New Covid-19 Clinical Guidance for Adult Patients with Rheumatic Diseases

Developed by the American College of Rheumatology (ACR) COVID-19 Clinical Guidance Task Force, this summary was approved by the ACR Board of Directors on April 11, 2020.

The purpose of this document is to provide guidance to rheumatology providers on the management of adult rheumatic disease patients in the context of the Covid-19 pandemic. These statements are not intended to replace clinical judgment.

Methods
The North American Task Force, including 10 rheumatologists and four infectious disease specialists, convened on March 26, 2020. Clinical questions were collated, and an evidence report was generated and disseminated to the panel. Questions and drafted statements were reviewed and assessed using a well-established method of consensus building (modified Delphi process). This included two rounds of asynchronous anonymous voting by email and two webinars including the entire panel.

Panel members voted on agreement with draft statements using a numeric scoring system, and consensus was determined to be “low” (L), “moderate” (M) or “high” (H), based on the dispersion in voting results. To be approved as guidance, median votes were required to correlate to pre-defined levels of agreement (with median values interpreted as “agreement”, “uncertainty” or “disagreement”) with either moderate or high levels of consensus.

Recommendations — General statements for patients with rheumatic disease
• The risk of poor outcomes from Covid-19 appears to be related primarily to general risk factors such as age and comorbidity (H);
• Patients should be counselled on general preventive measures, e.g., physical distancing and hand hygiene (H);
• As part of a shared decision-making process between patients and rheumatology providers, select measures to reduce healthcare encounters and potential exposure to SARS-CoV-2 (beyond general preventative measures) may be reasonable, e.g., reduced frequency of lab monitoring, optimal use of telehealth, increased dosing intervals between intravenous medications) (M/H);
• If indicated, glucocorticoids should be used at the lowest dose possible to control rheumatic disease, regardless of exposure or infection status (M/H);
• Glucocorticoids should not be abruptly stopped, regardless of exposure or infection status (H);
• If indicated, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should be continued in full doses or initiated (M/H).

Ongoing treatment of stable patients without infection or SARS-CoV-2 exposure
• Hydroxychloroquine or chloroquine (HCQ/CQ), sulfasalazine (SSZ), methotrexate (MTX), leflunomide (LEF), immunosuppressants (e.g., tacrolimus, cyclosporine, mycophenolate mofetil, azathioprine), biologics, Janus kinase (JAK) inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDs) may be continued (this includes patients with giant cell arteritis with an indication, in whom interleukin-6 [IL-6] inhibitors should be continued, if available) (M/H);
• Denosumab may still be given, extending dosing intervals to no longer than every eight months, if necessary to minimise healthcare encounters (M);
• For patients with a history of vital organ-threatening rheumatic disease, immunosuppressants should not be dose-reduced (M).

In patients with systemic lupus erythematosus (SLE):
• In newly diagnosed disease, HCQ/CQ should be started at full dose, when available (H);
• In pregnant women with SLE, HCQ/CQ should be continued at the same dose, when available (H).
• If indicated, belimumab may be initiated (M).

Treatment of newly diagnosed or active rheumatic diseases, in the absence of infection or SARS-CoV-2 exposure:
Active inflammatory arthritis:
• For patients well-controlled on HCQ/CQ, this disease-modifying anti-rheumatic drug (DMARD) should be continued, when available; when unable to access (including in patients with active or newly diagnosed disease), switching to a different conventional synthetic DMARD (either as monotherapy or as part of combination therapy) should be considered (M/H);
• For patients well-controlled on an IL-6 inhibitor, this DMARD should be continued, when available; when unable to access the agent, switching to a different biologic should be considered (M). The panel noted uncertainty regarding the use of JAK inhibitors in this situation;
• For patients with moderate to high disease activity despite optimal conventional synthetic DMARDs, biologics may be started (H). The panel noted uncertainty regarding the use of JAK inhibitors in this situation;
• For active or newly diagnosed inflammatory arthritis, conventional synthetic DMARDs may be started or switched (M).
• If indicated, low-dose glucocorticoids (≤10 mg prednisone equivalent) or NSAIDs may be started (M/H).

Other rheumatic diseases:
• In patients with systemic inflammatory or vital organ-threatening disease (e.g., lupus nephritis or vasculitis), high-dose glucocorticoids or immunosuppressants may be initiated (M);
• In patients with newly diagnosed Sjögren’s, given the paucity of data proving efficacy, HCQ/CQ should not be started (M).

Ongoing treatment of stable patients following SARS-CoV-2 exposure (without symptoms related to COVID-19):
• HCQ, SSZ, and NSAIDs may be continued (M/H);
• Immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test result for Covid-19 or after two weeks of symptom-free observation (M). The panel noted uncertainty re: temporarily stopping MTX or LEF in this situation;
• In select circumstances, as part of a shared decision-making process, IL-6 inhibitors may be continued (M).

Rheumatic disease treatment in the context of documented or presumptive Covid-19 infection:
• Regardless of Covid-19 severity, antimalarial therapies (HCQ/CQ) may be continued, but SSZ, MTX, LEF, immunosuppressant’s, non-IL-6 biologics, and JAK inhibitors should be stopped or held (M/H);
• For patients with severe respiratory symptoms, NSAIDS should be stopped (M). The panel demonstrated low consensus with regards to stopping NSAIDs in the absence of severe symptoms;
• In select circumstances, as part of a shared decision-making process, IL-6 inhibitors may be continued (M).

References available on request.

Author
Dr Fahim Khan, MBBS, MD, MRCP(UK) MRCP Rheumatology, FRCP London, FRCP Edin. FACP, FACP Rheum, Consultant Rheumatologist, Aut Even Hospital Kilkenny and Beacon Hospital Dublin.