Biologics during Covid-19
Question:
4/1/2020
During this pandemic COVID 19 outbreak, regarding administration of biologic meds (Xolair, Nucsla, Dupixent and Fasenra) I would like to know your opinion of giving those meds, especially for Nucala in which parasitic infections and shingles infections can be associated with Nucala. Similar concern of infections associations with Dypixent and Fasenra, should we continue injections of those meds. Most of the patients receiving those meds are asthma patients, and it is also important to control their asthma. Weighing risks and benefits, I would like to know opinion either should we continue giving them or hold off those injections during this pandemic.
Answer:
I am concerned that this pandemic will be with us until we have an effective vaccine. There is ample evidence that patients with respiratory disease are at risk for more severe disease and higher mortality, although age is the major discriminator. Based on a small cohort of 140 hospitalized patients in China the investigators reported that allergic diseases, asthma, and COPD are not reported as co-morbid conditions for SARS-CoV-2 infection. (1) This finding was echoed in a large review of case reports from China. The authors reported that in the 2019-nCoV epidemic, while mainly associated with respiratory disease and few extrapulmonary signs, there is a low rate of associated pre-existing respiratory comorbidities. (2) Obviously much more data is forthcoming, and we should stay-tuned.
By withdrawing biologic therapy, you run the risk or even the likelihood that asthmatics will become unstable and have a higher chance of worse outcomes. Afterall, we do not withhold biologics during an Influenza outbreak. We could apply the same risk to oral or even inhaled steroids, though again withholding or stepping down therapy would not be recommended, as this could result in worsening asthma control. We are entering untested waters. On a side note, there is rationale to move toward patients receiving biologics at home, rather than coming into an office or infusion center. Shaker et al. (3) provides further guidance for Allergist/Immunologists ranging from new models of delivering care as we go through this pandemic.
I would recommend that you continue providing management that offers optimal control of your asthmatics.
1) Zhang JJ, Dong X, Cao YY, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China [published online ahead of print, 2020 Feb 19]. Allergy. 2020;10.
2) Lupia T, Scabini S, Mornese Pinna S, Di Perri G, De Rosa FG, Corcione S. 2019 novel coronavirus (2019-nCoV) outbreak: A new challenge [published online ahead of print, 2020 Mar 7]. J Glob Antimicrob Resist. 2020;21:22–27. doi:10.1016/j.jgar.2020.02.021
3) Shaker MS, Oppenheimer J, Grayson M, et al. COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic [published online ahead of print, 2020 Mar 26]. J Allergy Clin Immunol Pract. 2020;S2213-2198(20)30253-1. doi:10.1016/j.jaip.2020.03.012
Respectfully submitted
Jeffrey G Demain, MD, FAAAAI