Pharmacist Optimization of Bowel Preparations in the Critically Ill: The Poopy Study

INTRODUCTION: Critically ill patients undergo stressful states while in the intensive care unit (ICU) and thus have alterations in bowel habits, including constipation in 20- 83% and diarrhea in 3.3-78%. Patients frequently receive opioid analgesics to assist with sedation and pain control. Appropriate bowel management is essential to prevent further complications during the ICU stay. The purpose of this study is to examine the various bowel preparations (BP) used in ICU patients, time to first bowel movement after initiation or escalation of a BP, and reason for BP discontinuation. METHOD(S): This multi-center, multi-ICU, retrospective observational review evaluated tele-critical care pharmacist interventions documenting initiation or change in BP from January 2, 2021 to June 30, 2021. Interventions were excluded if the BP was renewed, duplicate therapy and/or change in formulation. Descriptive statistics were used to describe the data. RESULT(S): One hundred ninety-six unique patients had at least one BP intervention. Baseline characteristics include 55% male, average age of 64 years, a BMI of 32.9, and 66% COVID-19 positive. One hundred seventy-four unique patients had a BP initiated or added on to current therapy, while 62 unique patients had current therapy escalated. The median days to first bowel movement after initiation or addition of a BP was 5.4 days (range 0-19). Ninety-eight percent of patients received an opioid, either continuous infusion or oral, and 90% received enteral nutrition. Docusate and senna were the primary BPs added when a regimen was initiated. Then, polyethylene glycol was added as the next BP. Lactulose and bisacodyl suppositories were added as 4th line treatment if the patient had not experienced a bowel movement. Methylnaltrexone was used in 1 patient. Fifty-two unique patients had one or more medications from their current bowel regimen discontinued due increased stool output, diarrhea, multiple bowel movements within last 24 hours, or the patient refusing the medication. CONCLUSION(S): Initiation of BPs in critically ill patients, especially if receiving an opiate, may be delayed. Bowel regimen initiation should be considered when the patient is placed on opiate therapy. If the patient continues to have a delayed response to therapy, prompt escalation of therapy may be warranted.

Tele-Critical Care Pharmacist Interventions before and after an Emergency Prescribing Protocol

INTRODUCTION: Prior to the COVID-19 pandemic, telecritical care (TCC) pharmacists evaluated patients at multiple ICUs across this healthcare system using clinical decision support (CDSS) alerts for abnormal laboratory values. To increase provider capacity for higher acuity activities, a critical care pharmacist emergency protocol (CCPEP) was enacted, allowing TCC pharmacists to manage therapy in multiple domains. The purpose of this review was to characterize TCC pharmacist interventions prior to and after CCPEP implementation. METHOD(S): This multi-center, multi-ICU, retrospective observational quality improvement project evaluated TCC pharmacist interventions documented from September 1, 2019, through November 30, 2019 (pre-CCPEP) compared with September 1, 2020, through November 30, 2020 (post- CCPEP). Descriptive statistics were reported. RESULT(S): In the pre-CCPEP period, 1448 interventions were performed in 655 unique patients (mean 2.2 interventions/patient) across 10 ICUs as compared to 2115 interventions in 861 unique patients (mean 2.5 interventions/ patient) across 8 ICUs post-CCPEP, a 46.1% increase in the total number of interventions. Glycemic control interventions decreased from 38.7% to 26.4% of interventions, while medication management interventions increased from 28.3% to 41.3% from the pre- to post-CCPEP period, respectively. In medication management, sedation and analgesia interventions increased from 57 (13.9%) in the pre- CCPEP period to 251 (28.8%) in the post-CCPEP period, cardiovascular medication recommendations decreased from 60 (14.6%) to 50 (5.7%), and gastrointestinal agent recommendations increased from 8 (2%) to 68 (7.8%). Electrolyte management, venous thromboembolism prophylaxis, and stress ulcer prophylaxis intervention rates remained similar. CONCLUSION(S): Implementation of a CCPEP facilitated more interventions by TCC pharmacists than CDSS review alone, especially in general medication management. Increased sedation and analgesia interventions in the post-CCPEP period suggest enhanced complexity of recommendations. More patients were intervened on in the post-CCPEP period with more interventions per patient, which may be due to increased census and acuity in addition to the CCPEP. Future directions include pursuing clinical pharmacist practitioner status in the TCC space.

Vitamin D to prevent COVID-19 or other acute respiratory infections: phase 3 randomised controlled trial (CORONAVIT)

IntroductionVitamin D deficiency associates with susceptibility to COVID-19 and other acute respiratory infections (ARI).ObjectiveTo determine whether a ‘test-and-treat’ approach to vitamin D replacement in the general population reduces incidence of COVID-19 or other ARI.MethodsWe randomly assigned 6200 UK adults to receive an offer of a postal vitamin D test with postal provision of a 6-month supply of higher-dose vitamin D (3200 IU/d, n=1550) or lower-dose vitamin D (800 IU/d, n=1550) to those with 25(OH)D <75 nmol/L vs no offer of vitamin D testing or supplementation (n=3100). The primary outcome was the proportion of participants experiencing at least one test- or doctor-confirmed ARI of any cause at 6 months. Secondary outcomes included incidence of COVID-19.Results2958/3100 adults randomised to intervention accepted the offer of testing, of whom 2690 (90.9%) had 25(OH)D <75 nmol/L and received vitamin D supplements (1356 higher-dose, 1334 lower-dose). 72 adults in the higher-dose offer group, 86 in the lower-dose offer group and 132 in the no offer group experienced at least one ARI of any cause during follow-up (odds ratio [OR] for higher-dose vs. no offer 1.05, 95% CI 0.78–1.40;OR for lower-dose vs. no offer 1.27, 0.96–1.68). COVID-19 was diagnosed in 32 adults in the higher-dose offer group, 48 in the lower-dose offer group and 68 in the no offer group (OR for higher-dose vs. no offer 0.90, 0.59–1.37;OR for lower-dose vs. no offer 1.37, 0.94–1.99).ConclusionsIn adults with a high baseline prevalence of vitamin D insufficiency, a test-and-treat approach to vitamin D replacement did not reduce risk of all-cause ARI or COVID-19.Please refer to page A209 for declarations of interest related to this .

FXR INHIBITION AS A NEW STRATEGY AGAINST COVID19 T Brevini1, M Maes2, GJ Webb3, CD Fuchs4, G Buescher5

Introduction: Vaccines revolutionised the management of COVID19. Nevertheless, they lack efficacy in high-risk or vulnerable groups (e.g., immunosuppressed patients), who may not mount an appropriate immune response. Monoclonal antibodies represent the gold-standard agents for such cases;but they are limited by availability, need for parenteral administration and the risk for viral escape because of spike protein mutations. Therefore, there is a pressing need for new prophylactic agents less prone to resistance.The viral receptor ACE2 represents an ideal target as it is essential for viral entry and transmission and because being a host protein it is not affected by viral mutations. However, the regulation of ACE2 remains elusive, due to the lack of appropriatein vitromodels. Cholangiocytes show one of the highest ACE2 expression levels in the body, representing an ideal platform for these studies. Here, we use cholangiocyte organoids as proof-of-principleto identify that the bile acid receptor FXR regulates ACE2 expression and SARS-CoV-2 infectionin vitro. We validate these findings in lung and gut organoids, animal models, human organs perfusedex situand patient cohorts. Aims & Methods: 1. Identify pathways controlling the transcriptional regulation of ACE2 2. Identify drugs modulating these pathways as novel prophylactic and therapeutic agents for COVID19. Organoids were propagated using established protocols. Marker expression was assessed using single-cell RNA sequencing, QPCR, and immunofluorescence. FXR binding on DNA was assessed with chromatin immunoprecipitation. SARS-CoV-2 was isolated from bronchoalveolar lavage of a COVID19 patient. Syrian golden hamsters were infected via direct inoculation and QPCR on oral swab, nasal turbinate and lung samples was used to measure SARS-CoV-2 infection. Human livers and lungs not used for transplantation were perfusedex-situusing normothermic perfusion. Nasopharyngeal swabs were used to measure ACE2 expression in nasal epithelial cells of healthy individuals taking UDCA at the standard therapeutic dose of 15 mg/kg/day. Patient registry data were compared using propensity score matching for sex, age, diabetes, NAFLD and Child- Turcotte-Pugh score. Result(s): We identified that FXR directly regulates ACE2 transcription in cholangiocyte organoids, while FXR inhibition with the approved drug ursodeoxycholic acid (UDCA), reduced ACE2 expression and SARS-CoV-2 infectionin vitro. We confirmed this mechanism in organoids from other COVID19-affected tissues, including the respiratory and intestinal systems. We validated our findingsin vivoin Syrian golden hamsters, showing that treatment with UDCA downregulates ACE2 and prevents SARS-CoV-2 infection. We confirmed that UDCA reduces ACE2 and SARS-CoV-2 infection in human lungs and livers perfusedex-situ. We performed a clinical study demonstrating that UDCA lowers ACE2 levels in the nasal epithelium of 6 healthy volunteers. Finally, we identified a correlation between UDCA and better clinical outcomes (hospitalisation, ICU admission and death) in COVID19 patients receiving UDCA for cholestatic diseases using the COVID-Hep and SECURELiver registry data. Conclusion(s): We identified FXR as a novel regulator of ACE2 expression. Using a bench-to-bedside approach combining in vitroand in vivomodels, exsituperfused human organs and clinical data we showed that FXR inhibition prevents or reduces SARS-CoV-2 infection and identified UDCA as an approved, cost-effective drug which could be repurposed for COVID19, paving the road for future clinical trials.

The City is an Ecosystem: Sustainable Education, Policy, and Practice

The City is an Ecosystem maps an interdisciplinary, community-engaged response to the great ecological crises of our time-climate change, biodiversity loss, and social inequality-which pose particular challenges for cities, where more than half the world's population currently live. Across more than twenty chapters, the three parts of the book cover historical and scientific perspectives on the city as an ecosystem;human rights to the city in relation to urban sustainability;and the city as a sustainability classroom at all educational levels inside and outside formal classroom spaces. It argues that such efforts must be interdisciplinary and widespread to ensure an informed public and educated new generation are equipped to face an uncertain future, particularly relevant in the post-COVID-19 world. Gathering multiple interdisciplinary and community-engaged perspectives on these environmental crises, with contemporary and historical case study discussions, this timely volume cuts across the humanities and social and health sciences, and will be of interest to policymakers, urban ecologists, activists, built environment professionals, educators, and advanced students concerned with the future of our cities. © Jerry Dantzic/Jerry Dantzic Archives. All rights reserved.

CHARACTERISTICS ASSOCIATED with POOR COVID-19 OUTCOMES in PEOPLE with PSORIASIS and SPONDYLOARTHRITIS: DATA from the COVID-19 PSOPROTECT and GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRIES

Background: Some factors associated with severe COVID-19 outcomes have been identifed in patients with psoriasis (PsO) and infammatory/autoimmune rheumatic diseases, namely older age, male sex, comorbidity burden, higher disease activity, and certain medications such as rituximab. However, information about specifcities of patients with PsO, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), including disease modifying anti-rheumatic drugs (DMARDs) specifcally licensed for these conditions, such as IL-17 inhibitors (IL-17i), IL-23/IL-12 + 23 inhibitors (IL-23/IL-12 + 23i), and apremilast, is lacking. Objectives: To determine characteristics associated with severe COVID-19 outcomes in people with PsO, PsA and axSpA. Methods: This study was a pooled analysis of data from two physician-reported registries: the Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection (PsoProtect), comprising patients with PsO/PsA, and the COVID-19 Global Rheumatology Alliance (GRA) registry, comprising patients with PsA/axSpA. Data from the beginning of the pandemic up to 25 October, 2021 were included. An ordinal severity outcome was defned as: 1) not hospitalised, 2) hospitalised without death, and 3) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics (age, sex, time period of infection), comorbidities (hypertension, other cardiovascular disease [CVD], chronic obstructive lung disease [COPD], asthma, other chronic lung disease, chronic kidney disease, cancer, smoking, obesity, diabetes mellitus [DM]), rheumatic/skin disease (PsO, PsA, axSpA), physician-reported disease activity, and medication exposure (methotrexate, lefunomide, sulfasalazine, TNFi, IL17i, IL-23/IL-12 + 23i, Janus kinase inhibitors (JAKi), apremilast, glucocorticoids [GC] and NSAIDs). Age-adjustment was performed employing four-knot restricted cubic splines. Country-adjustment was performed using random effects. Results: A total of 5008 individuals with PsO (n=921), PsA (n=2263) and axSpA (n=1824) were included. Mean age was 50 years (SD 13.5) and 51.8% were male. Hospitalisation (without death) was observed in 14.6% of cases and 1.8% died. In the multivariable model, the following variables were associated with severe COVID-19 outcomes: older age (Figure 1), male sex (OR 1.53, 95%CI 1.29-1.82), CVD (hypertension alone: 1.26, 1.02-1.56;other CVD alone: 1.89, 1.22-2.94;vs no hypertension and no other CVD), COPD or asthma (1.75, 1.32-2.32), other lung disease (2.56, 1.66-3.97), chronic kidney disease (2.32, 1.50-3.59), obesity and DM (obesity alone: 1.36, 1.07-1.71;DM alone: 1.85, 1.39-2.47;obesity and DM: 1.89, 1.34-2.67;vs no obesity and no DM), higher disease activity and GC intake (remission/low disease activity and GC intake: 1.96, 1.36-2.82;moderate/severe disease activity and no GC intake: 1.35, 1.05-1.72;moderate/severe disease activity and GC intake 2.30, 1.41-3.74;vs remission/low disease activity and no GC intake). Conversely, the following variables were associated with less severe COVID-19 outcomes: time period after 15 June 2020 (16 June 2020-31 December 2020: 0.42, 0.34-0.51;1 January 2021 onwards: 0.52, 0.41-0.67;vs time period until 15 June 2020), a diagnosis of PsO (without arthritis) (0.49, 0.37-0.65;vs PsA), and exposure to TNFi (0.58, 0.45-0.75;vs no DMARDs), IL17i (0.63, 0.45-0.88;vs no DMARDs), IL-23/IL-12 + 23i (0.68, 0.46-0.997;vs no DMARDs) and NSAIDs (0.77, 0.60-0.98;vs no NSAIDs). Conclusion: More severe COVID-19 outcomes in PsO, PsA and axSpA are largely driven by demographic factors (age, sex), comorbidities, and active disease. None of the DMARDs typically used in PsO, PsA and axSpA, were associated with severe COVID-19 outcomes, including IL-17i, IL-23/IL-12 + 23i, JAKi and apremilast.

Medical management of severe obstructive sleep apnoea in two cases during the coronavirus disease 2019 pandemic.

OBJECTIVE: Severe paediatric obstructive sleep apnoea in typically developing children with adenotonsillar hypertrophy is primarily managed surgically. Non-emergency ENT surgery was paused early in the coronavirus disease 2019 pandemic and children were offered medical management for obstructive sleep apnoea. METHODS: A service evaluation was performed to assess the impact of continuous positive airway pressure alongside medical management for severe obstructive sleep apnoea. RESULTS: Over 5 months during 2020, in a tertiary care setting, two children (one boy and one girl), aged 2.7 years and 4.1 years, were offered continuous positive airway pressure and medical treatments for severe obstructive sleep apnoea whilst surgery was paused during the coronavirus disease 2019 pandemic. Both children failed to establish continuous positive airway pressure therapy because of ongoing disturbed sleep on ventilation, and they proceeded to adenotonsillectomy. Sleep-Related Breathing Disorder scale scores improved following surgical intervention. CONCLUSION: Continuous positive airway pressure therapy is poorly tolerated in children with severe obstructive sleep apnoea secondary to adenotonsillar hypertrophy. Surgery remains the most appropriate treatment.

Tele-critical care medication management interventions via an emergency pharmacy protocol

INTRODUCTION: As a result of the COVID-19 pandemic, this healthcare system enacted a critical care pharmacist emergency prescribing protocol allowing pharmacists to manage therapy in multiple domains. Interventions performed by tele-critical care (TCC) pharmacists across 8 ICUs were categorized into venous thromboembolism prophylaxis, glucose management, electrolyte management, stress ulcer prophylaxis, and general medication management. The purpose of this study was to further characterize TCC pharmacist medication management interventions. METHODS: This multi-center, multi-ICU, retrospective observational review evaluated TCC pharmacist interventions categorized as medication management for adult, ICU-status patients documented from January 4th, 2021, to June 30th, 2021. Descriptive statistics were reported. RESULTS: A total of 2331 medication management interventions were documented for 700 unique patients (mean 3.3 interventions per patient). The average age was 63.4 years and 54.7% of patients were male. An average of 388.5 interventions were performed per month. The most common activities included discontinuing medications (39.2%), adding medications (15.6%), order clarification (11.8 %), dose adjustment (7.7%), changing route/ formulation (5.7%), and laboratory management (5.7%). Sedation medications were the most commonly involved (25.2%) followed by bowel regimens (14.2%), vasopressors (8.2%), and antibiotics (5.8%). Updating sedation score goals (45.5%) and discontinuing orders (45.3%) accounted for the majority of sedation interventions. Other interventions included neuromuscular blockade management, drug shortage management, adding corneal abrasion and ventilator-associated pneumonia prophylaxis, and home medication management. Four of the 8 facilities covered accounted for 83.6% of interventions performed, with one facility accounting for 25.2% of interventions. CONCLUSION: An emergency prescribing protocol allowed TCC pharmacists to proactively optimize pharmacotherapy across multiple categories of medication management interventions. This data will be used to support clinical pharmacist practitioner status in the TCC setting.

Tele-critical care (TCC) pharmacy first shift compared to second shift tcc pharmacist interventions

INTRODUCTION: Tele-critical care (TCC) use expanded dramatically during COVID19 pandemic. As a result of anticipated surges in ICU capacity and increased patient acuity secondary to the pandemic, this healthcare system enacted a critical care pharmacist emergency protocol (CCPEP) allowing critical care pharmacists to manage therapy in multiple domains, ultimately increasing provider bandwidth for additional patient review and higher acuity activities. The purpose of this study was to characterize TCC pharmacist interventions made using the CCPEP comparing first shift versus second shift. METHODS: This multi-center, multi-ICU, retrospective observational review evaluated TCC pharmacist interventions documented from September 1, 2020 through November 30, 2020 for first shift vs. second shift. Prospective chart review occurred for each ICU status patient on first shift, while patient review on second shift was in response to alerts or new admissions. Descriptive statistics were reported. RESULTS: A total of 2152 (1266 on 1st shift and 886 on 2nd shift) documented pharmacist interventions were made during the 3-month period using the critical care pharmacist emergency protocol for 861 unique patients (52.1% on 1st shift). An average of 2.8 interventions per patient were made on 1st shift and 2.1 interventions per patient on 2nd shift. In addition to interventions made for glucose, electrolyte management, stress ulcer prophylaxis and venous thromboembolism prophylaxis, the most common interventions (873/2150, 40%) were categorized as medication management. First shift had 588 interventions versus 2nd shift with 285 interventions. Examples of these interventions overall include sedation, analgesia, and paralytic management (35%);dose adjustments (13%);vasopressor management (4%);fluid management (3%) and clustering care for patients (3%). Adverse drug events avoided totaled 103, with 84% of interventions occurring on 2nd shift. CONCLUSION: Proactive review of patients led to more medication management interventions through use of the CCPEP. The use of the CCPEP expanded pharmacist practice during the COVID-19 pandemic to practice at the top of their license. Future directions include using this data as justification for clinical pharmacist practitioner status and additional critical care pharmacist positions.

Categorization of full-time tele-critical care pharmacist interventions based on shift

INTRODUCTION: Due to an anticipated patient surge related to the COVID-19 pandemic, a critical care pharmacist emergency prescribing protocol (EPP) was enacted allowing pharmacists to manage therapy in multiple domains. As a result of the EPP and an identified need for more proactive medication management, fulltime tele-critical care (TCC) pharmacists transitioned from working second shift to first shift hours, facilitating collaboration with multiple bedside providers in intensive care units (ICU) at 8 facilities. The purpose of this study was to categorize pharmacists' interventions completed on first versus second shift. METHODS: This multi-center, multi-ICU, retrospective observational review evaluated fulltime TCC pharmacist interventions documented from September 1, 2020 to November 30, 2020 (second shift) compared with February 8, 2021 to May 7, 2021 (first shift). While clinical decision support alerts triggered the majority of chart reviews on second shift, prospective chart reviews of select ICU patients were performed on first shift. Descriptive statistics were reported. RESULTS: On second shift, 710 interventions were performed in 395 patients;while on first shift, 1024 interventions were performed in 357 patients. Glycemic control interventions accounted for 43% of second shift interventions compared to 19.5% on first shift. Medication management interventions comprised 30% of second shift activities in contrast with 52.2% on first shift. As the TCC pharmacists cover multiple facilities across the system, a change in facility focus occurred as well. During second shift, one facility totaled 35% of all interventions. With the change to dayshift, two other facilities became the primary focus at 34% and 21.7%, respectively. CONCLUSIONS: By changing from a reactive or alert-driven model to prospective chart review utilizing EPP, a change in intervention type occurred. Medication management, which included sedation management, was a greater focus on first shift owing to greater collaboration with bedside providers. This information will be shared with critical care and pharmacy leadership to continue advancing care and for eventual justification of clinical pharmacist practitioner status in the inpatient space.

Factors associated with hospitalization due to COVID-19 in patients with psoriasis: Insights from a global registry

Psoriasis is a common immune-mediated inflammatory skin disease with frequent multimorbidity, and immunosuppressants are the mainstay of treatment in moderate-to-severe disease. An understanding of the impact of COVID-19 on individuals with psoriasis and the effect of psoriasis therapies on the course of COVID-19 is urgently required to inform clinical decision-making. This study sought to characterize the clinical course of COVID-19 in patients with psoriasis and to identify factors associated with hospitalization. Clinicianreported cases of confirmed or suspected COVID-19 in psoriasis were collected via an international online registry. Multivariable-adjusted logistic regression identified factors associated with hospitalization. Patient risk-mitigating behaviours were characterized using an independent global selfreport registry. In total, 334 clinician-reported cases (median age 50 years, 62% male, median body mass index 28 kg m-2, 85% white) from 22 countries [most frequently, the U.K. (35%), Italy (22%) and Spain (16%)] were available between 27 March and 20 June 2020. Altogether, 245 (73.3%) patients were receiving a biologic, 54 (16.2%) a nonbiologic and 31 (9.3%) no systemic treatment. Overall, 311 (93.1%) achieved a full recovery, 71 (21.2%) were hospitalized and nine (2.7%) died. Risk factors associated with hospitalization were older age [adjusted odds ratio (aOR) 1.71, 95% confidence interval (CI) 1.26-2.32], male sex (aOR 2.37, 95% CI 1.11-5.04) and nonwhite ethnicity (aOR 3.40, 95% CI 1.27-9.11), in addition to chronic lung disease (aOR 4.37, 95% CI 1.62-11.74) and hypertension (aOR 2.23, 95% CI 1.05-4.74). Reduced risk of hospitalization was associated with use of a biologic (aOR 0.42, 95% CI 0.18-0.98) vs. nonbiological systemic therapy. There was no difference in risk of hospitalization between classes of biologics. An independent selfreport psoriasis registry (1167 patients from 39 countries) suggested increased social isolation (76% vs. 66%;P < 0.05) but similar nonadherence to medication (18% vs 22%) in patients receiving biologics vs. nonbiological systemic treatments. In this international moderate-to-severe psoriasis case series, most patients fully recovered from COVID-19;older age, being male and being of nonwhite ethnicity increased risk of hospitalization. Use of biologics, when compared with nonbiological systemic therapies, was associated with reduced risk of hospitalization;however, this requires further study owing to potential selection bias and unmeasured confounding such as a difference in risk-mitigating behaviours.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey.

BACKGROUND: Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments. OBJECTIVES: We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation. METHODS: Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model. RESULTS: Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations. CONCLUSIONS: Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.