ACR Develops Clinical Guidance for the Management of Rheumatic Diseases During the COVID-19 Pandemic

doctor wearing face mask meeting with patient
The American College of Rheumatology developed clinical guidance for rheumatology providers for the management of rheumatic diseases during the COVID-19 pandemic.

The American College of Rheumatology (ACR) has developed clinical guidance for rheumatology providers for the management of rheumatic diseases during the coronavirus disease 2019 (COVID-19) pandemic. The full report is published on the ACR website.

Because the treatment of rheumatic diseases is highly specific, the ACR added that the guidance must not replace clinical judgment, instead, care should be provided to patients on a case-by-case basis, as part of a shared decision-making process.

A task force, including 10 rheumatologists and 4 infectious disease specialists, was put together by the ACR; using the modified Delphi process, the panelists created consensus-based clinical guidelines comprising high- and medium-level recommendations.

ACR Guidance for the Management of Rheumatic Diseases

General Guidance

  • Although there may be an association between general risk factors (eg, age and comorbidity) and risk for poor outcomes from COVID-19, the ACR panel recommended that all patients be counseled on general preventive measures, including social distancing and hand hygiene.
  • To reduce potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it may be reasonable for rheumatology providers to take specific measures such as decreasing the frequency of laboratory monitoring, exploring the use of telehealth options, and increasing dosing intervals between intravenous medications.
  • Regardless of exposure to or infection with SARS-CoV-2, if indicated, glucocorticoids are recommended in the management of rheumatic diseases at the lowest possible dose that will continue to control symptoms; these medications should be not be abruptly stopped.
  • The ACR panel recommended that angiotensin converting enzyme ACE inhibitors or angiotensin receptor blockers be initiated or continued in full doses, if indicated.

Treatment of Rheumatic Diseases

Newly Diagnosed/Active Rheumatic Diseases Without SARS-CoV-2 Exposure/Infection

  • For patients with well-controlled disease and receiving hydroxychloroquine/chloroquine (HCQ/CQ) or interleukin (IL)-6, rheumatology providers must continue treatment with the respective disease-modifying antirheumatic drug (DMARD); however, if access to the medications is limited, switching to a different conventional synthetic DMARD (csDMARD) or biologic, respectively, should be considered. Patients with newly diagnosed Sjögren syndrome should not be started on HCQ/CQ because of the lack of data on the efficacy of these drugs.
  • The ACR recommended switching to biologics for patients with moderate to high disease activity despite treatment with csDMARDs; however, there was uncertainty regarding the use of Janus kinase (JAK) inhibitors for these patients.
  • Treatment with csDMARDs may be started or switched for patients with active or newly diagnosed inflammatory arthritis.
  • Rheumatology providers may treat patients with low-dose glucocorticoids (equivalent to ≤10 mg prednisone) or nonsteroidal anti-inflammatory drugs (NSAIDs), if indicated; however, for patients with systemic inflammatory or organ-threatening diseases (eg, lupus nephritis or vasculitis), high-dose glucocorticoids or immunosuppressants may be initiated.

Ongoing Treatment of Stable Patients Without SARS-CoV-2 Exposure/Infection

  • The ACR recommended that patients with stable rheumatic diseases without exposure to or infection with SARS CoV-2 may continue to receive HCQ/CQ, sulfasalazine, methotrexate, leflunomide, immunosuppressants, biologics, JAK inhibitors, and NSAIDs.
  • Patients may continue to receive denosumab; to minimize healthcare encounters, dosing intervals may be extended, though not for longer than every 8 months.
  • Rheumatology providers are not recommended to reduce the dose of immunosuppressants for patients with a history of vital organ-threatening rheumatic diseases.

Ongoing Treatment of Stable Patients With SARS-CoV-2 Exposure Without Symptoms

  • Patients falling under this category may continue to receive HCQ, sulfasalazine, and NSAIDs; however, treatment with immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be temporarily stopped and restarted only after a negative COVID-19 test result or after being symptom-free for 2 weeks.
  • Although the ACR panel noted uncertainty regarding the cessation of methotrexate and leflunomide in this group of patients, they recommended the continuation of IL-6 inhibitors in certain circumstances, based on shared decision making.

Treatment of Rheumatic Disease With Suspected or Confirmed COVID-19

  • The panel suggested that rheumatology providers continue treatment with HCQ/CQ for patients with presumptive or documented COVID-19, regardless of severity; however, sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be at least temporarily stopped.
  • Treatment with NSAIDs should be stopped for patients with severe respiratory symptoms, but there was a low consensus from the panel on stopping NSAIDs for patients with less severe respiratory symptoms.
  • Rheumatology providers may continue to prescribe IL-6 inhibitors in certain circumstances, based on shared decision-making.

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Patients With Systemic Lupus Erythematosus (SLE)

  • Patients with newly diagnosed SLE should be initiated with full-dose HCQ/CQ, when available.
  • Pregnant women with SLE must continue to receive HCQ/CQ at the same dose, when available.
  • Treatment with belimumab may be started for selective patients with SLE.


American College of Rheumatology. COVID-19 clinical guidance for patients with rheumatic diseases. Updated April 11, 2020. Accessed April 20, 2020.