What the Experts Recommend
Most major medical societies, including the American Academy of Dermatology (AAD) and American College of Rheumatology (ACR), recommend temporarily discontinuing or postponing most biologic medications in patients with an active, symptomatic COVID-19 infection. This guideline is based on the general principle of pausing immunosuppressant therapy during any significant infection to allow the immune system to fully combat the pathogen. The reasoning is that while biologics target specific inflammatory pathways, their effect on overall immune response can theoretically complicate or prolong a viral illness, especially in more severe cases.
However, this is not a one-size-fits-all rule. The decision is highly individualized and must be made in consultation with your treating physician, considering your specific condition, the biologic you are on, and the severity of your COVID-19 symptoms.
Understanding the Risks of Pausing vs. Continuing
For patients with chronic autoimmune diseases, pausing a biologic is a significant decision. It involves balancing the potential for a worse infectious outcome against the risk of a disease flare-up.
The Risks of Continuing Your Biologic During COVID-19
- Hindered Immune Response: Biologics work by suppressing or modulating parts of the immune system to reduce inflammation. While this is beneficial for autoimmune diseases, it can also potentially interfere with the body's natural response to fight off a viral infection like COVID-19.
- Potential for Complications: Though data from the pandemic showed many biologics did not increase the risk of severe COVID-19 outcomes, there remains a theoretical risk, particularly for those with severe underlying disease or on potent immunosuppressants.
The Risks of Pausing Your Biologic Due to COVID-19
- Disease Flare-up: Abruptly stopping a biologic can trigger a relapse or flare of the underlying autoimmune disease (e.g., rheumatoid arthritis, psoriasis, inflammatory bowel disease). A flare can be debilitating and may require higher doses of other medications, like steroids, which have their own risks.
- Loss of Efficacy: Some biologics may become less effective if treatment is interrupted and then restarted. This is often due to the body developing antibodies against the drug. The drug may not work as well when reintroduced, or a new medication may be required.
Guidelines Vary: Mild vs. Severe COVID-19
The severity of the COVID-19 infection is a major factor in guiding the decision. Many professional societies provide tiered recommendations based on symptom severity.
- Mild or Asymptomatic COVID-19: For mild illness, some guidelines suggest that continuing the biologic might be appropriate after a discussion with your doctor, especially if the risk of a disease flare is high. However, the ACR and others have traditionally recommended holding all non-IL-6 biologics and immunosuppressants with known or presumptive COVID-19 infection, regardless of severity, for a short period.
- Moderate to Severe COVID-19: During moderate to severe illness, especially if hospitalization is required, the recommendation is almost universally to pause the biologic immediately. In these cases, prioritizing the body's ability to fight the active and serious infection takes precedence.
Different Biologics, Different Recommendations
Not all biologics have the same mechanism of action or the same impact on COVID-19 outcomes. Research from the pandemic has shed light on how different drug classes interact with the virus.
Table: Biologics and COVID-19 Considerations
| Biologic Class | Target | Typical Recommendation During Symptomatic COVID-19 | Rationale & Nuances |
|---|---|---|---|
| Anti-TNF (e.g., Humira, Enbrel) | Tumor Necrosis Factor | Hold temporarily | Studies showed some anti-TNF users had better outcomes or no increased risk of severe COVID-19, possibly by dampening the hyperinflammatory response. Still, pausing during active illness is standard precaution. |
| Anti-IL-6 (e.g., Tocilizumab) | Interleukin-6 | May be continued in specific, selective circumstances | Blocking IL-6 was sometimes continued because IL-6 is a key driver of the "cytokine storm" in severe COVID-19, potentially mitigating severe outcomes. This was a highly specific, individualized decision. |
| Anti-IL-17 (e.g., Cosentyx, Taltz) | Interleukin-17 | Hold temporarily | Data suggested these do not increase COVID-19 risk or worsen outcomes. However, standard guidelines still advise temporary discontinuation during an active infection. |
| Anti-IL-23 (e.g., Skyrizi, Tremfya) | Interleukin-23 | Hold temporarily | Generally considered safe with minimal impact on antiviral responses. Standard guidelines advise pausing during active infection. |
| Anti-IL-12/23 (e.g., Stelara) | Interleukin-12 and -23 | Hold temporarily | Similar to anti-IL-23, data are reassuring regarding COVID-19 outcomes, but temporary holding during active infection is standard practice. |
| JAK Inhibitors (e.g., Rinvoq, Xeljanz) | Janus Kinase pathway | Hold temporarily | Similar to other immunosuppressants, temporarily stopping is recommended during active infection to avoid hindering the immune response. |
When to Resume Your Biologic
The timing for restarting your biologic is just as important as the decision to pause it. The goal is to ensure the infection has resolved without risking a disease flare. Resumption should always be guided by your physician.
- Uncomplicated COVID-19: For mild cases that resolve fully, many guidelines suggest resuming treatment within 7 to 14 days of symptom resolution.
- Asymptomatic Positive Test: If you test positive but have no symptoms, resuming treatment might be considered 10 to 17 days after the positive test, but this is a decision for your doctor.
- Severe COVID-19: For patients recovering from severe illness, the decision to restart is highly individual and depends on overall recovery, any long-term effects of the infection, and a full medical assessment.
Your Treatment Plan: Always Consult a Professional
This information serves as a general guide based on the expert consensus that emerged during the pandemic. However, your specific medical history, comorbidities, disease severity, and the specific biologic you are taking all influence the best course of action. Do not stop or alter your medication schedule without consulting your specialist. Involving your entire healthcare team, including your rheumatologist, dermatologist, or gastroenterologist, is critical for making an informed and safe decision.
Conclusion: Informed Decisions for Better Health
When facing a COVID-19 infection, the question of whether or not to continue biologic therapy is a common and important concern for patients with autoimmune conditions. While most guidelines recommend a temporary pause during a symptomatic infection, the specific timing and conditions vary depending on the type of biologic and the severity of the illness. Discontinuing treatment without proper guidance risks a disease flare, potentially causing more harm than good. Conversely, continuing in a severe case may prolong the infection. The most important step is to contact your doctor immediately upon diagnosis to create a safe and effective plan tailored to your unique situation.
