COVID-19: Lessons learned for the path forward

We are now more than 2 years into the COVID-19 pandemic with more than 80 million people infected and nearly 1 million deaths in the United States alone.

Throughout this pandemic, Healio Psoriatic Disease has aimed to provide you with the most current and rigorous scientific findings while recognizing uncertainty when it exists and encouraging shared decision making with patients when necessary. One of the key lessons of the pandemic is the importance of rigorous science to guide treatment decisions.

There are many examples to draw on, but I will focus on two that are of special importance to the psoriatic disease community. First, early in the pandemic many experts were concerned about the safety of tumor necrosis factor (TNF) inhibitors and argued that these should be stopped in favor of more targeted biologics, such as interleukin (IL)-17 and IL-23 inhibitors.

Certainly, Black Box warnings of the risk for serious infections with TNF inhibitors were a cause for alarm in the face of the novel coronavirus. However, early data challenged this dogma. My lab conducted a series of meta-analyses of psoriasis trials and found that TNF inhibitors had no evidence of increasing the risk for respiratory tract infections, whereas a signal was detected for IL-17 and IL-23 inhibitors. Soon after, registries suggested that patients on TNF inhibitors did better with COVID than other treatments while studies out of Israel’s HMO system indicated that psoriasis patients on TNF inhibitors were less likely to be hospitalized for COVID-19 compared with patients on methotrexate or ustekinumab, with methotrexate having similar outcomes to IL-17 biologics.

The most striking finding, however, was just published — an analysis of U.S. claims data which showed that patients with rheumatoid arthritis or psoriatic arthritis on TNF inhibitors were 36% less likely to get hospitalized for COVID-19 compared with patients without rheumatic disease, suggesting a protective effect of blocking TNF alpha on severe covid outcomes. These data provide compelling information that TNF inhibitors may be used safely in the context of the pandemic.

A second cautionary tale is that of ivermectin. This drug, well known to dermatologists as we use it by mouth to treat scabies and topically to treat rosacea, garnered tremendous interest given that at very high concentrations it exhibits anti-viral effects in a test tube. However, such levels cannot be achieved safely in humans. A prominent virologist then published a meta-analysis suggesting that ivermectin actually worked dramatically well for COVID-19.

This finding seemed too good to be true — because it was too good to be true. The author later reanalyzed the data, excluding one study that was fraudulent (and had an implausibly high effect size) and focused the analysis on the few trials that had a low risk for bias and found no benefit of ivermectin. Finally, a well done trial of 3,515 patients, just published in The New England Journal of Medicine, found that ivermectin did not result in a lower incidence of medical admission to a hospital due to progression of COVID-19 or of prolonged emergency department observation among outpatients with an early diagnosis of COVID-19.

Undoubtedly, scores of resources were wasted on the use of ivermectin. One study estimated U.S. insurers spent $130 million over the course of a year paying for ivermectin treatment of COVID-19.

So where do we go now? Back to basic, evidence-based principles. Masking when necessary due to high transmission, mRNA vaccines with at least one booster, and early diagnosis and treatment of COVID-19 with agents such as Paxlovid (nirmatrelvir/ritonavir, Pfizer) in patients at risk for severe disease. Pharmacies with available outpatient COVID-19 treatments can be found at https://covid-19-test-to-treat-locator-dhhs.hub.arcgis.com.

Tremendous progress has been made in preventing and treating COVID-19. Now we just need to implement what we have learned in 2 short years.

For the most up-to-date recommendations, I encourage you to visit the National Psoriasis Foundation COVID-19 Task Force website: https://www.psoriasis.org/covid-19-task-force-guidance-statements/

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