Immunosuppression

Version 1: 19-03-2020

Immunosuppressants in COVID-19 patients

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Rheumatological diseases/ IBD 

Generally, the ongoing use of conventional disease modifying agents (methotrexate [1]) or biological agents (infliximab [2], etanercept [3], adalimumab [4], tocilizumab [5], abatacept [6], ustekinumab [7], tofacitinib [8], secukinumab [9], rituximab [10], golimumab [11]) is NOT advised if there is an active, severe infection [12]. This most likely applies to other biological agents as well, as they are immunosuppressive. There are no specific guidelines, apart from for Inflammatory bowel disease (IBD) [13] with respect to continuing these agents in suspected or proven CoVID-19 infection; however, extrapolating from above, it would be reasonable to HOLD these agents if there is suspicion for an active infection. This should be done in consultation with the prescribing specialist (in most cases Rheumatologist). There is NO role for prophylactically holding these agents PRIOR to an infection, as this can lead to a disease flare, which in itself in some cases can be quite dangerous. 

The use of steroids should be evaluated for every patient separately. Patients who use steroids chronically are at risk for adrenal insufficiency and can get sick if these are withdrawn acutely. 

There are reports of using Tocilizumab (IL-6 inhibitor) in patients with severe inflammatory reaction secondary to CoVID-19 infection. However, this has not been proven yet, and trials are underway

References

1. https://www.rheumatology.org/Portals/0/Files/Methotrexate-Fact-Sheet.pdf?ver=2019-06-25-153446-000

2. https://www.rheumatology.org/Learning-Center/Medication-Guides/Medication-Guide-Infliximab-Remicade

3. https://www.enbrel.com/support/side-effects-safety-information

4. https://www.humira.com/global/frequently-asked-questions

5. https://www.rheumatology.org/Learning-Center/Medication-Guides/Medication-Guide-Tocilizumab-Actemra

6. https://www.rheumatology.org/Learning-Center/Medication-Guides/Medication-Guide-Abatacept-Orencia

7. https://www.stelarainfo.com/safety

8. https://www.pfizermedicalinformation.com/en-us/xeljanz/warnings

9. https://www.cosentyxhcp.com/ankylosing-spondylitis/adverse-events-safety/

10. https://ard.bmj.com/content/70/6/909; https://www.rheumatology.org/Learning-Center/Medication-Guides/Medication-Guide-Rituximab-Rituxan

11. https://www.rheumatology.org/Learning-Center/Medication-Guides/Medication-Guide-Golimumab-Simponi-Aria

12. https://www.ncbi.nlm.nih.gov/pubmed?term=26545825

13. https://crohnsandcolitis.ca/Living-with-Crohn-s-Colitis/COVID-19-and-IBD

Transplant Recipients:

In transplant patients, the use of immunosuppressive agents is extremely important to prevent acute rejection of the transplanted organ (commonly azathioprine, myfortic, tacrolimus, cyclosporine). During an active infection, the medications may be modified to improve host response. However, this must be done with caution, and in such cases a transplant specialist should be involved. Again, there is no role for holding these medications prophylactically PRIOR to an infection [1].

References

1. http://www.transplant.bc.ca/Documents/Health%20Professionals/Clinical%20guidelines/Clinical%20Guidelines%20for%20Transplant%20Medications.pdf