Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was characterized as a pandemic by the World Health Organization.1

Among the populations likely to be at higher risk of developing severe infections are patients with rheumatic diseases, including lupus, rheumatoid arthritis (RA), scleroderma, undifferentiated connective tissue disease, and vasculitis.2 Medications for the management of rheumatologic conditions are typically known to be immunosuppressants, making patients more vulnerable to infection with viruses like the coronavirus. Experts note that clinicians need to exercise more caution with these patients.3

Several organizations have responded to the novel coronavirus outbreak: The European League Against Rheumatism released guidance for patients with rheumatic and musculoskeletal diseases receiving immunosuppressants like biologic agents, including Janus kinase inhibitors and disease-modifying antirheumatic drugs (DMARDs)4, and the British Society for Rheumatology released an update for its members about COVID-19 and risk to patients’ health.5

In this interview, we spoke with Douglas Roberts, MD, rheumatologist, Assistant Clinical Professor of Medicine at the University of California, Davis, and Medical Advisor to CreakyJoints, about COVID-19 infection risk and severity and preventive measures for patients who are immunocompromised with rheumatic diseases.


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With the current coronavirus outbreak, can you tell us about the risk for infection in patients who are immunocompromised with rheumatic diseases?  

Patients with rheumatologic conditions may be immunocompromised either by kidney disease, chronic lung disease, age, diabetes, or other comorbid conditions. In populations with a lot of comorbidities, the risk for infection is certainly higher if patients contract COVID-19.

As a clinician, I take it case by case. For example, young patients with RA receiving standard immunosuppressants may be temporarily able to stop these medications. Overall, most of my patients are more prone to infections. I have conversations with them about whether or not they feel comfortable with temporarily reducing or stopping their medications if their disease can be controlled.

The key is communication and letting patients know that they can call us or send a message on the patient portal if there is an issue or if they are concerned. Some patients are more worried than others and may also be more immunocompromised. With the right conversation, we can stop or reduce their immunosuppressive medications for a couple of months until we know what is going on. However, currently, we do not really know what the risk for COVID-19 infection is in these patients.

Some patients have had particularly bad experiences in the past with their disease; they have had progressive disease and joint damage and are not willing to revisit that scenario. In these patients, a frank discussion about the potential outcomes of COVID-19 is important, along with the reassurance that [clinicians] will be able to effectively address their flares or recurrent symptoms after the outbreak.

Are there particular rheumatologic conditions that are more susceptible to the virus?

There are certain immunologic conditions, such as severe lupus or systemic vasculitic conditions, which require more aggressive immunosuppressive therapy; that, in and of itself, is going to further immunosuppress patients’ systems, making them more immunocompromised and at a higher risk for infection. Patients who have severe systemic diseases often receive higher doses or stronger immunotherapies and they require detailed risk and benefit assessments; it is recommended that these patients be treated with extreme caution.

What specific preventive strategies can be provided to patients receiving immunosuppressive drug treatment for rheumatic conditions?

Strategies have been developed by the Centers for Disease Control and Prevention (CDC),6 and I follow their recommendations and prevention strategies. I advise patients to let their primary care providers know that they are on immunosuppressive medications.

It is important to alert providers that some patients are being treated with immunosuppressive medications and may not exhibit normal, high spiking fevers, and their white blood cell counts may not be as high as those of individuals who are noncompromised, so it is necessary to retain a high level of suspicion. If clinicians are on the fence, I would say err on the side of caution in terms of treating patients cautiously and follow-up with these patients closely.

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How can clinicians counsel their patients to continue treatment with DMARDs or other immunosuppressive drugs?

This is a moving target in the context of COVID-19. My main recommendations are to know your patients well, follow-up and teleconference with them, or bring them in for an examination if they have any concerns. Many [clinicians] are temporarily slowing or holding off DMARD therapy, but every clinical situation is different. Recommendations need to be personalized, emphasizing individualized care by doctors who know their patients well.

References

1. World Health Organization (WHO). WHO Director-General’s opening remarks at the media briefing on COVID-19- 11 March 2020. Published March 11, 2020. Accessed March 13, 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020

2. Hospital for Special Surgery. What to know about rheumatic disease and the COVID-19 coronavirus. Published March 11, 2020. Accessed March 13, 2020. https://www.hss.edu/conditions_rheumatic-disease-and-COVID-19-coronavirus.asp

3. GHLF CreakyJoints. Coronavirus facts: what you need to know if you have chronic illness or are immune-compromised. Published February 27, 2020. Updated March 13, 2020. Accessed March 13, 2020. https://creakyjoints.org/living-with-arthritis/coronavirus-facts-for-chronic-illness-patients/

4. European League Against Rheumatism (EULAR). EULAR Guidance for patients COVID-19 outbreak. Accessed March 13, 2020. www.eular.org/eular_guidance_for_patients_covid19_outbreak.cfm

5. British Society for Rheumatology. COVID-19 (coronavirus) – update for members. Accessed March 13, 2020. https://www.rheumatology.org.uk/news-policy/details/Covid19-Coronavirus-update-members

6. Centers for Disease Control and Prevention (CDC). Coronavirus disease 2019 (COVID-19). Updated March 12, 2020. Accessed March 13, 2020. https://www.cdc.gov/coronavirus/2019-ncov/index.html