








key: cord-307925-0nhsf90c
authors: Ordóñez‐Rubiano, Maria Fernanda; Campo, Isabela; Casas, Mirian
title: Dupilumab in atopic dermatitis, a protocol for SARS‐COV 2 infected patients
date: 2020-08-10
journal: Dermatol Ther
DOI: 10.1111/dth.14172
sha: 
doc_id: 307925
cord_uid: 0nhsf90c

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During SARS-COV 2 pandemic scarce articles have been written regarding the possible effects of biologics and immunosuppressants in chronic inflammatory skin diseases, such as atopic dermatitis (AD) 1 . Looking after optimal skin care, the most appropriate topical and systemic treatments and balanced mental status of AD patients is an important role of dermatologist not only for patients, but for health systems and emergency rooms occupancy. Therefore, it is important as dermatologist to be involved in health care of infected or COVID-19 patients having severe dermatological diseases and making appropriate decisions for their skin health.

Biologics have shown minimal increased risk of infection and its discontinuation can lead to loss of efficacy and drug-autoantibodies 2 . Dupilumab is an inhibitor of IL-4 and IL-13 signaling pathway that, theoretically, could lower risk for SARS-CoV-2 2 . The virus has tropism for cells expresing the angiotensin converting This article is protected by copyright. All rights reserved. enzyme 2 receptor and then hyperactivates the immune response (CD8+ and CD4+, specially helper 1, T cells) releasing proinflammatory cytokines that results in lung impairment 3 . But IL-4 and IL-13 pathways have not been implicated in the host defense mechanism against viral infections, neither cytokine storm in COVID-19 3 . This type of cellular response also appears to be common to other coronavirus-induced infection 2 . Also, by treating asthma dupilumab may theoretically decrease risk for COVID-19 and severe respiratory disease 7 .

In Latin America COVID-19 is rapidly spreading, in Colombia numbers are increasing, positioning us now as the second country with the most cases in Latin America and it has encountered our AD clinic.

We report a 22 year old male nurse, diagnosed with AD at 14 with no comorbidities, who is in treatment with dupilumab since September 2019. On This article is protected by copyright. All rights reserved.

November 2019 he stopped dupilumab for 3 months due to insurance problem (the medication was not provided because of an administrative issue) and had to be admitted in the ER because of a severe flare. He restarted dupilumab in January 2020 with control of the disease and no new flares.

On May 18th, 2020 he was diagnosed with asymptomatic SARS-COV 2 by PCR due to occupational exposure, to our knowledge the first patient in Latin America infected while in treatment with dupilumab. Given the documented flare with suspension and need for ER attention we decided to continue the medication and stablished a protocol (shown in Figure 1 ) for these patients at our clinic (currently 90 patients treated with dupilumab for severe AD).

We would like to highlight the importance of reassessing decisions periodically in all immunodepressed or immunomodulated patients due to scarce information This article is protected by copyright. All rights reserved. 2, 4, 5, 6 . It is stated that dupilumab may be preferred over traditional immunosuppressive drugs when starting treatment in selected severe cases during the pandemic 4,5 . As described in the literature, in our Country biologics are difficult to dispense due to administrative problems and costs that make them inaccessible many times to patients and that makes continuity and adherence to medications difficult for AD patients, even though it This article is protected by copyright. All rights reserved.

is the only biological authorized for the treatment of severe adult AD 8 . We share our institutional protocol in order to optimize AD patients care, especially in centers where severe AD is treated with dupilumab.

This article is protected by copyright. All rights reserved.

Evidencedbased best practice advice for patients treated with systemic immunosuppressants in relation to COVID-19

Dupilumab and COVID-19: What should we expect?

Safety of dupilumab in atopic patients during COVID-19 outbreak

Belloni Fortina A. SARS-CoV-2 asymptomatic infection in a patient under treatment with dupilumab

European Task Force on Atopic Dermatitis (ETFAD) statement on severe This article is protected by copyright. All rights reserved

acute respiratory syndrome coronavirus 2 (SARS-Cov-2)-infection and atopic dermatitis

Management of adult patients with severe atopic dermatitis treated with dupilumab during COVID-19 pandemic: a single center real-life experience

Considerations for safety in the use of systemic medications for psoriasis and atopic dermatitis during the COVID-19 pandemic

Severe Adult Atopic Dermatitis: Clinical Challenges

Figure 1: Protocol for atopic dermatitis In patients treated with dupilumab This article is protected by copyright. All rights reserved

Accepted Article This article is protected by copyright. All rights reserved.

