To the Editor:
We read with interest the article by Sweiss et al1 in a previous issue of CHEST (September 2020) that provides guidance on how to adjust immunosuppressive therapy in patients with sarcoidosis during the coronavirus disease 2019 (COVID-19) pandemic. The authors point out the importance of reducing the dose of immunosuppressive drugs to decrease the risk of infections and poor outcome. These recommendations are based on the results of some systematic reviews and meta-analyses that were conducted in other rheumatic diseases and that found an increased risk for serious infections, mostly with systemic glucocorticoids and biologic agents.
Although we agree on the need to consider attentively the dosage of immunosuppressive drugs in patients with sarcoidosis to prevent deterioration from COVID-19, we would like to highlight some points.
First, most studies that evaluated the risk of infection were conducted mostly in rheumatoid arthritis, not sarcoidosis.2 Immunomodulation differs significantly in sarcoidosis vs the other rheumatic disorders, and the macrophage/T-cell system alteration and granulomas formation represent key steps to trigger and maintain persistent inflammation. Immunosuppressive drugs, therefore, could interfere differently with the immune system.
Second, the specific effect of immunosuppression in the management of COVID-19 is still under study. Preliminary results from the RECOVERY trial have demonstrated that low dexamethasone doses significantly reduce the 28-day risk of death in patients with COVID-19 who are receiving invasive mechanical ventilation or oxygen.3
The interruption of the hyperinflammatory response has beneficial effects in the early phase of the disease; a rapid dose reduction of immunosuppressive agents such as glucocorticoids thus could worsen the COVID-19 progression. Considering also that an acute relapse of sarcoidosis could contribute to reduce the lung function, we suggest much caution in envisaging a drastic reduction of immunosuppressive therapy.
Third, specifically regarding tocilizumab, even if the compound has demonstrated some benefits in terms of oxygen status improvement in severe COVID-19 pneumonia, its effects on the global survival and in patients with sarcoidosis are unknown.4
Last, the recent observation that patients with autoimmune disorders who are treated with disease-modifying antirheumatic drugs are not at increased risk of severe COVID-19 does not exclude the fact that those patients who receive IL-6 or IL-12/IL-23 axis inhibitors might be protected against the severe forms of the disease.5
In this view, it could be useful to consider different treatment scenarios, based on the presence of COVID-19 coinfection, baseline treatment, and phase of both diseases. Ad hoc studies are needed urgently to investigate the interaction between the two disorders and how the immunosuppressive treatment could change their natural history.
Footnotes
FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.
References
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