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Immunosuppressive biologics not linked to higher risk of COVID-19 infection or mortality

11th January 2022

Immunosuppressive biologics have been found to be not linked to both a greater risk of COVID-19 infection or subsequent mortality

Immunosuppressive biologics are not associated with an increased risk of either infection with COVID-19 or a higher incidence of death according to the findings from a team from the Department of Dermatology, Massachusetts General Hospital, Boston, US.

Whether immunosuppressive biologics would heighten the risk of infection with COVID-19 seems, at least from some evidence, to be unfounded. Despite this, other work has revealed an increased risk of mortality among patients with rheumatic diseases prescribed non-biologic immunosuppressants such as azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus.

With a potential risk for viral reactivation of an underlying chronic viral infection during immunosuppressive therapy, some have questioned whether patients with psoriasis, for example, should be started on immunosuppressive biologics.

In the present analysis, the US team focused on adult patients (18 years and over) and given at least one prescription for a biologic between July 2019 and February 2020 at their hospital. They undertook a retrospective, matched cohort study and set the primary outcome as the risk of COVID-19 infection and the secondary outcome as subsequent mortality.

Using multivariable logistic regression, they calculated the odds ratio (OR) for a COVID-19 diagnosis between those prescribed immunosuppressant biologics and the control group and examined other potential factors associated with either infection or mortality.


A total of 7361 patients receiving immunosuppressant biologics were matched with 74,910 controls. The most common biologic agents were tumour necrosis factor inhibitors including adalimumab (28.4%), infliximab (15.6%) and etanercept (11.9%), CD20-directed antibodies including rituximab (15.6%) and interleukin-4A inhibitors such as dupilumab (8.6%).

Among the 7361 patients, the primary indication for the immunosuppressive biologics were mainly dermatological diseases such as psoriasis (27.3%) and atopic dermatitis (27.5%), although patients also received these drugs for rheumatoid arthritis (27.5%) and asthma (19.4%).

After adjustment for demographics and co-morbidities, overall, biologics were not associated with COVID-19 (OR = 0.88, 95% CI 0.71-1.09, p = 0.25). Patients prescribed tumour necrosis factor inhibitors were less likely to be diagnosed with COVID-19 compared to matched controls (OR = 0.69, 95% CI 0.48 – 0.98, p = 0.05). Similarly, those treated with dupilumab also had lower risk of being diagnosed, but this difference was non-significant (OR = 0.38, 95% CI 0.12 – 1.18, p = 0.10).

For the secondary outcome of mortality, after adjustment, the difference in rates between the those taking immunosuppressive biologics and controls were non-significant (OR = 1.13, 95% CI 0.57 – 2.76, p = 0.57).

In their regression analysis, the odds of mortality was significantly associated only with age (OR = 1.06, 95% CI 1.04 – 1.09, p < 0.001) with female patients having a much lower odds of mortality (OR = 0.53, 95% CI 0.34 – 0.83, p < 0.01).

They concluded that dermatologists and patients should prioritise the recognised risk factors for infection when making therapy decisions, given how immunosuppressive biologics do not appear to be a risk factor for either infection or mortality.


Pahalyants V et al. Immunosuppressive biologics did not increase the risk of COVID-19 or subsequent mortality: A retrospective matched cohort study from Massachusetts J Am Acad Dermatol 2021.