Immunosuppressants and Coronavirus: What to Know, and When You Should Talk to Your Doctor

You've heard the warnings about coronavirus: Though the virus usually causes only mild symptoms for the majority of people, it can be severe or even fatal for the high-risk population—that means anyone over the age of 60, those with chronic conditions like heart or lung disease, and anyone who is immunocompromised in some way. But what about people taking immunosuppressive drugs—are they considered immunocompromised, too?

Yes and no, says rheumatologist Doug Roberts, M.D., assistant clinical professor of medicine at the University of California Davis Medical School and medical advisor to CreakyJoints. Although the terms “immunocompromised” and “immunosuppressed” are often used interchangeably, they’re not exactly the same. "Immunocompromised people have an underlying condition that reduces their actual ability to respond effectively to infections, while people on immunosuppressive drugs can become compromised as a result of the medication they’re taking," he explains.

Either way, people with suppressed or compromised immune systems may be wondering what to do as coronavirus continues to spread. Here’s everything you need to know about taking immunosuppressive drugs during the current outbreak.

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These drugs suppress the immune system, essentially turning off or reducing the body’s typical immune response. There are several classes of immunosuppressants, with each type working in different ways for different conditions; some patients, particularly those pre- or post-organ transplant, may need to take multiple types.

• Inhibitors block specific enzymes or proteins that affect the way the immune system works. Checkpoint inhibitors are used in cancer treatments, per the National Cancer Institute (NCI).
• Steroids, like prednisone, reduce the immune response caused by autoimmune conditions and may also be prescribed after organ transplants, according to the National Kidney Foundation.
• Monoclonal antibodies work in many different ways, one of which is by blocking immune system cells that prevent cancer-fighting ones from doing their job, the NCI says.
• Biologics are chemical proteins that target certain parts of the immune system, specifically the ones that trigger inflammation, according to the Arthritis Foundation.

Immunosuppressants are commonly used after organ transplants, so the body doesn’t reject the new organ, and often play a role in cancer treatment. They’re also prescribed to treat a variety of autoimmune conditions.

The bodies of those with autoimmune conditions are attacked by their own immune systems, which can cause inflammation and  tissue, organ, and joint damage, along with overgrowth of cells. Those conditions are varied and include diseases like rheumatoid arthritis, lupus, inflammatory bowel disease (IBD), and psoriasis, among others. Suppressing the immune system in these cases can reduce these symptoms for many people with autoimmune disorders.

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Anyone who has an autoimmune disease and is taking immunosuppressants, is undergoing cancer treatment, or has had a recent transplant has been given strict instructions on how to protect and support their immune system. Being immunocompromised or immunosuppressed affects your body’s ability to defend itself from many pathogens, and while it's possible and even likely that this high-risk population is more at risk for complications from coronavirus, unfortunately we don’t know enough about COVID-19 yet to estimate the size of the risk.

“As of this week, the American College of Rheumatology declared there’s not enough data [to set official guidelines], so all patients should be taken on a case by case basis,” says Dr. Roberts.

In other words, no one knows what the prognosis is for immunosuppressed patients who contract coronavirus, or whether the likelihood of infection for them is increased. We also don’t know how immunosuppressive drugs interact with the virus itself. Finally, with COVID-19, there’s no clear way to determine where on the spectrum of risk an immunocompromised person even falls. "There are so many different kinds of immunomodulators and where you are on the spectrum changes based on which medications you’re on, [how old you are and the severity of your symptoms],” Dr. Roberts explains.

That said, when it comes to other viruses, like the flu, those who are immunosuppressed may be at a higher-risk of influenza complication like more severe illness and hospitalization, according to the Centers for Disease Control and Prevention (CDC). Something else the CDC notes in those who are immunosuppressed who also have the flu: While they may develop typical symptoms of influenza, fever may not always be present. That means, if influenza is suspected in an immunosuppressed patient with acute respiratory symptoms, even without a fever, they should be tested for the flu. In the case of COVID-19, that may also be relevant information.

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If you’re immunocompromised, being told to wash your hands, stay away from sick people, and disinfect regularly-used items like cell phones is nothing new, says Judith Lytle, MD, a general practitioner associated with Boston Medical Center. "I think many patients on immunosuppressants are probably already well-versed and doing the hand washing that is important for everyone," she says. “It’s the people who are healthy—and serving as vectors for this virus, passing it to those less healthy—that need to be every bit as diligent.”

So if you’re practicing common sense hygiene habits and following the current instructions on social distancing as much as possible, changing your personal behaviors won’t change your risk. Instead, Dr. Lytle says that if everyone got on board with some basic protective measures, it would go a long way toward helping immunocompromised or immunosuppressed people. Increasing hand washing and disinfecting, practicing social distancing, and engaging in self-care (like managing stress, eating healthy, and getting enough sleep) are all that’s needed to protect your health—but you need everyone around you to do those things, too. "More people doing basic things, like hand washing, is more impactful," she says.

Of course, aside from taking the CDC- and WHO-recommended safety precautions, it's also important to make sure you're as healthy as possible at this time. That means making sure any underlying conditions are identified and well-controlled, and that you're practicing healthy habits like eating right, getting enough sleep, and exercising as long you feel well enough, to boost your immune system.

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OK, now for the tricky part: Since immunosuppressants may leave you more vulnerable to illness, should you stop taking them while coronavirus is beginning to ramp up here in the US?

Unfortunately there is no one answer. It depends on why you’re taking them, how severe your condition is, your age and overall health, how well your condition is being controlled on the drugs, and several other factors.

To that end, different doctors have different opinions on whether immunosuppressed patients should pause treatment during the coronavirus outbreak. Some medical professionals, like Dr. Roberts and Dr. Linkner suggest talking with your physician about pausing or reducing your treatment based on your medical history and condition. "I've seen many of my patients for 10 to 20 years, so I'm making individual recommendations based on what I know about their history," says Dr. Roberts. Those usually include minimally severe issues like psoriasis, says Dr. Linkner.

If you're on a medication that's controlling a more severe underlying autoimmune disease, however, pausing medication is not a good idea, says Dr. Lytle. "I think most people are getting more benefit from the medication than they will be stopping the medication to prevent coronavirus," she says. "Plus, if you have an underlying autoimmune disease—like inflammatory colitis, for example—you're at a higher risk of getting sick if your symptoms return, and if you're well-controlled right now on your drugs, it's hard to get back on them later with the same clinical benefit."

The one thing all the doctors agreed on? Deciding whether or not to pause or reduce your immunosuppressive treatment is highly individual, and should be taken under consideration with your doctor, and should not be done on your own. If you’re worried, reach out to your provider and ask them to counsel you on the right choice for your health.

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.

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