Does atopic dermatitis have an increased risk of acquiring COVID-19?

Based on the best available evidence, patients with atopic dermatitis (AD) do not appear to face an increased risk of contracting COVID-19 or being hospitalized because of the virus.

“This is an area that will continue to evolve, and better understanding will improve the health advice we provide to our patients,” said Jacob P. Thyssen, MD, PhD, DmSci, at the Revolutionizing Atopic Dermatitis Virtual Symposium. “The general recommendation for now is to continue systemic treatments for AD during the pandemic, but the risk of acquiring COVID-19 is different for different drugs. “

According to Thyssen, professor of dermatology at the University of Copenhagen, Denmark, early management advice from the European Atopic Dermatitis Working Group (ETFAD), the European Academy of Allergy and Clinical Immunology (EAACI) and the International Eczema Council (IEC) say patients with AD who take biologics or immunosuppressants should continue treatment if they are not infected with COVID-19. For example, the EIC statement states that the IEC “does not recommend the temporary discontinuation of systemic treatments for AD affecting the immune system in patients without COVID-19 infection, or in those with COVID- 19 but are asymptomatic or have only mild symptoms ”.

EAACI guidelines recommend patients with AD who are infected with COVID-19 to withhold biologic therapy for at least 2 weeks until they have recovered and / or have a SARS-CoV-2 test negative.

“However, if you have a more serious respiratory illness, the advice for dermatologists is to see an infectious medicine specialist or pulmonologist,” Thyssen said. “It is outside our area of ​​expertise. But in terms of AD, there is no reason to stop treatment as long as the patient has mild symptoms or is asymptomatic. AD patients treated with immunosuppressive agents may have a higher risk of complications from COVID-19. Treatment with traditional immunosuppressive drugs increases risk of infections. But what about COVID-19? “

Traditional systemic immunosuppressive therapies in AD with azathioprine, cyclosporine and methotrexate suppress the immune system for 1 to 3 months, Thyssen continued. “We know that the vaccine response is reduced when using these agents,” he said. “The half-life of dupilumab [Dupixent] is 12-21 days. It takes about 13 weeks before dupilumab is completely cleared from the system, but it is such a targeted therapy that it does not lead to systemic immunosuppression. “

During this time, the half-life of JAK inhibitors such as baricitinib (Olumiant) is approximately 13 hours. “It’s a broader immunosuppressant because there will be off-target effects if you have a high dose, but it’s much more specific than traditional immunosuppressants,” he said. “We now have JAK1 and JAK2 inhibitors in AD, which do not interfere with vaccine responses to the same degree as traditional immunosuppressants.”

To assess the risk of COVID-19 in patients with AD, researchers at the Center for Dermatology Research at the University of Manchester, UK, conducted a cross-sectional study of 13,162 dermatology patients seen in the UK between June 2018 and February 2021. of the 13,162 patients, 624 (4.7%) had AD. They found that 4.8% of patients without a history of COVID-19 infection had AD, compared with 3.4% with a history of COVID-19. The risk of COVID-19 in patients with AD was similar to that of controls (adjusted odds ratio, 0.67).

The authors of a separate cross-sectional study published in May assessed the health insurance medical records of 269,299 patients who were tested for SARS-CoV-2 at University of California medical centers. Of these, 3.6% tested positive for SARS-CoV-2. Of 5,387 patients with AD, the infection rate was 2.9%, which was lower than that of patients without AD (3.7%; P = .0063). Hospitalization and mortality did not increase in patients with AD.

Another study, a case-control study of over 4.6 million HMO patients in Israel, found that taking systemic corticosteroids, advanced age, comorbid cardiovascular disease, metabolic syndrome and COPD were independent predictors of hospitalization associated with COVID-19. Mortality from COVID-19 has been independently predicted by metabolic syndrome and COPD, but not by variables related to AD.

“So for our AD patients there is no need to worry that they will develop COVID-19 infection or have a severe course, but we have a few drugs that would slightly increase the risk,” Thyssen said. .

In another analysis, researchers assessed data derived from Symphony Health’s COVID-19 research database to assess the risk of COVID-19 infection in adults with AD. The AD cohort consisted of 39,417 patients and the non-AD cohort comprised 397,293 patients. Of the AD patients, 8,180 received a prescription for prednisone, 2793 received a prescription for dupilumab, 714 received a prescription for methotrexate, and 512 received a prescription for cyclosporine. The risk of COVID-19 was slightly increased in the AD cohort compared to the non-AD cohort (adjusted incidence rate ratio [IRR], 1.18; P <.0001>

“There can be various explanations for this,” Thyssen said. “I still think we should maintain that AD on its own is not a risk factor for COVID-19, but some of the drugs may slightly increase the risk.”

In other results, investigators observed that treatment with dupilumab compared to no systemic drug reduced the risk of COVID-19 by 34% (adjusted IRR: 0.66; P P = .32). However, compared to no systemic drug use, the use of prednisone slightly increased the risk of COVID-19 (Adjusted IRR, 1.13; P = 0.03), as was the use of cyclosporine (adjusted IRR, 1.20; P = 0.32) and azathioprine (adjusted IRR, 1.61; P =. 16).

More recently, researchers evaluated the records of 1,237 patients with moderate to severe AD (aged 9 to 95 years) to assess the self-reported severity of COVID-19 symptoms among those who received dupilumab compared to others. treatments.

Of the 1237 patients with AD, 632 were on dupilumab, 107 were on other systemic treatments, and 498 were on little or no treatment. Patients treated with dupilumab were less likely to report moderate to severe symptoms of COVID-19 compared to patients taking other systemic treatments, or limited or no treatments.

Vaccines and AD

Thyssen pointed out that the risk-benefit ratio of currently approved COVID-19 vaccines is better than the risk of infection with SARS-CoV-2. “AD is not a contraindication to vaccination,” he said. “The COVID-19 vaccine does not cause worsening of AD because the vaccine response is mainly biased by Th1. He added that systemic immunosuppressants and JAK inhibitors used to treat AD may attenuate the vaccine response, but no attenuation is expected with dupilumab. “The half-life of JAK inhibitors is so short that vaccination followed by a week of treatment break is a good strategy for patients.”

Thyssen has revealed that he is a speaker, advisory board member and / or investigator for Asian, Arena, Almirall, AbbVie, Eli Lilly & Co., LEO Pharma, Pfizer, Regeneron and Sanofi-Genzyme.

The Revolutionizing Atopic Dermatitis Symposium. December 11-13, 2021.

Doug Brunk is an award-winning San Diego-based reporter for MDedge and Medscape who began covering healthcare in 1991. He is the author of two books related to the University of Kentucky Wildcats men’s basketball program. .

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