMan70Ps23Yes
      UstekinumabMan30Ps100No
      UstekinumabMan49Ps2No
      UstekinumabWoman51Ps36Yes
      AprilGuselkumabMan56Ps18No
      UstekinumabWoman71Ps35No
      SecukinumabWoman73Ps56No
      MayAdalimumabMan43Ps91No
      IxekizumabWoman32Ps21No
      Biologics reviewed included adalimumab, brodalumab, certolizumab, etanercept, guselkumab, infliximab, ixekizumab, risankizumab, secukinumab, and ustekinumab.
      Ps, Psoriasis; PsA, psoriatic arthritis.
      Table IIPercentage of patient-driven temporary biologic treatment discontinuation during the coronavirus disease 2019 pandemic
      VariableCombinedAdalimumabBrodalumabCertolizumabEtanerceptGuselkumabInfliximabIxekizumabRisankizumabSecukinumabUstekinumab
      Total patients
      Total number of patients receiving a biologic for psoriasis as of February 1, 2020, and followed throughout the entire 4-month study period.
      2095290294636538848249105204371
      Discontinued before April 117 (0.81)5 (1.7)0005 (1.3)1 (2.1)2 (0.8)004 (1.08)
      Discontinued before May 118 (0.86)5 (1.7)0006 (1.5)1 (2.1)001 (0.5)5 (1.35)
      Discontinued before June 118 (0.86)5 (1.7)0006 (1.5)1 (2.1)1 (0.4)01 (0.5)4 (1.08)
      Total no. of restarts52000002001
      Combined all months
      Total number of patients who discontinued their biologic, including those who restarted before June 1.
      23 (1.1)7 (2.4)0006 (1.5)1 (2.1)3 (1.2)01 (0.5)5 (1.35)
      Data are presented as No. (%) unless otherwise indicated.
      Total number of patients receiving a biologic for psoriasis as of February 1, 2020, and followed throughout the entire 4-month study period.
      Total number of patients who discontinued their biologic, including those who restarted before June 1.
      The results of this study demonstrate that the rate of patient-driven biologic discontinuation during the peak of COVID-19 cases in Canada remained low during the entire 4-month follow-up period. Although interleukin 17 inhibitors had the lowest rate of temporary discontinuation, there did not appear to be a major class-specific difference in rates. Our findings provide some of the earliest evidence supporting current COVID-19 biologic treatment guidelines and encourage continuation of biologics in asymptomatic patients with negative COVID-19 test results despite the risk of future outbreaks.
      • Lebwohl M.
      • Rivera-Oyola R.
      • Murrell D.F.
      Should biologics for psoriasis be interrupted in the era of COVID-19?.
      ,
      • Shah P.
      • Zampella J.G.
      Use of systemic immunomodulatory therapies during the coronavirus disease 2019 (COVID-19) pandemic.
      Discontinuation of treatment out of concerns about contracting COVID-19 is not supported because it may lead to decreased efficacy outcomes with reintroduction or a flare of psoriasis, as observed with our cohort. Low volumes of new biologic initiations highlight the need for improved access to nonurgent care during the pandemic.

      References

        • Warren R.B.
        • Gooderham M.
        • Burge R.
        • et al.
        Comparison of cumulative clinical benefits of biologics for the treatment of psoriasis over 16 weeks: results from a network meta-analysis.
        J Am Acad Dermatol. 2019; 82: 1138-1149
        • Kim H.J.
        • Lebwohl M.G.
        Biologics and psoriasis: the beat goes on.
        Dermatol Clin. 2019; 37: 29-36
        • Johns Hopkins Coronavirus Resource Center
        COVID-19 case tracker.
        (Available at:)
        https://coronavirus.jhu.edu/
        Date: 2020
        Date accessed: June 2, 2020
        • Lebwohl M.
        • Rivera-Oyola R.
        • Murrell D.F.
        Should biologics for psoriasis be interrupted in the era of COVID-19?.
        J Am Acad Dermatol. 2020; 82: 1217-1218
        • Shah P.
        • Zampella J.G.
        Use of systemic immunomodulatory therapies during the coronavirus disease 2019 (COVID-19) pandemic.
        J Am Acad Dermatol. 2020; 82: e203-e204