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Guidance on the use of immunosuppressive agents


Due to the recent pandemic, there is concern about the use of systemic immunosuppressive agents regarding Coronavirus (COVID-19). Currently, the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have no guidelines on the use of systemic immunosuppressive agents during the pandemic. The main priority for dermatologists, at this point, is to keep our patients out of emergency rooms and urgent care not to burden the health care system unnecessarily. Dermatologists must delicately balance the risk of immunosuppression with the risk of disease flare requiring urgent intervention. Therefore, the Academy strongly recommends that patients should not stop their ongoing systemic immunosuppressive therapy without consulting their physicians.

To better serve patients and their physicians, the Academy has created interim recommendations on the use of immunosuppressive agents and spironolactone (PDF, updated 4/14/20):

1. Patients on systemic immunosuppressive agents who have not tested positive or exhibited signs/symptoms of COVID-19: There is insufficient evidence to recommend discontinuation of systemic immunosuppressive agents at this time. Physicians should use their clinical judgments to stop or continue the patients on these drugs. See the PDF download for further guidance.

2. Patients on systemic immunosuppressive agents who have tested positive for COVID-19 or exhibit signs/symptoms of COVID-19: We recommend physicians discontinue or postpone the systemic immunosuppressive agents until the patient recovers from COVID-19, consistent with guidelines on the management of patients with active infections on systemic non-biologic and biologics therapy. See the PDF download for further guidance.

3. Patients who have halted systemic immunosuppressive therapy after testing positive for COVID-19: We recommend physicians can re-initiate the systemic immunosuppressive therapy after ensuring the patients have completely recovered from COVID-19. See the PDF download for further guidance.

4. Patients being considered for systemic immunosuppressive agents: We recommend physicians assess the risk vs. benefits in lower-risk patients before initiating immunosuppressive agents on a case-by-case basis, recognizing that anyone may develop serious complications from COVID-19 infection. See the PDF download for further guidance.

Guidance on the use of spironolactone

There are no experimental or clinical data demonstrating beneficial or adverse outcomes among COVID-19 patients on spironolactone. For patients currently on spironolactone, we recommend continuation of spironolactone for those patients who are currently prescribed such agents for indications for which these agents are known to be beneficial. In the event patients with dermatologic disease are diagnosed with COVID-19, individualized treatment decisions should be made according to each patient's status and clinical presentation. Therefore, be advised not to add or remove spironolactone, beyond actions based on standard clinical practice. See the PDF download for further guidance.


Additional COVID-19 clinical guidance resources

All content solely developed by the American Academy of Dermatology

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