COVID-19 IN RHEUMATOLOGY

People with systemic rheumatic diseases (SRDs) like rheumatoid arthritis, lupus, scleroderma, spondyloarthritis and other connective tissue disorders may be more susceptible to COVID-19 infection, and to more severe manifestations of disease. This could be related to the disease itself, associated comorbidities and/or the medications used to treat these conditions, particularly immunosuppressive treatments. There is limited data to support this supposition however as the disease develops we will have a better understanding of the impact on people with rheumatic diseases.Up till now, risk factors for severe coronavirus disease presentations include older age (>65 years); pregnant females; hypertension; diabetes; coronary artery disease and underlying chronic lung disease.

There is a heightened anxiety surrounding the use of immunosuppressive treatments, including conventional DMARDs, but particularly biologics and targeted synthetic agents. Currently, there is insufficient data to provide definitive advice for changes in medication. We can however extrapolate from evidence related to the management of infections in patients with SRDs:-

• • Patients who do not present with symptoms of COVID-19 and who have not come into close contact with a PUI (see definitions above [2]) should continue their chronic medication, including immunosuppressive therapies like biologics.
  • Patients who are well, but where there has been close contact with a COVID-19 positive person, we suggest testing despite deviation from NICD guidelines (if uncertain – contact NICD hotline 0800 029 999), particularly in those patients who fulfill any one of the previously defined high risk factors. We would suggest:-
    1. Consider limiting use of anti-inflammatories, such as NSAIDs and prednisone at doses >5mg/day unless absolutely necessary. If patients are already on prednisone, they should be advised not to stop suddenly.
    2. If a patient is taking conventional DMARDs such as methotrexate, chloroquine, salazopyrine or leflunomide, they should be advised to continue their treatment unless there is a high index of suspicion for infection. This should be a joint decision between doctor and patient, particularly if the disease is quiescent, where one might consider interrupting therapy while a potential risk exists. Chloroquine may be continued.
    3. If a patient tests positive for COVID-19 or has symptoms of possible COVID-19 (awaiting results), one should discontinue biologic and targeted synthetic DMARDs based on standard practice for infections in these therapeutic users. The decision to stop conventional DMARDs should be a joint decision between doctor and patient, taking into consideration the severity of the disease, presence of risk factors for poor COVID-19 outcomes and the activity of the underlying rheumatic condition. Chloroquine may be continued. If a patient is on prednisone, this should not be abruptly stopped for fear of worsening the infection; one should rather attempt to wean to lower doses if possible. Treatment should only be reinstituted once the infection is controlled and the patient is better, and only after consultation with the treating rheumatologist.
  • Despite the postulated risk of ACE-inhibitors and ARBs worsening COVID-19, international cardiology guidelines advise against stopping these treatments, as there is currently no conclusive evidence to support this hypothesis.
  • A note on steroids: The latest NICD guidelines throws caution on the routine use of systemic corticosteroids for treatment of COVID-19, unless indicated for another reason. This is based on lack of evidence to suggest benefit, and potential to harm. This does not imply that patients or doctors should discontinue steroids due to a fear of worsening COVID infection.
    • Some additional considerations:-
      • Patients who have been on long-term corticosteroid therapy should be advised not to abruptly discontinue their treatment. Sudden stopping could result in adrenal crisis which could mimic SIRS or septic shock and confound presentations of possible or confirmed COVID-19.
      • We suggest that rheumatic patients on long-term corticosteroids who develop moderate to severe COVID-19 infection; or mild disease with risk factors for severe disease (see NICD for definitions); receive stress doses of corticosteroids i.e. hydrocortisone 100mg 8 hourly to prevent addisonian crisis.
  • Regarding ACE inhibitors (ACEi) and Angiotesin receptor blockers (ARBs)
    • Despite the postulated risk of ACE-inhibitors and ARBs worsening COVID-19, international cardiology guidelines advise against stopping these treatments, as there is currently no conclusive evidence to support this hypothesis. Discontinuing or switching may be unnecessarily deleterious to patients.
    • Local guidelines from the NICD has since stated clearly that pending further evidence, it is not recommended to switch patients off ACEi or ARBs unless there are other medical reasons to do so.
  • A note on NSAIDs: Guidance regarding the use of NSAIDs in COVID-19 disease has been extremely ambiguous. There is no conclusive evidence to suggest that NSAIDs worsen COVID-19 outcomes (refer to FDA and EMA statement on NSAIDs).
    • Nonetheless, in line with our NICD guidelines, where short-term fever or pain relief is required, it may be prudent to avoid this class of agents where possible.
    • Most importantly for our patients, especially spondyloarthritis patients, where NSAIDs form part of their chronic treatment, evidence is not definitive enough to recommend discontinuation.

There are as yet no specific therapies approved for the treatment of COVID-19. Mild disease presentations should be treated symptomatically. Severe disease management centres upon cardiorespiratory support. Some experimental treatment regimens for severe disease presentations showing good results include chloroquine, ritonavir or lopinavir and tocilizumab, often in combination.AS per the recently updated NICD guidelines – Chloroquine at doses of 10mg/kg base for 2 days then 5mg/kg base for 1 day, can be considered for severe disease or mild disease with risk factors. This treatment regimen however is not fully validated and may be subject to change as new data emerges.

Refer to the definitions of PUI and close contact. If one meets the criteria, one should follow the procedures for testing and quarantine as stipulated by the NICD. Contact the NICD or your infectious diseases department if in any doubt.We advise to prevent this potential situation by following the suggestions provided earlier (4.1 and 4.2). We also advise ensuring meticulous infection prevention and control to avoid being a PUI.

Yes. It is advisable for all patients to get their seasonal influenza vaccine and pneumococcal vaccines as indicated by their disease and therapies. This will avoid secondary infections which may mask or worsen COVID-19 disease.

I would reinforce the importance of hand hygiene, general hygiene, limiting human contact and social distancing practices, especially around patients that are ill. Education is key. Please utilize the patient resources listed under section 3 above.