Guidance on the use of biologic agents during COVID-19 outbreakDue to the recent pandemic, there is concern about the immunomodulatory effects of biologic
therapy in the context of coronavirus (COVID-19). Currently, the Centers for Disease Control andPrevention (CDC) and the World Health Organization (WHO) have no guidelines on the use ofbiologics during the pandemic. In addition, there is no data on the specific risk of COVID-19
infection with biologic therapy. Specifically, we do not have direct evidence to support any
preferred biologic class or mechanism-of-action with regard to COVID-19 infection risk at thismoment; although we will continue to monitor the situation as more data becomes available. A
main priority for dermatologists, at this point, is to keep our patients out of emergency rooms andurgent care so as to not tax the healthcare system unnecessarily. Dermatologists must delicatelybalance the risk of immunosuppression with the risk of disease flare requiring urgent intervention.
Therefore, the Academy strongly recommends that patients should not stop biologic
therapy without consulting their physicians. To better serve patients and their physicians, theAcademy is putting forth the following interim recommendations.
Patients already on biologic therapy
1) Patients on biologic therapy who have not tested positive or exhibited signs/symptoms of
COVID-19: There is insufficient evidence to recommend discontinuation of biologics at thistime. Physicians should continue to weigh the risk vs. benefits of the use of biologic
medication on a case-by-case basis. The discussion, at the level of the individual patient,should include the original indication for the biologic, the severity of the original indication,
the patient’s age (whether they are >60 years old) and comorbidities. Comorbidities thatmay put patients at higher risk for serious illness from COVID-19 include serious chronic
medical conditions such as cardiovascular disease, diabetes, severe hypertension, liverdisease, kidney disease, respiratory system compromise, internal malignancies or tobaccouse, among others.1-32) Patients on biologic therapy who have tested positive for COVID-19: We recommend
physicians discontinue or postpone the biologic therapy until the patient recovers fromCOVID-19, consistent with guidelines on the management of patients with active infections
on biologics therapy (AAD Biologic Guideline).

Patients not on biologic therapy3) Patients being considered for biologic therapy initiation: We recommend physicians assess
the risk vs. benefits in low-risk patients before initiating biologics therapy on a case-by-casebasis. In a high-risk population (e.g.: individuals 60 years and older, or patients withrecognized comorbidities such as cardiovascular disease, diabetes, severe hypertension,liver disease, kidney disease, respiratory system compromise, internal malignancies or
tobacco use, among others),1-3 we recommend that physicians consider deferring initiationof biologic therapy. Alternative therapeutic approaches can be considered to treat high-riskpatients.
This document was prepared on March 18, 2020, and will be updated as new data evolves in thisarea. For the latest information on the COVID-19 outbreak, refer to the World Health Organization(WHO) and the Centers for Disease Control and Prevention (CDC) website. Also, refer to theInternational Psoriasis Council (IPC) recommendations and the American College ofRheumatology (ACR) recommendations for additional insights on the use of biologics

References
1. Wang T, Du Z, Zhu F, et al. Comorbidities and multi-organ injuries in the treatment of COVID-19.
Lancet. 2020.
2. Yang J, Zheng Y, Gou X, et al. Prevalence of comorbidities in the novel Wuhan coronavirus(COVID-19) infection: a systematic review and meta-analysis. Int J Infect Dis. 2020.
3. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus atincreased risk for COVID-19 infection? Lancet Respir Med. 2020.