ACR COVID-19 Guidance for Rheumatic Disease Patients Save
On April 11th, the ACR Board of Directors approved a COVID-19 guidance document written by an ACR task force charged with updating and clarifying recommendations for rheumatologists and rheumatic disease patient management during the current COVID-19 crisis.
This ACR release, in its entirety, can be found here. A full rapid A&R publication will soon follow and include its authors.
These recommendations and statements are not intended to replace clinical judgment. The task force notes that this guidance is provided as part of a ‘living document’, recognizing rapidly evolving evidence and the anticipated need for frequent updates as such evidence becomes available.
The North American Task Force included 10 rheumatologists and 4 infectious disease specialists, which rapidly developed key clinical questions and an evidence report was generated and disseminated to the panel. The recommendations put forth are the results of two rounds of a Delphi process design to identify areas of consensus or agreement. Hence, these recommendations were valued as either “low” (L), “moderate” (M) or “high” (H), based on the dispersion in voting results of the panel, using pre-defined levels of agreement.
Editor's notes:
- Overall, the consensus is that for unexposed and noninfected patients, rheumatologists should maintain the therapies that have previously been acceptable and effective in their patients; and that those patients who need additional or new therapies, prior standards of practice would be appropriate to continue.
- These recommendations are expert consensus and not grade A, evidence based recommendations; as such do not exist amidst this crisis. Hence the ACR Task Force and Board deserve high praise and should be commended for stepping up in this time of need.
- High consensus by the Task Force was not possible in rheumatic disease patients known or suspected to have a COVID-10 infection. There were no low consensus recommendations.
I have listed these recommendations in a different manner than that published by the ACR. I have listed these according to the strength of committee member consensus and whether the patient is A) not affected by COVID-10, or B) has a suspected or documented infection. Lastly, the comments on the far right column represent my views and comments, not the ACR or the Task Force.
General Recommendations for Patients Not Infected, nor Suspected to have COVID-19 | |
High Consensus | Editor's Comments |
- The risk of poor outcomes from COVID-19 appears to be related primarily to general risk factors such as age and comorbidity - - Patients should be counseled on general preventive measures - Glucocorticoids should not be abruptly stopped, regardless of exposure or infection status - Patients with moderate to high disease activity despite optimal conventional synthetic DMARDs, biologics may be started (The panel noted uncertainty regarding the use of JAK inhibitors in this situation) - In newly diagnosed SLE, HCQ/CQ should be started at full dose, when available - In pregnant women with SLE, HCQ/CQ should be continued at the same dose, when available | - Interestingly, there have been few reports of our SLE, RA or other patients being uniquely or severely affected. Age, DM, heart and lung disease appear to be important risk factors. - Uncontrolled disease activity and high inflammation would likely be more harmful than any of our meds or diagnoses. - Early reports do not show an untoward problem between COVID and pregnancy. |
Moderate to High Consensus |
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- csDMARDs (HCQ, CQ, SSZ, MTX, LEF), JAK inhibitors, biologics, immunosuppressants (AZA, MMF, CsA, Tacrolimus) and NSAIDS may be continued. - If indicated, glucocorticoids should be used at the lowest dose possible to control rheumatic disease, regardless of exposure or infection status (M/H) - Stable patients on HCQ, CQ or IL-6 inhibitors should continue - If HCQ or CQ becomes unavailable, switching to a different conventional synthetic DMARD (either as monotherapy or as part of combination therapy) should be considered - In SLE, belimumab may be initiated, if indicated | - Data accrued so far by the Rheum- Covid.org registry has shown that there are Rheum patients with COVID infection who have entered into the database and they are taking most of these medicines. It is unclear at this point if NSAIDs, HCQ, DMARDs, JAKs or biologics play any role in the host reponse to COVID infection. |
Moderate Consensus |
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- If indicated, glucocorticoids should be used at the lowest dose possible to control rheumatic disease, regardless of exposure or infection status (M/H) - For patients with a history of vital organ-threatening rheumatic disease, immunosuppressants should not be dose-reduced - Active or newly diagnosed inflammatory arthritis, conventional synthetic DMARDs may be started or switched and low-dose glucocorticoids (≤10 mg prednisone equivalent) or NSAIDs may be started (M/H). - If an IL-6 inhibitor is unavailable, switching to a different biologic should be considered (The panel noted uncertainty regarding the use of JAK inhibitors in this situation) - Patients with systemic inflammatory or vital organ-threatening disease (e.g., lupus nephritis or vasculitis), high-dose glucocorticoids or immunosuppressants may be initiated - In newly diagnosed Sjögren’s, given the paucity of data proving efficacy, HCQ/CQ should not be started
| - My belief (and the ACR guideline) is that we should continue to optimally use our meds to best treat our patients, in the same manner we would if we didn't consider the low individual risk of acquiring the COVID infection. - In the event of a HCQ or IL-6 inhibitor shortage we have several options: a) evaluate if the patient even needs the agent; b) change HCQ to CQ or azathioprine, etc; c) change IV IL-6 inhbitors to subcutaneous IL-6 therapy. |
Treatment of Stable patients following SARS-CoV-2 exposure (without COVID-19 symptoms) | |
High Consensus |
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| In the unfortunate and difficult circumstance of an active COVID infection, there is no clear guidance and I believe we should rely on moderate consensus suggestions. |
Moderate to High Consensus |
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- Continue treatment with HCQ, SSZ, and NSAIDs | These seem very appropriate. |
Moderate Consensus |
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- Temporarily stop Immunosuppressants, non-IL-6 biologics, and JAK inhibitors pending a negative test result for COVID-19 or after 2 weeks of symptom-free observation (panel noted uncertainty re: temporarily stopping MTX or LEF in this situation) - IL-6 inhibitors may be continued, as part of a shared decision-making | I would disagree somewhat here as it is unknown what the detrimental effect would be for continuing DMARDs, immuno-suppressants, biologics and JAK inhibitors. I would recommend that the fate of these agents be considered on a case by case basis based on how effective/needed the agent is in that patient versus the known or anticipated harm; keeping in mind that: - The half-life of many biologics makes this a moot decision that only looks good on paper. - methotrexate is certainly antiinflammatory and less so immunosuppressive at the doses we commonly use. - But methotrexate and rituximab are the 2 agents we use that most consistently blunt humoral responses to commonly used vaccines. - Available evidence does not support discontinuation of DMARDs at the time of surgery or during hospitalization for serious infections. This is admitedly a difficult scenario. |
Treatment of in the context of documented or presumptive COVID-19 infection | |
High Consensus |
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Moderate to High Consensus |
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- Continue anti-malarials (HCQ/CQ) regardless of COVID-19 severity) - Stop or hold SSZ, MTX, LEF, immunosuppressants, non-IL-6 biologics, and JAK inhibitors | - Unclear why SSZ would be held. - See above comments about potentially continuing these agents. - HCQ, IL-6 inhibitors and baricitinib (not other JAKinhibitors) have been touted as potentially beneficial to COVID infected patients. |
Moderate Consensus |
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- Stop NSAIDs with severe respiratory symptoms - IL-6 inhibitors may be continued, as part of a shared decision-making | It's unclear to me why NSAIDs are singled out with severe respiratory symptoms as there is NO Evidence that NSAIDs are a detriment in COVID infected patients. The warning about NSAIDs (from the French Govt) have been universally dismissed as being nothing more than a common sense decision to use acetaminophen over NSAIDs in managing any symptoms, especially a cold, URI or flu. |
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Considering Janus kinase inhibitors' effect on risk of thrombosis (https://acrabstracts.org/abstract/risk-of-thromboembolism-with-janus-ki…), is there cause for concern about hypercoagulability (https://doi.org/10.1111/jth.14849) in COVID-19 patients who have been receiving them? Should this issue be taken into account as we compose recommendations for our patients?
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