Practice Perspectives on Optimal Patient Care in the Management of Psoriatic Arthritis - Episode 13
Three colleagues share insights into their evolving approaches regarding the management of patients with psoriatic arthritis who test positive for COVID-19.
John Tesser, MD: All this stuff is very important in the age of COVID-19. Nehad, what are you advising, and how are you managing patients who’ve tested positive for the virus?
Nehad Soloman, MD: If you asked me that question a month ago, I would have given you a slightly different answer than what I’m about to give you. In the age of alpha, beta, gamma, delta variants, the answer would have been to hold your medication and probably not to restart it until 2 to 4 weeks after recovering fully from your condition and having a negative test. Part of that is 2-fold. One, we don’t want to aggravate the situation if there’s already an infection. But part is also the unknowns. Early in the disease, we felt maybe these biologics confer some protective effect against the scary aspects of COVID-19 with the cytokine surge, etc. That may hold true for some of the therapies, which are still under investigation and under emergency authorization use as well. But more recently with this new variant that seems to be milder, that seems to cause a recovery within a few days. I don’t know how much longer we should keep them off their therapies.
I’d give the same advice: hold it while you’re sick and if you’re symptomatic. If you just tested positive but have no symptoms, there may not be a role to hold the therapy. But if you’re symptomatic, certainly hold it while you’re symptomatic. The question is, do we hold it for an extended period of time thereafter? I don’t know the answer, to be honest. We’re getting phone calls every day: “I’m positive. What should I do?” We’re making it up as we go along.
The reality is that we need to lay the benefit-risk of everything and whether it’s continuing treatment. It’s going to depend on which therapy we’re talking about. You mentioned previously that we should hold certain immunotherapies when considering the vaccine. One thing we’ve stumbled upon is that there are certain molecules that, regardless of when you hold it, don’t seem to confer any benefit from the vaccine. Ultimately we need to start further defining and taking it on case by case, depending on what therapies they’re on as we get more data. I’m hoping our study better solidifies this, rather than the dabbling we’ve been doing over the last several months.
John Tesser, MD: My own take on this has been evolving. As we were well into the delta surge and knowing how deadly delta could be, we had good antibody therapies for the delta. So I informed my patients that if they developed symptoms that could possibly be related to COVID-19, [then they should] get tested. And if they were positive, [I told them to] immediately contact 1 of the hospital systems, urgent care, or emergency departments to determine whether they should receive the antibody therapies, which were obviously very effective—both the Lilly and the Regeneron antibody therapies. Then omicron came around. As we’ve learned, it has been far more infectious but not quite as deadly. Unfortunately, the Lilly and Regeneron products don’t work against omicron.
There’s this notion of telling them to immediately get tested and go to a facility, but what are they going to give them unless they’re getting very sick? The GSK [GlaxoSmithKline] antibody is coming into play, and we have the 2 approved pills by Pfizer and Merck, but we don’t have much of them available. I don’t know how much is available or how much isn’t. I’m still taking the same tack and telling my patients they have autoimmune diseases, so they’re immunodeficient and immunocompromised. If they’re on these agents, it’s probably best to contact these services to take them through whatever options are available. Unfortunately, our hospital systems are getting overloaded, but that’s a different story.
I have a comment about the vaccine itself. We can say with some evidence, particularly for our patients with rheumatoid arthritis, that in general the vaccines haven’t been flaring their disease. It’s not a blanket statement for every patient, and I’ve had several patients who’ve flared. Maybe you have too, Nehad and Jen [Simpson]. Nonetheless, although they might flare, they’re still advised to get vaccinated because they probably won’t. I just wanted to throw that in.
Nehad Soloman, MD: The other aspect is when weighing the decision about vaccinating or rolling the dice and get the virus, a month ago I would have said, “Getting the virus probably has much more deleterious effects than the potential flare that you’re concerned about or potential adverse effects compared with getting the virus.”
John Tesser, MD: I want to take a slight step back to COVID-19 and talk about the individual callout of rituximab and the real challenge we have with that drug, which removes circulating B cells that are very important in terms of their maturation to plasma cells and antibody production. This is a very bad time to be using a B-cell–depleting drug in the era of a viral pandemic. Vaccination in patients who can’t make antibodies is a very problematic exercise. We’re very much aware of this, but I wanted to bring it out for the audience’s understanding. We try to work around it. We try to vaccinate at the end of a cycle. You don’t know if that’s going to work either, so maybe don’t use rituximab in some patients if you have other alternatives. But in some diseases, like vasculitis, there are no other alternatives that are good ones.
This transcript has been edited for clarity.