The European League Against Rheumatism (EULAR) has released provisional recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) with respect to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). The full report was published in Annals of the Rheumatic Diseases.

The task force convened by EULAR included 22 members who agreed on 5 overarching principles and 13 recommendations with 4 themes, including general and preventive measures for infection with SARS-CoV-2, management of RMDs when social distancing measures are in place, management of COVID-19 for patients with RMDs, and the prevention of other infections besides SARS-CoV-2.

Overarching Principles

  • According to the task force, there is currently no evidence that indicates that patients with RMDs have a higher risk for SARS-CoV-2 infection or worse prognosis compared with those who do not have RMDs.
  • For the diagnosis and treatment of COVID-19, patients with RMDs should be referred to specialists who treat this disease, including pulmonologists, internists, or infectious disease specialists.
  • Rheumatologists should be involved in a decision making process with their patients about maintaining or continuing immunosuppressive treatment during the pandemic.
  • Because of the evolving nature of treatments for COVID-19, the EULAR task force has recommended that rheumatologists participate in local, regional, or national guideline committees for COVID-19, as treatment with immunosuppressive therapy should be a multidisciplinary decision.
  • Rheumatologists must discourage the off-label use of disease-modifying antirheumatic drugs (DMARDs) outside of clinical trials.

Recommendations for the Management of RMDs in the Context of SARS-CoV-2


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General Safety and Prevention Measures

  • Rheumatologists must strongly advise patients with RMD to follow all preventive and control measures according to guidance from local and national health authorities.
  • Overall, patients with RMDs must be advised to take the same safety measures as those without RMDs.
  • Rheumatologists are recommended to continue prescribing treatment, including nonsteroidal anti-inflammatory drugs (NSAIDs), DMARDs, glucocorticoids, and analgesics, to patients with RMDs but who do not have suspected or confirmed infection with COVID-19.

Management of RMDs With Physical Distancing in Effect

  • Rheumatology consultations may be postponed (for a maximum of up to 6 months) or conducted remotely if the disease and treatment are stable and symptoms of drug toxicity are absent.
  • For patients with active RMDs who have recently started receiving therapy, require adjustments to their therapy, or have symptoms of drug toxicity, a shared decision for in-person vs remote consults must be taken based on the evaluation of benefits and risks.
  • Rheumatology providers and staff are also advised to comply with guidance, including the use of personal protection equipment, for the prevention and control of COVID-19, especially when patients with RMDs make physical visits.

Management of COVID-19 in Patients With RMDs

  • After careful consideration, the task force has recommended that patients with RMDs without COVID-19 symptoms but in contact with an individual who has tested positive for SARS-CoV-2 also be tested for active viral infection.
  • Rheumatologists must continue treatment with glucocorticoids for patients with RMDs and COVID-19 symptoms.
  • Treatment changes for patients with RMDs and mild COVID-19 symptoms, including sore throat, nasal congestion, and elevated body temperatures (<100.4 °F), must be considered on an individual case basis.
  • Patients with RMDs and mild but worsening COVID-19 symptoms, including fever ≥100.4 °F, subjective shortness of breath, and tachypnea (>20/min), must be referred to experts in treating COVID-19, based on local circumstances.
  • Rheumatologists are advised to follow local treatment recommendations developed by experts for patients with RMDs who are admitted to the hospital with significant COVID-19, which may include all the symptoms of worsening COVID-19 such as low- to high-grade fever, shortness of breath, tachypnea, hypoxia, and cyanosis.

Prevention of Infections Other Than SARS-CoV-2

  • Patients with RMDs without COVID-19 symptoms should be encouraged to receive vaccinations, especially pneumococcal and influenza, based on the updated EULAR vaccination recommendations.
  • According to the task force, rheumatologists must consider Pneumocystis jiroveci pneumonia prophylaxis in patients with RMDs who are receiving treatment with cyclophosphamide or glucocorticoids.

“The task force hopes that the release of these expert-opinion-based recommendations meant for patients with RMD and their caregivers in ‘COVID-time’ will be a stimulus to initiate and conduct [further] research,” they concluded.

Disclosures: Several authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Landewé RBM, Machado PM, Kroon F, et al. EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2 [published online June 5, 2020]. Ann Rheum Dis. doi:10.1136/annrheumdis-2020-217877