Rheumatologists Offer First COVID-19 Guidance for Rheumatoid Arthritis Treatment, Despite Limited Data

The American College of Rheumatology releases preliminary advice for doctors treating people with rheumatic disease during the coronavirus crisis, urging patients work with doctors.

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A task force issued advice for people with rheumatoid arthritis and the doctors who treat them.iStock; Everyday Health

Recognizing that people with rheumatoid arthritis (RA) and other rheumatic diseases have an added layer of uncertainty surrounding COVID-19, the American College of Rheumatology (ACR) recently convened a panel of experts.

This North American task force, made up of more than a dozen rheumatologists and infectious disease experts, considered various recommendations to offer physicians of people with rheumatic disease. This includes those who have no exposure to the novel coronavirus, who do have exposure to it, and who have active symptoms of COVID-19.

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There Are Special Considerations for People With RA, Other Rheumatic Disease

Having a disease such as rheumatoid arthritis in and of itself does not seem to put you at greater risk of poor coronavirus outcomes. However, being on immunosuppressant medication, being older, or having common comorbidities like heart disease adds to the complexity for patients, says Ellen M. Gravallese, MD, chief of rheumatology, inflammation, and immunity at Brigham and Women’s Hospital in Boston and president of the ACR.

“We felt it was important to convene a task force with a variety of expertise to look at the literature, even though it is limited,” Dr. Gravallese says.

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There’s Not Enough COVID-19 Evidence to Be Certain

COVID-19 is a new disease, and to date, not much is known about how it specifically affects people with rheumatoid arthritis, Gravallese says.

For this reason, the ACR considers their recommendations early treatment guidance, which may change, perhaps significantly, as more evidence becomes available. And, the experts stress, the advice is not intended to replace an individualized plan from your doctor, who knows your health history and other risk factors.

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What Is High Consensus in Respect to Treatment Guidance?

Formal guidelines issued by medical organizations around any number of issues generally categorize their findings based on the quality of scientific evidence that supports them. In the case of coronavirus for people with RA, though, such high-quality evidence does not yet exist. Therefore, the panel determined their recommendations based on how much agreement the members of the task force had for each idea.

A more detailed version of this guidance is expected to be published in a medical journal within the next month or so.

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The Primary Advice for People With Rheumatic Disease: Stay on Your Meds

The overall consensus of the panel is that people with RA or other rheumatic disease who are not exposed or stricken with COVID-19 should stay on the medications that are currently working for them.

Panel members agreed that people with RA whose disease has been stabilized should continue to take prescribed medications, including these:

In some instances, it can be difficult for people with RA to get HCQ or CQ because they are currently being touted as a treatment for coronavirus, even though more research is needed. For those who cannot get the drug, your doctor can switch you to a different conventional synthetic disease-modifying antirheumatic drug (DMARD), the panel says.

If Rheumatic Disease Is New or Flaring

People newly diagnosed with RA or those with active inflammation, and who don’t have coronavirus exposure, should largely be treated as they would have been before the pandemic.

Glucocorticoids or NSAIDs can be started or changed as needed, as can DMARDs or biologics.

“We want people to treat their rheumatic disease,” Gravallese says, noting that uncontrolled inflammation has negative consequences for the body.

The panel indicated some uncertainty about JAK inhibitors. These drugs can block a pathway important for a response to viruses, Gravallese explains. “We don’t know if that’s going to be a problem with COVID-19, but that’s why the caution” in the guidance, she says.

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Consider Telehealth to Consult Your Doctor

To encourage people to practice physical distancing as much as possible, the task force suggests that patients optimize their use of telehealth if their physician’s office offers it.

Your doctor might also allow you to reduce the frequency of routine lab monitoring.

And if you and your doctor agree, stretching out the time between doses of intravenous medications may be advisable as a way to limit possible coronavirus exposure in a medical setting. Still, if you need to stay on your original infusion schedule to control your RA, you shouldn’t worry, Gravallese says, noting that centers are following careful disinfecting and social distancing practices.

If You’ve Been Exposed to Coronavirus

People who have been exposed to someone with the coronavirus may not know if they will get the disease for several weeks.

During that time, the panel recommends that HCQ, SSZ, and NSAIDs be continued, and in select circumstances in consultation with your doctor, IL-6 inhibitors may also.

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However, the panel recommends that immunosuppressants, non-IL-6 biologics, and JAK inhibitors be stopped temporarily, until you either get a negative COVID-19 test result or pass two weeks without symptoms.

“If you are on an immunosuppressive agent, you might not be able to fight off the disease. We felt any risk of coming off medication quickly is outweighed by the risk of being on them at that point,” Gravallese says.

Glucocorticoids, however, should not be stopped abruptly.

And the task force was uncertain about whether patients should avoid methotrexate or leflunomide during this time.

Once Diagnosed with COVID-19

If you get a positive coronavirus test or are certain you have the disease, changes should be made to your RA medications. However, members of the task force were not able to come to as much consensus, since good evidence in people with RA who have COVID-19 does not yet exist.

Nonetheless, the panel agreed that people on SSZ, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should stop taking these meds once they develop COVID-19.

HCQ and CQ may be continued, and in select circumstances, IL-6 inhibitors can be as well.

The panel stated that people with severe respiratory symptoms from the coronavirus should stop taking NSAIDs, but they were less certain about NSAIDs for others.

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Knowing There’s Guidance May Help Soothe Patients

People with RA, especially those on immunosuppressive drugs, admit they’re worried about how the virus might specifically affect them.

“There’s a lot of concern on the social media boards, especially with all the misinformation out there,” says Shannan O’Hara-Levi, an arthritis patient advocate who has RA and lives on Staten Island, New York.

O’Hara-Levi herself takes Enbrel (etanercept), and her husband is a police officer at extra risk of exposure to the coronavirus, so she herself has been apprehensive, too.

She’s glad the ACR has taken up the task of offering expert guidance. “They are a trusted source, so I’m happy to have this from them,” she says. Plus, knowing that her rheumatologist will have access to this information when making medical decisions with her offers an added layer of reassurance, she says.

Basic Hygiene Is the Most Important Measure

The task force emphasized that the best way for people with RA to avoid COVID-19 is the same way everyone should avoid it: by taking steps to minimize contact with people who might be infected.

This includes washing your hands regularly, avoiding touching your face, keeping a physical distance of 6 feet from others, and wearing a cloth facial covering in public.