Incidence and prognosis of COVID-19 in psoriasis patients on biologic therapy: a multicentre retrospective cohort study.

Conflict of interest

Dr. Vender has been a speaker, consultant, advisory board member and investigator for AbbVie, Actelion, Amgen, Astellas, Celgene, Dermira, Eli Lilly, Galderma, Janssen Ortho, Leo, Merck, Novartis, Pfizer, Regeneron and Takeda. Dr. Prajapati has been an investigator for AbbVie, Amgen, Arcutis, Asana, Boehringer Ingelheim, Bristol Meyers Squibb, Celgene, Concert, Dermira, Eli Lilly, Galderma, Incyte, Janssen, LEO Pharma, Novartis, Pfizer, Regeneron, Sanofi Genzyme, UCB and Valeant; and consultant, advisor and/or speaker for AbbVie, Actelion, Amgen, Aralez, Aspen, Bausch Health, Boehringer Ingelheim, Celgene, Cipher, Eli Lilly, Galderma, GlaxoSmithKline, Homeocan, Janssen, LEO Pharma, L’Oreal, Medexus, Novartis, Pediapharm, Pfizer, Sanofi Genzyme, Sun Pharma, Tribute, UCB and Valeant. Dr. Yeung has been a speaker, consultant and investigator for AbbVie, Allergan, Amgen, Arcutis, Astellas, Bausch Health, Boehringer Ingelheim, Bristol Meyers Squibb, Celgene, Centocor, Coherus, Dermavant, Dermira, Forward, Galderma, GlaxoSmithKline, Incyte, Janssen, Kyowa, Leo Pharma, Lilly, Medimmune, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi Genzyme, Sun Pharma, Takeda, UCB and Xenon. Dr. Georgakopoulos and Dr. Mufti have no conflicts of interest to disclose.

Editor

Current guidelines recommend continuing biologic therapy in dermatologic patients who have not tested positive for or exhibited signs/symptoms of COVID‐19 and postponing biologic therapy in patients who have tested positive for or exhibited signs/symptoms of COVID‐19. , , In order to help guide current recommendations, we aimed to investigate the incidence and prognostic outcomes of positive SARS‐CoV‐2 infection in psoriasis patients on biologic therapy.

Following ethics committee approval, a multicentre retrospective cohort study was undertaken at two tertiary academic hospitals and four community practices in Canada. Inclusion criteria were all adult and paediatric patients treated with a biologic for moderate‐to‐severe psoriasis since COVID‐19 was declared a global pandemic. Data were obtained from Patient Support Program (PSP) Case Managers of all major biologic suppliers and patient‐reported clinical documentation.

As of 15 January 2021, there were 2647 patients on biologic therapy who met the inclusion criteria. In this cohort, 10 patients (0.4%) had confirmation of SARS‐CoV‐2 infection via nasal swab. Incidence of COVID‐19 was highest in those treated with interleukin (IL)‐12/23 inhibitors (3/443, 0.7%) and IL‐17a inhibitors (5/667, 0.7%), compared to IL‐23 inhibitors (2/799, 0.2%) and tumour necrosis factor‐alpha (TNF‐α) inhibitors (0/738, 0%). Biologic‐specific incidence included that of adalimumab (0/336), brodalumab (1/80), certolizumab (0/60), etanercept (0/288), guselkumab (1/530), infliximab (0/54), ixekizumab (3/267), risankizumab (1/269), secukinumab (1/320) and ustekinumab (3/443). Of those who tested positive, mean age was 42 ± 15 years, with the majority being male (7/10, 70%), Caucasian (7/10, 70%) and on a biologic for over 12 months (7/10, 70%; mean: 34 ± 35 months). Six patients (60%) had symptoms of COVID‐19, compared to three patients (40%) who were asymptomatic carriers (Table 1). Seven patients (70%) discontinued biologic therapy due to COVID‐19. Six patients restarted treatment with a mean restart time of 19 ± 10 days, while one patient elected to remain off treatment due to persistently well‐controlled disease.

Table 1

Demographics and clinical symptoms of individuals on a biologic and who tested positive for COVID‐19

Patient	Biologic therapy	Age (years)	Gender	Nationality	Comorbidities	Biologic duration†	Biologic interruption‡	Biologic restart	Duration of interruption§	COVID‐19 symptoms	Oxygen therapy	Hospital admission
1	Brodalumab	38	M	Asian	None	3 months	Y	Y	28 days	Moderate lower RT symptoms	N	N
2	Guselkumab	31	F	Caucasian	Grave’s	3 weeks	Y	Y	7 days	Mild upper RT symptoms	N	N
3	Ixekizumab	37	M	Caucasian	None	29 months	Y	N	ongoing	Headache	N	N
4	Ixekizumab	37	M	Caucasian	None	7 months	Y	Y	28 days	None	N	N
5	Ixekizumab	72	M	Caucasian	Hypertension, Ex‐smoker	37 months	Y	Y	10 days	Sore throat, nasal congestion	N	N
6	Risankizumab	51	M	Eastern European	Hypertension, T2DM, CAD, Dyslipidaemia	18 months	N	NA	NA	Mild upper RT symptoms	N	N
7	Secukinumab	54	F	Caucasian	Hypertension	54 months	Y	Y	28 days	Fever, fatigue nausea, vomiting	N	N
8	Ustekinumab	19	M	Asian	None	31 months	N	NA	NA	None	N	N
9	Ustekinumab	32	M	Caucasian	Ex‐smoker	120 months	N	NA	NA	None	N	N
10	Ustekinumab	49	F	Caucasian	None	42 months	Y	Y	13 days	None	N	N

Abbreviations: CAD, coronary artery disease; N, no; NA, not applicable; RT, respiratory tract; T2DM, type 2 diabetes; Y, yes.

Time from biologic initiation until positive SARS‐CoV‐2 nasal swab.

Biologic therapy stopped due to a confirmed SARS‐CoV‐2 diagnosis.

Delay in receiving their next biologic dose following a confirmed SARS‐CoV‐2 diagnosis.

The results from this study suggest that patients with moderate‐to‐severe psoriasis on a biologic agent have a similar or perhaps even lower incidence of COVID‐19 (10/2647, 0.4%) compared to the general public (1.8%, reported Canada wide rate as of 15 January 2021). This supports current recommendations that psoriasis patients should not discontinue their biologic therapy out of risk or fear of contracting COVID‐19. , However, these findings contrast prior evidence in a cohort of 1193 psoriasis patients on a biologic, suggesting increased risk of COVID‐19 infection. Furthermore, our results suggest good prognosis for COVID‐19‐positive psoriasis patients on a biologic as symptoms were mild and no patients required oxygenation or hospitalization. This is in contrast to early reports demonstrating psoriasis patients, with and without biologic exposure, are at higher risk of COVID‐19 hospitalization and mortality, which may be driven by associated comorbid conditions. , Permanent discontinuation of biologic therapy due to COVID‐19 was uncommon with just one patient holding treatment long term, compared to three patients who did not interrupt therapy and six patients who resumed within four weeks of their confirmed COVID‐19 diagnosis.

Limitations of this study include the short‐term follow‐up and retrospective nature. Although close to 100% of biologic patients in Canada are enrolled in PSPs, we may have potentially missed a rare patient who is not enrolled in PSPs and their diagnosis of COVID‐19 was not reported to their dermatologist. In summary, psoriasis patients on a biologic have an incidence of COVID‐19 that is no worse than the general public, with TNF‐α inhibitors demonstrating the lowest rate of infection. Symptom severity and mortality remain low supporting emerging evidence that interruption of biologic therapy should be reserved for clinically unwell patients.

IRB approval status

Ethical approval was granted by the Research Ethics Board at Sunnybrook Health Sciences Centre (287‐2010) and Women’s College Hospital (2010‐0041‐E).

Funding sources

None.