RheumNow Podcast- COVID Siege (3.20.20) Save

It's the 03/20/2020. This is the RheumNow podcast. I'm doctor Jack Cush, executive editor of rheumnow.com. This week, it's all about corona and COVID nineteen. It's been mounting.

It's been growing. It's become oppressive. We're under siege. It's hard to know what to do next. So this week, we've largely covered what's going on with the coronavirus in medicine and rheumatology and in government, in epidemiology.

It's a never ending stream of new information, and it's dramatically changing the way we practice, the way we live. It's as important to us as it is to our patients. I think it's important for us to be sort of unified in our knowledge base and in our messaging, because there's a lot of misconceptions about, our diseases and our patients. So let me go through with you a lot of the items we covered this past week and give you some of my spin. This is COVID nineteen siege.

So we started out, I think it was yesterday, we had breaking news that the FDA has approved hydroxychloroquine for treatment of the coronavirus. Well, that's actually not right. President Trump was, addressing the media and talking about available therapies, and he did mention that chloroquine and chloroquine are FDA approved medications. Although the cadence in which it was delivered made it sound like it's approved for the coronavirus, it is not. The FDA website says there are currently no FDA approved therapies for the treatment of the coronavirus infection, but there are a number of therapies that are under evaluation by the FDA and that are in clinical trials right now.

Hydroxychloroquine is an important therapy and this will be used to treat a number of patients. You can look at the link we have on there and see the video as it was announced. So it is FDA approved, as you know, for rheumatoid arthritis, for lupus, and for malaria, but it is not currently FDA approved for the coronavirus. The problem with this, of course, is there's going to be a run on antimalarial therapy. Prior to this, epidemic, there was probably a shortage of hydroxychloroquine largely due to several manufacturers going out of business, and then the others being in short supply.

As you know, placenta has been in short supply in the past. Its price as a generic drug used to be cheap and has gone up quite a bit in the last five years. But nonetheless, now it's gonna really get sort of competitive, if not ridiculous. There will be a shortage of hydroxychloroquine. For those patients of yours who are dependent upon hydroxychloroquine, I would encourage you to reach out to them and try to get a supply before this gets any worse.

Again, chloroquine may suffice, and maybe the question we're going to have in ensuing weeks is what to do when these are in short supply and what the alternative therapies are. And I'll explain why hydroxychloroquine is going to be in short supply in the next item I'm gonna talk about. In my tweet on this, was met with a lot of, positive comments saying that's what they were seeing, meaning that they too are seeing that the pharmacies are out of this and there's a back order of hydroxychloroquine, So be prepared. Catherine Dow, I believe, tweeted that there are 10 manufacturers of hydroxychloroquine. There are several of them that are, that are actually producing fraudulent and counterfeit unsafe medicines.

These are gonna be vetted by the FDA, of course. But, again, there are links on there that you can see what the current supply situation is going to the ASHP website, which is a pharmacy website in, Utah, and also the FDA website to see their most useful when it comes to determining what drugs are in short supply. An interesting, Lancet article came out this week. We want to, Nigel Herron made this available on, Twitter, and Catherine Dow, retweeted this that there is some pregnancy data on Twitter. Not surprisingly, young and older affected by this infection, and not surprisingly, there are some issues about pregnancy that need to be resolved.

There is a report out of China of nine patients with successful pregnancy both for the mother and the child. And this is important because, you know, the other big outbreaks, you know, no pregnancy effects with, SARS that we know about or with Ebola, but there was, as you remember, the Zika virus has significant issues, with regard to fetal malformations and whatnot, but this is not the case with COVID thus far, and we need registries to further evaluate this amongst our patients. I'll talk about registries in a moment. There's an interesting study that appeared in the also in Lancet on a French study, a 26 patient open label study of hydroxychloroquine six hundred milligrams a day, And then in some of those patients actually receiving azithromycin with a significantly reduced SARS CoV-two viral load as measured by PCR suggesting the success of this treatment. If you read the study, it's a it's not a well designed study.

It's an open label study. Some are in, some are out. Not everybody got, azithromycin. The criteria for getting azithromycin, not so clear. Clearly, hydroxychloroquine does lower viral load and reduce replication.

Whether there's an it looked like there might be an added value of adding azithromycin to this. This is one of the reasons why hydroxychloroquine may be in short supply. I also saw this week that Bayer, a big maker of chloroquine, has supplied a mega, amount of chloroquine to The US market, US government. So there while there may be a shortage of hydroxychloroquine, there may not be a shortage of chloroquine, and you might have to make the adjustment realizing that it is not as safe as hydroxychloroquine, make some dose adjustments and, counsel your patients, but it may be able to control their lupus or arthritis as an interim, agent to use if Plaquenil is in short supply. We mentioned earlier that there is a registry that has been started.

It's been started by Doctor. Philip Robinson. You should follow him on Twitter. We have the link on our website and on our Twitter account to join the rheumatology COVID-nineteen registry. We have, a, information about this registry and, b, how you can join.

This registry has been backed by a number of agencies. I'm going to list them here if I can find it, including, creaky joints and the ACR and a number of leaders in our field. It's been IRB approved through the UCSF IRB, and I think that, we're going to launch this. The point is, if we want to know what to say with our patients who have rheumatic disease, autoimmune disease, and are on biologics, we're gonna have to collect the data and report to the world what the observations are. You can do this.

My partner came to me and said, Why don't you start writing down the number of patients who you think could possibly be affected by COVID, by symptoms or history or whatever? And I said, gee, I don't think I've got any. And then the more I started dwelling on this, like the next two days, I had eight people on my list who might could possibly have COVID, infection. So, I think we should collect this data. I think we should be aggressive about entering data, as a community to answer the big questions that are thus far unanswerable.

Again, look for that link, on the website. What can you do to, manage your patients now in this environment? Well, a lot of people are going to telephone call visits and telemedicine visits. Catherine Dow wrote a nice, blog on this giving her spin on how to best manage patients, in the era of telemedicine and telephone call medicine. She says, number one, set up and get ready to do this.

Have a template for these visits. Let your patient know that, we're gonna be doing remote visits by teleconferencing, televideo, telephone. You need to obtain their consent to do such a video, or a telephone call, and you can conduct the visit. Get the high points, review their medicines, review the most common recent problem, find out what the refills are they need, make sure they get their laboratory tests. All this can be done remotely, and also you can do a joint exam.

And there's a lot you can do on telemedicine, which I'll talk about in a minute. Refill their medications and then schedule a follow-up visit. Again, when should that be? The earliest estimates we're hearing is early June. I think if these are q six month patients, make them every six months from now, which is gonna be in in September, October, August, something like that.

If they're not stable, you might wanna connect with them in the next month or in three months. But, again, these remote visits, televisits are, now, all the rage and the current standard of care in rheumatology and other parts of medicine. I noted that in given this last two weeks, with all this going on and all this scare about not going home and social distancing and six feet, and no handshakes, I found that all my patients were coming to the clinic. And I think that tells us something important. I think it tells us the patients need information from you, the expert, you, the doctor they trust, you, the one who understands them better than anyone else.

So, we do they would come if you had open clinics. I I don't think we should do that right now. I think you should reserve face to face meetings for people who are urgent or patients who are new who are urgent. Otherwise, these can all be done remotely, but they need to hear from you. They need to get your guidance on what to do.

So for instance, in my template that I've built in my EMR to do these telephone and televideo visits, it ends with, you know, five questions about COVID. Do you have any questions? Do have questions about going to work? Who you should be around? Should you travel?

What about my kids? What about coworkers? What about my medicines? Should I stop them? Who should I talk?

Who should I listen to? Should I get tested? Should I get a vaccine? Should I get other vaccines? Again, all that should be answerable by you and that data is out there for you to discuss with your patients.

I tweeted earlier this week that, how you can manage your patients. I think you should advise the patients to follow current precautions with regard to social distancing, being amongst crowds and whatnot. The big issue is our patients. Are they immunosuppressed and are they at greater risk? There's not a lot of clear evidence, and I think most of our patients who think they're immunosuppressed are not.

We've controlled their disease with powerful anti inflammatory therapies, not powerful immunosuppressants. If they were very immunosuppressed, we'd see more cancers, more bizarro infections, and instead by better treating them, we avoid those things. So, I think you have to correct the patient and tell them how at risk you think they are. I had a patient yesterday who she's 78, she's got major pulmonary disease with bronchiectasis, she's had hospitalization, she's at risk regardless of whatever her rheumatic diagnosis is or regardless whatever biologic she's on. On the other hand, you know, a young lupus patient of mine who's 40, healthy, goes to the gym taking two drugs.

I told her she's not particularly at any higher risk than another 40 year old who's also going to the gym. So, number one, tell them do not stop their biologic or immunosuppressors. And the rules for stopping are A, only I, the rheumatologist, the person who prescribed it, can stop that drug. B, the rules for stopping are getting hospitalized. And C, the last rule is if you have a high fever greater than 102, then stop and call or go to your family doctor for an assessment.

Further rules for conduct in clinic, I wash my hands before every patient. If I'm seeing patients, I wear gloves when I'm examining the patient. You know, that's an OSHA guideline. OSHA guidelines make you wear gloves to protect you, the physician, when you're doing joint injections. The gloves need not be sterile.

But the patients will appreciate you're wearing gloves when you examine them. I think you should clean your workspace on a twice daily basis. And if you feel sick or you're coughing, leave the room as a courtesy to the patient. If you're really sick, don't come to work and please get tested. What do you tell your patients with regard to testing?

I tell them there's no need for testing at this point, not unless you have symptoms of myalgias, cough, chest pain, fever, chills, sweats, upper respiratory symptoms, URI, chorizo, nasal congestion, you know, allergy kind of symptoms, URI kind of symptoms, that's not part and parcel of this condition. Severe headaches can be, occasional GI complaints can be. So you should know that at RheumNow live last week, Kevin Winthrop was one of our featured speakers, and he talked about managing infections. Not surprisingly, we talked about the coronavirus. And the bottom line takeaway from that discussion, is that you should not you should tell your patients not to stop their biologics, and there's no compelling reason to stop their Imuran or methotrexate because of this news and the COVID-nineteen siege we were under.

There is research out there that I'll discuss in a minute about the utility of maintaining and maybe potential benefits of Plaquenil, Baricitinib, and IL-six inhibitors. So, I'll put up a I put up a tweet this week about the Bush administration and its federal guidelines for dealing with public health crises. I thought it was instructive. I think it said a few things that can tell you a lot about how you should manage yourself during this pandemic. The core principles of the Bush administration federal guidelines on crises, and it would be like, you know, disasters like tornadoes and hurricanes and and other things, including a pandemic.

The administration's principles included first, be right be first and be right. Next was be credible. Next was show respect. And last, promote action. So in my clinic, you know, I have to be the authority.

I have to teach my staff on what the right answers are to the difficult questions they're getting. We have to be respectful to the patient's fears no matter what they are. At the beginning of this, I had a patient call and ask for a ninety day supply of medicine. As she had heard, there could be a short supply of many medicines because they're made in China. I, you know, I said, no, that's not necessary.

We don't need to do that. I handled that wrong. I think I should have said, I don't think that's gonna be an issue, but yes, let's go ahead and put in the ninety day prescription, and promote action so as to let the patient know that you're alongside them and that you're in partnership with them. If you haven't seen the tweet today, you should know that Doctor. Kevin Winthrop has a very timely, full read, open access article in Arthritis and Rheumatology entitled Who Needs Corona?

It's a very important article you read. He basically goes through the most common questions that he and you hear on a regular basis. He tells you when we don't know the answer. He'll also tell you what the answers are that we do know. So I want you to take a look at that.

We posted a piece called COVID Rheumatology News, where in there we posted, the press release or the announcement from the ACR about the COVID crisis and that the ACR is aware of it, that they want to provide information to you as is necessary. They have a lot of good information on that site, on that link, about telemedicine, about CMS has all new rules that govern telehealth. You know, they're fairly restrictive. Medicare, CMS, Medicaid, fairly restrictive. Now, it's been very liberalized so that you can actually conduct even a telehealth, televideo consult over state lines, in patients who have Medicare, not commercial insurance, Medicare or Medicaid.

There are new guidelines and fact sheets from Health and Human Services on the relaxation of the new of HIPAA rules, siding with the physician and the need to intervene in the patient's behalf during this public health crisis. There's other resources on there from the AMA and the American College of Physicians on links on how to do and conduct yourself in telemedicine. You should look at those. They're on the ACR website, or if you wanna find it, go to our article entitled COVID nineteen rheumatology news. Again, doctor Dow had a great piece on rheumatologist tips for telemedicine that you should look at.

And then we wrote a piece on the COVID-nineteen and rheumatology drugs that are out there. I think you should look at that because it'll tell you a lot of the evidence as to why we are currently using hydroxychloroquine, the antimalarials. What we do cover on there is the number one, the French declaration that you shouldn't use nonsteroidals. That's all wrong. That was, I think, an overestimation and an oversimplification of a common principle, which is when people are sick, it's probably better to use acetaminophen than to use ibuprofen.

But it came off as do not use ibuprofen if you have COVID nineteen. There's actually no evidence to suggest that it's more dangerous or you're gonna get a Rye syndrome or anything like that. So that's important. You can use nonsteroidals as you need to in these people who are sick with myalgias and arthralgias and whatnot. Next, antimalarials.

Again, chloroquine, hydroxychloroquine have been shown to limit viral replication of the coronavirus, and that's why they're being used as first line therapy and people are sick or hospitalized. Whether or not they need other therapies to reduce viral replication, there are several that are in development. There are several antiviral drugs. Remdesivir is out there, not easily, available, but I think it's being used in patients who are hospitalized. And then there's JAK inhibitors.

There's good evidence to suggest that baricitinib, I can't tell you about the other JAKs, but baricitinib is a potential treatment for the acute infectious COVID infection because, basically it's been shown to inhibit AKA1, a key regulator of endocytosis, and that's how the COVID virus gets access to cells. So it basically will inhibit endocytosis, and there are other drugs that are also been tested. But baricitinib was actually quite effective. And then lastly, a lot of good reports about IL-six inhibitors, both, tocilizumab and sorrelimab. There are clinical trials that are underway, with a lot of these therapies, looking at the utility of these drugs.

The idea being here that with acute infection, there is a massive release of IL-six and sort of a cytokine storm. It is this hyper inflammation that leads to excessive damage and maybe morbidity, if not mortality. There's a twenty patient study in China using tocilizumab where nineteen out of the twenty patients, had their fever abate and were discharged with from the hospital within two weeks. There is a trial going on both with sorrelimab and another trial going on, 272 patients has thus actually, another trial is planned for with tocilizumab. There's been a report, two seventy two patients treated with tocilizumab in the literature, you can find that citation.

There are no there is no negative evidence about the, benefits or hazards of other biologics, specifically TNF inhibitors, so I would not stop those therapies in patients who are, on them and either living in fear of the COVID virus or are actually infected by COVID. So, next week, we plan to cover this further. We'll try to get an interview with, Kevin Winthrop to further give you the latest data on this. Look at my, our website and check out the video that's gonna be posted today and Monday from Alvin Wells, five questions on how to do telehealth in your practice. It's really instructive.

Alvin's the expert at this. He's been doing it for a while. And then next week, we're gonna play his replay his TED Talk from RheumNow Live, a fifteen minute talk where he goes over why telemedicine, telerheumatology should be a part of your future. A long broadcast this week, but it was definitely needed. Please email me or call me if you have questions or suggestions about what we should be covering, in the weeks to come, on RheumNow.

Take care of yourselves.