As the COVID-19 pandemic continues, evidence-based insights into risk stratification and guidelines for the management of patients with rhematic diseases are now emerging. In an ACR Convergence 2020 session, two members of the Global Rheumatology Alliance (GRA) COVID-19 Steering Committee presented data from the COVID-19 GRA Registry on the impact of the pandemic on the rheumatology community.
Registered attendees have on-demand access to watch a replay of that session, COVID-19 Around the World: Impact on Rheumatology, through Wednesday, March 11, 2021.
Rebecca Grainger, PhD, FRACP, MBChB, associate professor at the University of Otago, New Zealand, reviewed the global incidence and distribution of COVID-19 and the impact on rheumatic disease populations, including risk factors for poor outcomes.
Looking at data from the GRA Registry and other sources, Dr. Grainger said that initial studies suggested that people with rheumatic disease may have an increased risk of COVID-19 infection compared to the general population. But she said subsequent data collected from rheumatic disease populations suggest this is not the case, and there is not an increased risk of infection in people with rheumatic diseases.
“On analysis of demographic factors, COVID-19 deaths in people with rheumatic disease were associated with age, being male, ever smoking in people with rheumatoid arthritis only, and associated with moderate-to-high disease activity,” Dr. Grainger said. “In multi-variable logistic regression analysis, when compared to methotrexate use as a reference drug, COVID-19 death was associated with the use of no DMARDs and use of moderate glucocorticoid dose with a prednisone equivalent of more than 10 milligrams per day.”
With regard to outcome disparities, Dr. Grainger said that, as in the general population, data suggests higher odds of poor outcomes in people from ethnic minorities with rheumatic diseases.
“As rheumatologists, we are in a strong position to advocate. We must advocate for measures that protect people with rheumatic disease, in particular people from racial and ethnic minorities,” she said. “We must advocate for information, reduced infection risk, and widespread testing.”
Jean W. Liew, MD, assistant professor of medicine at the Boston University School of Medicine, discussed management strategies for patients with rheumatic disease during the pandemic, including ACR COVID-19 Task Force recommendations.
“In general, if a patient has not had suspected exposure to someone who is COVID-19 positive and they are not themselves COVID-19 positive and they don’t have any symptoms that are suspicious for this, then the recommendations are to continue their current therapy, even if they’re on immunosuppressants or biologics,” Dr. Liew said. “NSAIDs can be continued, as well, and these recommendations are supported by a moderate to high level of consensus.”
Looking at the use of hydroxychloroquine, a drug that received a lot of attention in the first few months of the pandemic, Dr. Liew said that in patients with newly diagnosed lupus, it’s important to start hydroxychloroquine at a full dose, as long as medication is available.
“In well-controlled disease, whether it is lupus or RA, hydroxychloroquine should be continued if it’s available, but if they are having difficulty accessing the medication, then consider switching to a different csDMARD,” she said. “Another point regarding the context of a medication shortage, please refrain from starting hydroxychloroquine outside of FDA-approved indications.”
With regard to the off-label use of hydroxychloroquine in COVID-19 patients, Dr. Liew said that in randomized controlled trials and large well-designed observational studies, hydroxychloroquine has not been shown to be an effective treatment as pre- or post-exposure prophylaxis for mild or early COVID-19, including non-hospitalized patients, or for moderate or severe COVID-19, including patients requiring ICU level of care.
Dr. Liew also discussed the impact of isolation and quarantine on quality of life and access to care in both the general population and people with rheumatic disease.
“There have been a few studies evaluating disease activity and quality of life during the pandemic,” she said. “For example, my colleagues and I found that during the early phase of the COVID-19 pandemic, individuals who had higher levels of stress or anxiety had significantly higher disease activity compared to those with lower levels of stress or anxiety.”
She said a large study from the United Kingdom showed that among those with rheumatic disease, those who are isolating had significantly worse mental and physical scores than those who are not isolating.
“So, as clinicians, it’s important to recognize this and help patients adapt as well as possible,” Dr. Liew said.