Precautionary approach advised with immunomodulators during COVID-19


By Mardi Chapman

2 Apr 2020

Interim advice on the management of patients with severe dermatological disease says most patients should continue to take their immunomodulator therapy against a background of the COVID-19 pandemic.

However in patients with confirmed COVID-19 disease, immunomodulators should be stopped immediately, with the possible exception of systemic corticosteroids where sudden stopping was unwise.

“There is little specific evidence of COVID-19 infection being aggravated by immunomodulators as used in otherwise healthy dermatology patients, but a precautionary approach is mandated, particularly as any secondary bacterial infection as part of COVID-19 may be aggravated by concurrent use of immunomodulators,” the advice said.

“Although median COVID-19 infection duration is in the order of 2 weeks, it would be sensible to discontinue systemic immunomodulators for at least 4 weeks, and until the patient has completely recovered.”

The advice, co-authored by New Zealand’s Professor Marius Rademaker and Australians Associate Professor Chris Baker, Associate Professor Peter Foley, Dr John Sullivan and Dr Charlie Wang, suggested lowering the dose of or temporarily ceasing immunomodulators for two weeks in patients with cold or flu symptoms but no confirmation of COVID-19 disease.

It said there was insufficient evidence to suggest that people on immunomodulators were more susceptible to infection but they may be at higher risk of more serious disease.

“Patients with more severe skin disorders (e.g. severe psoriasis) are inherently at increased risk of developing pneumonias, of any cause,” it said.

Suggested dose lowering included:

  • azathioprine: reduce to ≤0.5 mg/kg/day
  • biologics: no specific data available, but as their half lives are considerable, they may better modified on a case-by-case basis
  • ciclosporin: reduce to ≤1 mg/kg/day. Some in vitro evidence of potential benefit in COVID-19 disease
  • methotrexate: reduce to ≤10 mg/week
  • mycophenolate mofetil: reduce to ≤1 gm/day (mycophenolic acid to <720 mg/day)
  • retinoids: no need for dose adjustment
  • systemic corticosteroids: reduce to ≤10 mg/day prednisone equivalent.

The advice supported usual infection control measures such as the annual influenza vaccination.

The statement, published as a Correspondence Letter in the Australasian Journal of Dermatology, said an Australia/New Zealand consensus document is in development.

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