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Background: This study aimed to consider the main risk factors related to adverse clinical outcomes in MS patients with COVID-19., Methods: Using the electronic health records systems, this is a cross-sectional study of two years of hospital admissions in terms of COVID-19 in Iran from March 2019 to August 2021. The severities of COVID-19 outcomes were admitted to ICU, hospitalization days, and in-hospital mortality., Results: A total of 1634 hospitalized MS patients with a definite diagnosis of COVID-19 based on PCR were recorded in the electronic health systems. MS patients had a 7% increased risk for longer hospitalization, a 3% increased risk for the need to the ICU, and no increased risk of mortality compared with the general population. MS patients who were taking immunosuppressive (IS)-disease modifying therapies (DMT) had longer hospitalization (adjusted OR=2.06, 95%CI: 1.48, 2.86) and higher mortality risk (adjusted OR=2.05, 95%CI: 1.52, 6.29) compared to patients were under the immunomodulatory (IM)-DMT. There was not any significant association between the types of DMT and ICU (12.2% vs. 12.7%). Besides, MS patients who were vaccinated against COVID-19 before admission had shorter hospitalization (adjusted OR=0.40, 95% CI: 0.18, 0.92)., Conclusions: The current data suggest that MS healthcare providers should consider specific risks of severe COVID-19 infection before starting IS-DMT., Competing Interests: Declaration of Competing Interest The Authors declare that there is no conflict of interest., (Copyright © 2022. Published by Elsevier B.V.)

Background: Cryptococcal infection has been increasingly reported in patients with COVID-19 infection, but the epidemiological factors, presentation, diagnostic certainty, and outcome have not been well-described., Methods: We reviewed the published cases of COVID-19-associated Cryptococcus infections (CACI) to shed the light on the burden of this infection., Results: We identified 13 patients with confirmed cryptococcal infection. Cryptococcus infection was primarily seen in patients with severe COVID-19 disease who received corticosteroids therapy and admitted to the intensive care unit. Pulmonary CACI was the most common reported infection followed by cryptococcal meningitis., Conclusion: In light of the high mortality rate, clinicians should maintain a high clinical suspicion of CACI in critically ill patients., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Coronavirus disease 2019 (COVID-19) was reported as a global pandemic in March 2020 after invading many countries and leaving behind tens of thousands of infected patients in a brief time span. Approval of a few vaccines has been obtained and their efficacy of varying degrees established. Still, there is no effective pharmaceutical agent for the treatment of COVID-19 though several drugs are undergoing clinical trials. Recent studies have shown that dexamethasone, a corticosteroid, can reduce the rate of COVID-19-related mortality in the intensive care unit by 35 % for patients who are on mechanical ventilation. Although variable efficacy of other combination therapies has been reported for treating COVID-19 associated with acute respiratory distress syndrome (ARDS), dexamethasone is an extensively used drug in many treatment regimens against COVID-19. The current review aims to explore the role of dexamethasone as an efficient combination treatment for COVID-19., (© 2022 Nader Namazi, published by Sciendo.)

Background: There is concern about susceptibility of psoriatic patients on biologics to coronavirus disease 2019 (COVID-19) and its clinical course., Purpose: The aims of present review were to determine whether the biologic treatment of psoriasis increases the risk of SARS-CoV-2 infection and if biologics affect the clinical course of COVID-19 in these patients., Methods: We searched database of MEDLINE (PubMed) for key term of psoriasis biologic and COVID-19 until June 9, 2020 and all published 14 papers and an experience from Iran (10509 cases) related to the psoriatic patients on biologics and COVID-19 along with relevant papers were summarized. In spite of limitation in some reports, due to some of strengths that will be discussed, all papers were included in this review., Results: According to 8769 medical reports around 0.3% of psoriatic patients had COVID-19 and the rate of hospitalization was 0.1%. No death due to COVID-19 was reported among 10509 patients. Reports indicated psoriatic patients on biologics were not more susceptible to COVID-19 and the severe clinical course of disease., Conclusion: While there is not definitive controlled trial data, the available evidence suggests that patients with psoriasis without COVID-19 can continue the biologic therapy for psoriasis.

Background: Steroid therapy is an immunosuppressive treatment and may have possible side effects in a pandemic period. However, the number of studies on the use corticosteroids for the treatment of idiopathic Granulomatous Mastitis (IGM) especially during the pandemic is almost negligible., Methods: The data of patients with the diagnosis of IGM between January-December 2020 in the General Surgery Clinic were retrospectively analyzed. The patients were explained in detail that steroid therapy is an immunosuppressive treatment and it may have possible side effects. Prednisolone 0.5-1 mg/kg/day was given as steroid therapy. The treatment was planned for 4-6 months according to the severity of the symptoms and was completed by reducing it to a total dose of 10 mg/month., Results: Eleven patients were included in the study. Five patients had completed steroid treatment and continued their follow-up. In our study, a total of six patients were receiving steroid therapy., Conclusions: There is no consensus yet on the use of the steroid in the COVID-19 pandemic. Low doses Corticosteroids (<1 mg/kg/day) don't have an effect on increase mortality in patients with severe COVID-19. We can think that low-dose corticosteroids used by many centers in IGM treatment do not have a negative effect on mortality.

Immunomodulatory agents are often used in the systemic treatment of non-infectious uveitis. These drugs consist of corticosteroids, conventional immunosuppressives, and biological agents. As it is known that they suppress the immune system, the most important concern associated with immunomodulatory therapy (IMT) is the increased risk of infection. The World Health Organization declared COVID-19 a pandemic on 11 March 2020. Although severe acute respiratory distress syndrome secondary to SARS-CoV-2 infection may develop in all people, patients who receive IMT may be at higher risk in terms of both the transmission of the infection and more severe disease course. Therefore, guidelines on the management of patients receiving IMT due to uveitis during the pandemic are needed. In this review, we examined the immunomodulatory drugs used in the treatment of uveitis in terms of infectious complications and the data of patients who received IMT during the COVID-19 pandemic and discussed recommendations for the use of these drugs. According to the latest information, patients who receive IMT may continue their treatment as long as there are no disruptions in regular complete blood count (especially white blood cell count >4,000/µL) and liver and kidney function tests. Patients diagnosed with COVID-19 should be managed with a multidisciplinary approach.

Aims: In the Danish population, we examined whether patients treated with thiopurines, methotrexate, systemic corticosteroids, anti-tumour necrosis factor (TNF)-α agents, anti-interleukin therapeutic agents, selective immunosuppressive agents and cyclosporine/tacrolimus had an increased risk of hospitalization for COVID- 19, compared to the background population., Methods: A nationwide cohort study including all people alive in Denmark on 1 March 2020. Exposed patients constituted those exposed to thiopurines (n = 5484), methotrexate (n = 17 977), systemic corticosteroids (n = 55 868), anti-TNF-α agents (n = 17 857), anti-interleukin therapeutic agents (n = 3744), selective immunosuppressive agents (n = 3026) and cyclosporine/tacrolimus (n = 1143) in a period of 12 months prior to 1 March 2020 (estimated time of outbreak in Denmark). We estimated the adjusted risk of hospitalization for COVID-19 for patients treated with the above-mentioned categories of medications, compared to the rest of the population., Results: The adjusted odds ratios of hospitalization in patients treated with corticosteroids and cyclosporine/tacrolimus were 1.64 (95% confidence interval [CI] 1.35 to 2.00) and 4.75 (95% CI 1.96 to 11.49), respectively. The risks of hospitalization in patients treated with thiopurines, methotrexate, and anti-TNF-α agents, were 1.93 (95% CI 0.91 to 4.08), 0.74 (95% CI 0.43 to 1.28), 1.00 (95% CI 0.52 to 1.94), respectively. The number of outcomes in patients treated with anti-interleukin therapeutic agents and selective immunosuppressive agents was too small for analysis., Conclusion: Patients treated with systemic corticosteroids and cyclosporine/tacrolimus had a significantly increased risk of being hospitalized for COVID-19. Our study does not uncover whether the increased risk is related to the drug itself, the underlying condition for which the patient is treated or other factors., (© 2020 British Pharmacological Society.)

In patients with specific dermatologic disorders who are affected by new corona virus, we know little about disease course (underlying disease and new onset infection), and the most proper management strategies include both issues that are what this systematic review targets. Databases of PubMed, Scopus, Google Scholar, Medscape, and Centre of Evidence-Based Dermatology, coronavirus dermatology resource of Nottingham University searched completely up to May 15, 2020, and initial 237 articles were selected to further review and finally 9 articles (including 12 patients) entered to this study. From 12 patients with chronic underlying dermatologic disease treated with systemic therapies, only 1 patient required Intensive Care Unit admission, the others have been treated for mild-moderate symptoms with conventional therapies. The biologic or immunosuppressive/immunomodulator agents have been ceased during the course of disease. The course of coronovirus diseases 2019 (COVID-19) and its management was as similar as normal populations. Their underlying dermatologic disease were exacerbating from mild to moderate. Their treatment has been continued as before, after the symptoms improved. Exacerbation of patients underlying dermatologic disease was mild to moderate. Discontinuing the treatment in the acute period of COVID and the restart after recovery may prevent severe recurrence and disturbing cytokine storms in these patients., (© 2020 Wiley Periodicals LLC.)

Background: With COVID-19 pandemic, concerns about kidney transplant recipients are rising. However, the incidence, clinical course, outcome, and predictive factors of disease severity are obscured., Methods: We describe clinical and laboratory manifestations, radiologic findings, clinical course, and finally outcome of kidney transplant recipients with COVID-19 pneumonia., Results: Of 2493 kidney transplant recipients under follow-up in our clinic, 19 cases (4 cases diagnosed based on radiologic findings) were admitted. The mean age of patients was 47.6 ± 12.4 years, and the mean time from transplantation was 115.6 ± 70.3 months. Lymphopenia and eosinopenia were 84.2% and 78.9%, respectively. Nine patients did not survive the hospital course. History of acute rejection during the past 12 months, diabetes, higher N/L ratio, lower platelet count, elevated N/L x CRP, higher levels of LDH, positive D-dimer, higher troponin, and prolonged PT were associated with mortality. Among patients with positive COVID-19 test, history of acute rejection, low platelet count, and positive D-dimer were associated with poor outcome. Treatment with cyclosporine was associated with better clinical outcome., Conclusions: Low rate of admission in transplant recipients specially in the very first years of transplantation might be due to protective effects of immunosuppressive agents against cytokine storm or modification of immunity function. We suggest evaluation of T-cell number, function, and cytokine profile as a guide to manage COVID-19 mainly in patients with higher risk of mortality., (© 2020 Wiley Periodicals LLC.)

Objective: The study aimed to examine the demographic, clinical and therapeutic characteristics of people with neuromyelitis optica spectrum disorders (NMOSD, pwNMOSD) during the coronavirus disease 2019 (COVID‐19) pandemic. Methods: This was an observational study of pwNMOSD at a tertiary care clinic. Data on COVID‐19 infection were collected between 11 March 2020 and 30 April 2022. Data on COVID‐19 symptoms, severity and death rate were analyzed. Results: We observed 16 confirmed COVID‐19 cases and three suspected cases. Three (15.8%) patients had severe infections, whereas 16 (84.2%) had mild conditions. Only one person was admitted to the hospital due to pneumonia. COVID‐19 re‐infection was reported by three patients. No pwNMOSD died as a result of COVID‐19 disease. Cough was the most frequently reported symptom. The incidence of COVID‐19 infection in our cohort was 21.1%. Immunosuppressants were taken by 57.9% of pwNMOSD with COVID‐19, and by 84.5% of pwNMOSD without COVID‐19. Conclusions: Due to the small sample size, there was no predominant difference in infection between infected and uninfected patients with or without immunosuppressant drugs. However, given that immunosuppressants are a risk for infection, patient decision‐making in their selection is important. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Transplant recipients have a higher risk of SARS-CoV-2 infection owing to the use of immunosuppressive drugs like tacrolimus (FK506). FK506 and nirmatrelvir (NMV) (an anti-SARS-CoV-2 drug) are metabolized by cytochrome P450 3A4 and may have potential drug-drug interactions. It is important to determine the effect of NMV on FK506 concentrations. PATIENTS AND METHODS: Following protein precipitation from blood, FK506 and its internal standard (FK506-13C,2d4) were detected by ultra-high performance liquid chromatography/ tandem mass spectrometry (UHPLC-MS/MS). Total 22 blood samples (valley concentrations) from two coronavirus disease 2019 (COVID-19) patients were collected and analyzed for FK506 concentrations. RESULTS: Blood levels of FK506 (0.5-100 ng/ mL) showed good linearity. The UHPLC-MS/MS method was validated with intra- and inter-batch accuracies of 104.55-107.85%, and 99.52-108.01%, respectively, and precisions of < 15%. Mean blood FK506 concentration was 12.01 ng/mL (range, 3.15-33.1 ng/mL). Five-day co-administration with NMV increased the FK506 concentrations from 3.15 ng/mL to 33.1 ng/mL, returning to 3.36 ng/mL after a 9-day-washout. CONCLUSIONS: We developed a simple quantification method for therapeutic drug monitoring of FK506 in patients with COVID-19 using UHPLC-MS/MS with protein precipitation. We found that NMV increased FK506 blood concentration 10-fold. Therefore, it is necessary to re-consider co-administration of FK506 with NMV. [ABSTRACT FROM AUTHOR]

Background and Aims: Immunosuppressive therapy has a key role in developing coronavirus disease‐2019 (COVID‐19)‐associated mucormycosis. In this study, we investigated the effect of the type and cumulative dose of immunosuppressive agents on COVID‐19‐associated mucormycosis. Methods: We designed a descriptive cross‐sectional study involving three COVID‐19 hospitals in Iran. Clinical and demographic data were gathered from the medical records and checked by two independent researchers to minimize errors in data collection. Results: Seventy‐three patients were included in the study. The mean age of cases was 57.41 (SD = 12.64) and 43.8% were female. Among patients, 20.5% were admitted to the intensive care unit (ICU) during COVID‐19. Furthermore, 17 patients (23.29%) had a history of diabetes mellitus. Sixty‐nine patients (94.52%) had a history of receiving corticosteroids (dexamethasone) during treatment of COVID‐19, and of those, five patients (6.85%) received Tocilizumab beside. The mean cumulative dose of corticosteroids prescribed was 185.22 mg (SD = 114.738). The average cumulative dosage of tocilizumab was 720 mg (SD = 178.89). All of the included patients received amphotericin B for mucormycosis treatment, and 42 survived (57.53%). Also, there was a significant relationship between hospitalization in ICU for COVID‐19 and the mucormycosis outcome (p = 0.007). However, there weren't any significant associations between cumulative doses of immunosuppressive drugs and mucormycosis outcome (p = 0.52). Conclusion: The prevalence of COVID‐19‐associated mucormycosis is increasing and should be considered in the treatment protocols of COVID‐19. Controlling risk factors such as diabetes, malignancy and the administration of immunosuppressive agents based on recommended dosage in validated guidelines are ways to prevent mucormycosis. [ABSTRACT FROM AUTHOR]

Background: Neurological disability associated with multiple sclerosis and immunosuppressive or immunomodulatory therapy which is administered for it may increase the risk of SARS-CoV-2 infection and its morbidity/mortality.In this study, we evaluated the severity of SARS-CoV-2 infection in patients with multiple sclerosis based on their demographic and disease data.Methods: A total of 1361 multiple sclerosis patients from Fars province were interviewed by phone from April 3 to June 20, 2020. Basic demographic data, information about their disease and any symptoms or laboratory results relevant to COVID-19 were gathered.Results: Among the studied patients, 68 ones (5%) were COVID-19 suspected cases and 8 ones (0.58%) were in the confirmed group. Five cases in the confirmed group needed hospitalization. Two patients died while both of them were taking rituximab. The frequency rate of suspected cases with RRMS was 57 (87.7%), followed by 5 (7.7%) PPMS and 2 (3.1%) CIS. In the confirmed group, 25% used corticosteroid drug and 50% were on rituximab; moreover, 62.5% of the confirmed cases had a high disability level and needed assistance to walk. In whole, 36.8% of the suspected and 25% of the confirmed cases were on IFN-β1; eventually, all of them recovered well from COVID-19 infection.Conclusion: In the present study, the rate of developing COVID-19 in multiple sclerosis patients was similar to the general population and most of patients with multiple sclerosis recovered from COVID-19 without referral to a medical specialist.

Abstract Background and Aims Immunosuppressive therapy has a key role in developing coronavirus disease‐2019 (COVID‐19)‐associated mucormycosis. In this study, we investigated the effect of the type and cumulative dose of immunosuppressive agents on COVID‐19‐associated mucormycosis. Methods We designed a descriptive cross‐sectional study involving three COVID‐19 hospitals in Iran. Clinical and demographic data were gathered from the medical records and checked by two independent researchers to minimize errors in data collection. Results Seventy‐three patients were included in the study. The mean age of cases was 57.41 (SD = 12.64) and 43.8% were female. Among patients, 20.5% were admitted to the intensive care unit (ICU) during COVID‐19. Furthermore, 17 patients (23.29%) had a history of diabetes mellitus. Sixty‐nine patients (94.52%) had a history of receiving corticosteroids (dexamethasone) during treatment of COVID‐19, and of those, five patients (6.85%) received Tocilizumab beside. The mean cumulative dose of corticosteroids prescribed was 185.22 mg (SD = 114.738). The average cumulative dosage of tocilizumab was 720 mg (SD = 178.89). All of the included patients received amphotericin B for mucormycosis treatment, and 42 survived (57.53%). Also, there was a significant relationship between hospitalization in ICU for COVID‐19 and the mucormycosis outcome (p = 0.007). However, there weren't any significant associations between cumulative doses of immunosuppressive drugs and mucormycosis outcome (p = 0.52). Conclusion The prevalence of COVID‐19‐associated mucormycosis is increasing and should be considered in the treatment protocols of COVID‐19. Controlling risk factors such as diabetes, malignancy and the administration of immunosuppressive agents based on recommended dosage in validated guidelines are ways to prevent mucormycosis.

Objectives: The aim of this study was to evaluate the knowledge and practices about vaccination in adults with autoimmune inflammatory rheumatic diseases (AIRD) among primary care physicians (PCPs), internal medicine specialists (IMSs), and rheumatologists and to emphasize the importance of vaccination. Patients and methods: Between March 2021 and April 2021, a total of 310 IMSs, PCPs, and rheumatologists (132 males, 178 females; mean age: 37.4±9.5 years; range, 24 to 64 years) were included. A web-based questionnaire was used in the study. Results: Of the physicians, 87.7% were aware of that patients with AIRD were among adults with vaccination indications, but 53.9% reported that they knew about recommended vaccines, and 53.2% recommended vaccines to their patients. The most common reasons for not recommending vaccination were reservations about the drugs used (22.3%) and lack of information (17.7%). Those with longer practice as physicians and older physicians had less knowledge about the vaccine than the other participants. While 59.7% of the participants thought that the vaccination plans of the patients should be made by the rheumatologist, the rate of PCPs who did not prefer to apply the planned vaccines in the first step was 50.7%. A total of 50% of the participants did not recommend the administration of the COVID-19 vaccine in a primary healthcare institution to those receiving immunosuppressive therapy. Conclusion: Considering that one of the major obstacles to adult vaccination is the physician's refusal to recommend it, our study highlights the missing points in the vaccination knowledge and approach of physicians. Providing advice on adult vaccination and immunization of risky groups to more physicians and periodic training to prevent loss of knowledge after graduation may contribute to an increase in the vaccination rate of adults with AIRD. [ABSTRACT FROM AUTHOR]

Immunomodulatory agents are often used in the systemic treatment of non-infectious uveitis. These drugs consist of corticosteroids, conventional immunosuppressives, and biological agents. As it is known that they suppress the immune system, the most important concern associated with immunomodulatory therapy (IMT) is the increased risk of infection. The World Health Organization declared COVID-19 a pandemic on 11 March 2020. Although severe acute respiratory distress syndrome secondary to SARS-CoV-2 infection may develop in all people, patients who receive IMT may be at higher risk in terms of both the transmission of the infection and more severe disease course. Therefore, guidelines on the management of patients receiving IMT due to uveitis during the pandemic are needed. In this review, we examined the immunomodulatory drugs used in the treatment of uveitis in terms of infectious complications and the data of patients who received IMT during the COVID-19 pandemic and discussed recommendations for the use of these drugs. According to the latest information, patients who receive IMT may continue their treatment as long as there are no disruptions in regular complete blood count (especially white blood cell count >4,000/μL) and liver and kidney function tests. Patients diagnosed with COVID-19 should be managed with a multidisciplinary approach.

Management of ANCA-associated vasculitis (AAV) during the COVID-19 pandemic poses unique therapeutic challenges. An online survey was conducted to understand physician's choices for treating AAV during the COVID-19 pandemic. Web-based survey featuring nineteen questions was circulated amongst physicians across various specialties. The responses regarding immunosuppressive therapy for remission induction and maintenance, COVID-19 testing, and preventive measures were recorded. A total of 304 responses were recorded. Most of the respondents were from India (83.9%) and comprised rheumatologists (66%) in practice for ≥ 5 years (71%). Though a majority preferred Rituximab or intravenous cyclophosphamide (CYC) as a remission induction agent, a significant proportion opted for oral CYC and mycophenolate mofetil (MMF) also. Only one-third wanted to test for COVID-19 before initiating immunosuppressive therapy in patients with organ/life-threatening manifestations. Rituximab was the most favored maintenance therapy (47%), followed by azathioprine, MMF, and methotrexate. The results of this focused survey of managing AAV patients depict the real-world dilemmas and physicians' choices in this setting. [ABSTRACT FROM AUTHOR]

Background: Neurological disability associated with multiple sclerosis and immunosuppressive or immunomodulatory therapy which is administered for it may increase the risk of SARS-CoV-2 infection and its morbidity/mortality. In this study, we evaluated the severity of SARS-CoV-2 infection in patients with multiple sclerosis based on their demographic and disease data. Methods: A total of 1361 multiple sclerosis patients from Fars province were interviewed by phone from April 3 to June 20, 2020. Basic demographic data, information about their disease and any symptoms or laboratory results relevant to COVID-19 were gathered. Results: Among the studied patients, 68 ones (5%) were COVID-19 suspected cases and 8 ones (0.58%) were in the confirmed group. Five cases in the confirmed group needed hospitalization. Two patients died while both of them were taking rituximab. The frequency rate of suspected cases with RRMS was 57 (87.7%), followed by 5 (7.7%) PPMS and 2 (3.1%) CIS. In the confirmed group, 25% used corticosteroid drug and 50% were on rituximab; moreover, 62.5% of the confirmed cases had a high disability level and needed assistance to walk. In whole, 36.8% of the suspected and 25% of the confirmed cases were on IFN-β1; eventually, all of them recovered well from COVID-19 infection. Conclusion: In the present study, the rate of developing COVID-19 in multiple sclerosis patients was similar to the general population and most of patients with multiple sclerosis recovered from COVID-19 without referral to a medical specialist. [ABSTRACT FROM AUTHOR]

Mahtabalsadat Mirjalili,1 Mojtaba Shafiekhani,1,2 Afsaneh Vazin1 1Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran; 2Shiraz Organ Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, IranCorrespondence: Mojtaba ShafiekhaniShiraz Organ Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, IranTel +9871133441551Fax +987136430038Email mojtabashafiekhani@gmail.comAfsaneh VazinDepartment of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, IranTel| Fax +987132424255Email vazeena@sums.ac.irAbstract: The 2019 novel coronavirus disease (COVID-19) was first detected in Wuhan, Hubei Province, China, in late 2019. Since then, COVID-19 has spread to more than 200 countries in the world, and a global pandemic has been declared by the World Health Organization (WHO). At present, no vaccines or therapeutic regimens with proven efficacy are available for the management of COVID-19. Hydroxychloroquine/chloroquine, lopinavir/ritonavir, ribavirin, interferons, umifenovir, remdesivir, and interleukin antagonists, such as tocilizumab, have been recommended as potential treatment options in COVID-19. Transplant patients receiving immunosuppressant medications are at the highest risk of severe illness from COVID-19. At the same time, with regard to receiving polypharmacy and immunosuppressants, treatment options should be chosen with more attention in this population. Considering drug–drug interactions and adverse effects of medications used for the treatment of COVID-19, such as QT prolongation, the dose reduction of some immunosuppressants or avoidance is recommended in transplant recipients with COVID-19. Thus, this narrative review describes clinically important considerations about the treatment of COVID-19 and immunosuppressive regimens regarding modifications, side effects, and interactions in adult kidney or liver allograft recipients.Keywords: SARS-CoV-2, COVID-19, liver transplant, kidney transplant, immunosuppressive, transplantation

Immunomodulatory agents are often used in the systemic treatment of non-infectious uveitis. These drugs consist of corticosteroids, conventional immunosuppressives, and biological agents. As it is known that they suppress the immune system, the most important concern associated with immunomodulatory therapy (IMT) is the increased risk of infection. The World Health Organization declared COVID-19 a pandemic on 11 March 2020. Although severe acute respiratory distress syndrome secondary to SARS-CoV-2 infection may develop in all people, patients who receive IMT may be at higher risk in terms of both the transmission of the infection and more severe disease course. Therefore, guidelines on the management of patients receiving IMT due to uveitis during the pandemic are needed. In this review, we examined the immunomodulatory drugs used in the treatment of uveitis in terms of infectious complications and the data of patients who received IMT during the COVID-19 pandemic and discussed recommendations for the use of these drugs. According to the latest information, patients who receive IMT may continue their treatment as long as there are no disruptions in regular complete blood count (especially white blood cell count >4,000/μL) and liver and kidney function tests. Patients diagnosed with COVID-19 should be managed with a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Aims: There is currently no evidence-based guideline to show how to manage immunosuppressive treatment in patients with hidradenitis suppurativa (HS) during the Coronavirus disease-2019 (COVID-19) pandemic. Therefore, we updated our routine clinical protocol to 1) inform patients with ongoing treatment about the potential risks of their medications in the case of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection, 2) discuss opt out of treatment temporarily, and 3) perform a closer follow-up on a monthly basis. The aim of this study was to evaluate the clinical outcomes in patients with HS, who suspended and continued immunosuppressive therapy following COVID-19 outbreak. Methods: This retrospective study included patients with HS, who had been receiving biologic/ immunosuppressive treatment when the COVID-19 pandemic was announced. Those who withdrew treatment for any reason or continued were analyzed. The primary endpoint was physician-diagnosed disease exacerbation. The secondary outcomes were changes in visual analogue scale (VAS) and COVID-19 diagnosis. Results: A total of 37 patients were included in the analysis. The majority of the patients were on adalimumab treatment (n=33). Fifteen (40.5%) patients withdrew the treatment for COVID-19 related concerns. During 83.2±0.6 days of follow-up following the withdrawal, all patients in this group had at least one exacerbation. Also, the mean VAS score increased from 5.7±0.56 to 8.6±0.57 (p=0.001). On the other hand, three patients (13.6%) who continued the treatment reported worsening in disease course, 12 patients (54.5%) remained stable and seven of them (31.9%) had clinical relief. We did not observe any confirmed SARS-CoV-2 infection in any of our 37 HS patients. Conclusions: The present study suggests that even a temporary withdrawal of biologic/ immunosuppressive treatments may have significant adverse consequences on disease course and quality of life in patients with HS. These individuals may safely continue the treatment provided that maximum measures are taken to avoid COVID-19 infection. [ABSTRACT FROM AUTHOR]

Background: Psoriasis is a chronic skin disease that needs continuous medical care. During COVID‐19, delivering medical service was negatively affected. Aims: To describe the impact of COVID‐19 on psoriasis healthcare delivery, management, and practice. Methods: This observational cross‐sectional study was conducted on 197 dermatologists using a validated online questionnaire. The survey evaluated the effect of COVID‐19 on the decisions, prescription patterns, appointments rescheduling, and healthcare delivery for psoriasis patients by dermatologists. The questionnaire was developed and validated with a reliability score >0.7. Results: During the pandemic, most dermatologists delayed initiating biological/immunosuppressive therapy for psoriasis unless urgently needed by the patient. For patients already receiving biologics or immunosuppressive treatment, most dermatologists favored continuation of therapy. Almost half (44.2%) of participants do not perform SARS‐CoV‐2 PCR screening before initiating biologics/immunosuppressive therapy. Dermatologists also reported an increased prescription of topical medications (79.2%), natural sunlight (28.4%), acitretin (26.9%), and home UVB (21.3%). Opinions regarding the use of hydroxychloroquine for COVID‐19 treatment/prophylaxis for psoriasis patients were controversial. Intervals between face‐to‐face follow‐up visits were prolonged by 71.6% of dermatologists. More than half of participants reported that their patients discontinued treatment without medical consultation. More than three fourth of responders either agreed or strongly agreed that COVID‐19 negatively affected psoriasis patients. Conclusions: The COVID‐19 pandemic has a negative impact on psoriasis management and healthcare delivery. Dermatologists are cautious about using biologics and immunosuppressive drugs during the pandemic, making case‐by‐case decisions. Psoriasis patients need compliance monitoring, and psychological support during the pandemic, which can be facilitated by teledermatology. [ABSTRACT FROM AUTHOR]

Rheumatology practice, during Coronavirus Disease 2019 (COVID-19) pandemic, has faced multifaceted challenges. Rheumatologists routinely prescribe immunosuppressant medications to their patients with multisystem autoimmune rheumatic diseases who are concerned about the increased risk of acquiring COVID-19 infection and are anxious to know if they should continue or hold these medications. Rheumatologists are often inundated by calls from their patients and physician colleagues caring for COVID-19 patients in hospitals, about how to manage the immunosuppression. Physicians face the challenging task of keeping up with the most up-to-date information on COVID-19. There are uncertainties about the mode of spread, clinical features, management options as well as long-term complications of COVID-19. Data are rapidly evolving and different studies on treatment options are showing contradictory results. It is known that viral illnesses can trigger a flare-up of underlying rheumatic disease that was previously in remission. To further complicate the scenario, some of the immunosuppressants have shown to have antiviral properties. This has created dilemma in the light of current COVID-19 crisis, as whether to continue or stop the immunosuppressive agents which could be essential to prevent complications of the rheumatic diseases including organ failure but also there is concern about acquiring COVID-19 or developing serious infection. Until we get an effective vaccine, immunosuppressant management for rheumatic diseases as well as other autoimmune diseases and transplants will pose difficult questions. This article is an attempt to review and understand COVID-19 and its impact on the immune system with special emphasis on managing medications used for autoimmune rheumatic diseases. We have provided general guidance about decision making, in regards to the immunosuppressive agents used in rheumatology practice with an understanding that this may change in near future. [ABSTRACT FROM AUTHOR]

Introduction: During the midst of the coronavirus disease 2019 (COVID-19) pandemic, dermatologists treating psoriasis are presented with the challenge of managing immunosuppressive and immunomodulatory therapies while ensuring patient safety. Objective: Here we discuss the systemic therapies for psoriasis and their implications in the context of COVID-19 pandemic, including the recommendations of leading dermatological societies and organizations. Discussion: Currently, there are no definitive data regarding the impact of specific immunosuppressive and immunomodulatory therapies used for psoriasis on the natural history of COVID-19. However, the concern is that many of these medications may increase the risk of infection or prolong the clearance of the virus, although there is some ongoing speculation that some immunomodulatory therapies may actually prevent detrimental complications of coronavirus infection. Conclusions: Due to the lack of evidence, we recommend that all patients on immunomodulatory and immunosuppressive therapies for psoriasis stop their treatment immediately if they are diagnosed with COVID-19 or are exposed to someone diagnosed with COVID-19. Meanwhile, until the current situation gets resolved, we recommend that the decision to continue or stop systemic treatments for psoriasis should be made on an individual basis, taking into account the patient’s current progress on the treatment and the patient’s concomitant risk factors for COVID-19 as outlined by the Centers for Disease Control and Prevention (CDC).

Background: Over the month of April, Spain has become the European country with more confirmed cases of COVID-19 infection, after surpassing Italy on April 2nd. The community of Castile and León in Spain is one of the most affected by COVID-19 infection and the province of León has a total of 3711 cases and 425 deaths so far. Rheumatic patients should be given special attention regarding COVID-19 infection due to their immunocompromised state resulting from their underlying immune conditions and use of targeted immune-modulating therapies. Studying epidemiological and clinical characteristics of patients with rheumatic diseases infected with SARS-CoV2 is pivotal to clarify determinants of COVID-19 disease severity in patients with underlying rheumatic disease. Objectives: To describe epidemiological characteristics of patients with rheumatic diseases hospitalized with COVID-19 and determine risk factors associated with mortality in a third level Hospital setting in León, Spain. Methods: We performed a prospective observational study, from 1st March 2020 until the 1st of June including adults with rheumatic diseases hospitalized with COVID-19 and performed a univariate and multivariate logistic regression model to estimate ORs and 95% CIs of mortality. Age, sex, comorbidities, rheumatic disease diagnosis and treatment, disease activity prior to infection, radiographic and laboratorial results at arrival were analysed. Results: During the study period, 3711 patients with COVID-19 were admitted to our hospital, of whom 38 (10%) had a rheumatic or musculoskeletal disease. Fifty-three percent were women, with a mean age at hospital admission of 75.3 (IQR 68–83) years. The median length of stay was 11 days. A total of 10 patients died (26%) during their hospital admission. Patients who died from COVID-19 were older (median age 78.4 IQR 74.5–83.5) than those who survived COVID-19 (median age 75.1 IQR 69.3–75.8) and more likely to have arterial hypertension (9 [90%] vs 14 [50%] patients; OR 9 (95% CI 1.0–80.8), p 0.049), dyslipidaemia (9 (90%) vs 12 (43%); OR 12 (95% CI 1.33–108), p 0.03), diabetes ((9 (90%) vs 6 (28%) patients; OR 33, p 0.002), interstitial lung disease (6 (60%) vs 6 (21%); OR 5.5 (95% CI 1.16–26), p 0.03), cardiovascular disease (8 (80%) vs 11 (39%); OR 6.18 (95% IC 1.10–34.7, p 0.04) and a moderate/high index of rheumatic disease activity (7 (25%) vs 6(60%); OR 41.4 (4.23–405.23), p 0.04). In univariate analyses, we also found that patients who died from COVID-19 had higher hyperinflammation markers than patients who survived: C-reactive protein (181 (IQR 120–220) vs 107.4 (IQR 30–150; p 0.05); lactate dehydrogenase (641.8 (IQR 465.75–853.5) vs 361 (IQR 250–450), p 0.03); serum ferritin (1026 (IQR 228.3–1536.3) vs 861.3 (IQR 389–1490.5), p 0.04); D-dimer (12,019.8 (IQR 843.5–25,790.5) vs 1544.3 (IQR 619–1622), p 0.04). No differences in sex, radiological abnormalities, rheumatological disease, background therapy or symptoms before admission between deceased patients and survivors were found. In the multivariate analysis, the following risk factors were associated with mortality: rheumatic disease activity (p = 0.003), dyslipidaemia (p = 0.01), cardiovascular disease (p = 0.02) and interstitial lung disease (p = 0.02). Age, hypertension and diabetes were significant predictors in univariate but not in multivariate analysis. Rheumatic disease activity was significantly associated with fever (p = 0.05), interstitial lung disease (p = 0.03), cardiovascular disease (p = 0.03) and dyslipidaemia (p = 0.01). Conclusions: Our results suggest that comorbidities, rheumatic disease activity and laboratorial abnormalities such as C-reactive protein (CRP), D-Dimer, lactate dehydrogenase (LDH), serum ferritin elevation significantly associated with mortality whereas previous use of rheumatic medication did not. Inflammation is closely related to severity of COVID-19. Key Points • Most patients recover from COVID-19. • The use of DMARDs, corticosteroids and biologic agents did not increase the odds of mortality in our study. • Rheumatic disease activity might be associated with mortality. [ABSTRACT FROM AUTHOR]

The ongoing COVID‐19 epidemic has brought to the fore many concerns related to use of immunosuppressive agents (ISAs) in dermatology. While it is unclear whether the patients on ISAs for skin conditions are more prone to develop COVID‐19, and what impact the ISA may have on the clinical outcome if a patient does get infected, rationalizations based on the specific immune effects of each drug, and existing literature on incidence of various infections with each, are possible. In this review, we provide the readers with practically useful insights into these aspects, related to the conventional ISAs, and briefly mention the clinical outcome data available on related scenarios from other patient groups so far. In the end, we have attempted to provide some clinically useful points regarding practical use of each dermatologically relevant conventional ISA in the current scenario. [ABSTRACT FROM AUTHOR]

Severe Acute Respiratory Syndrome related to Coronavirus-2 (SARS-CoV-2), coronavirus disease-2019 (COVID-19) may cause severe illness in 20% of patients. This may be in part due to an uncontrolled immune-response to SARS-CoV-2 infection triggering a systemic hyperinflammatory response, the so-called "cytokine storm". The reduction of this inflammatory immune-response could be considered as a potential therapeutic target against severe COVID-19. The relationship between inflammation and clot activation must also be considered. Furthermore, we must keep in mind that currently, no specific antiviral treatment is available for SARS-CoV-2. While moderate-severe forms need in-hospital surveillance plus antivirals and/or hydroxychloroquine; in severe and life-threating subsets a high intensity anti-inflammatory and immunomodulatory therapy could be a therapeutic option. However, right data on the effectiveness of different immunomodulating drugs are scarce. Herein, we discuss the pathogenesis and the possible role played by drugs such as: antimalarials, anti-IL6, anti-IL-1, calcineurin and JAK inhibitors, corticosteroids, immunoglobulins, heparins, angiotensin-converting enzyme agonists and statins in severe COVID-19. • Severe COVID-19 forms may be related to a hyperinflammatory syndrome. • Severe COVID-19 is associated with clot pathway hyperactivity and sometimes, with thromboses. • Immunosuppression may be a complementary therapy in COVID-19 patients. • Antimalarials, heparin, cytokine blockers, JAK-inhibitors, IVIG could be useful for treating severe COVID-19 patients. • In SARS-CoV-2 infections the effectiveness of the hyperimmune plasma remains uncertain. [ABSTRACT FROM AUTHOR]