key: cord-322798-5r3kf9wa
authors: Freeman, Esther E.; McMahon, Devon E.
title: Creating Dermatology Guidelines for Covid-19: The Pitfalls of Applying Evidence Based Medicine to an Emerging Infectious Disease
date: 2020-04-09
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.04.002
sha: 
doc_id: 322798
cord_uid: 5r3kf9wa

nan

To the Editor: We recently co-authored a piece in the JAAD about modifications the American Academy of Dermatology (AAD) implemented to enhance the rigor of evidence-based clinical practice guidelines. 1 Although we believe this change will serve the AAD well in the future, we must be flexible about guideline generation during the coronavirus disease-2019 (Covid-19) outbreak. Like the WHO, the AAD already adopted a rapid advice guidelines protocol, but this process relies on evaluating a body of evidence, which does not yet exist for Covid-19.

To address this gap, the AAD established the Covid-19 taskforce, which published interim guidance within five days of establishment. Although this advice is essential, it is by necessity made on limited and rapidly evolving evidence, and must be tailored to individual patients. Issues include how to grade evidence from gray literature, risks and benefits of use of anecdotal experiences and indirect evidence, and harmonizing guidance simultaneously produced by other organizations.

The harms of potentially issuing incorrect guidance must be balanced with the ethical risks of issuing no guidance at all. 2 One example of this challenge is managing patients on immunosuppressives during Covid-19. A recent JAAD study examined the occurrence of upper respiratory infection (URI) for patients treated with various classes of biologic therapies for psoriasis, as a proxy for risk of Covid-19 infection while on a biologic. 3 While we commend the authors for compiling this data, there are several issues with indirect evidence: i) these trials compared biologics to placebo, ii) they were not powered for the outcome of URI, and iii) the similarity of Covid-19 to URI is unknown. Due in part to these concerns, the AAD Covid-19 taskforce published interim guidance that did not distinguish among biologic classes.

Dermatology societies are not struggling alone with creating interim guidelines. In cardiology, there has been concern over the use of angiotensin converting enzyme (ACE)-inhibitors due to an observational study that many patients with hypertension admitted for Covid-19 were on ACE-inhibitors. 4 In the face of uncertainty, societies including the American College of Cardiology took a stance to keep patients on ACE-inhibitors while they await more evidence. 5 When guidelines can no longer be based on the highest level of evidence, then indirect studies, gray literature, case-reports and expert consensus may be the only tools left in our arsenal. We need 3 guidance not just on biologics, but many topics, including scaling up teledermatology programs and managing patients with invasive skin cancers. These changes to dermatology guidelines do not exist in a vacuum; important ethical implications include patient outcomes such as missed melanomas and the loss of employment for practice staff. With so much uncertainty in our medical practice, guidance is needed now more than ever. We should acknowledge the shift from evidence based medicine to reliance on expert guidance, and appreciate the potential for guideline reversal. But in a time of rapidly changing evidence, we must be willing to take on these risks to guide with the goal of maintaining the highest standard of patient care.

Modernizing clinical practice guidelines for the American Academy of Dermatology

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

Should biologics for psoriasis be interrupted in the era of COVID-19?

Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?

Patients taking ACE-i and ARBs who contract COVID-19 should continue treatment, unless otherwise advised by their physician: Statement from the American Heart Association, the Heart Failure Society of America and the American College of Cardiology

The authors would like to acknowledge Dr. Benjamin Stoff for his advice regarding the ethics of clinical practice guideline generation, as well as Dr. George Hruza and Dr. Bruce Thiers for their comments on a preliminary draft of this manuscript.