ACR: Suspend immunosuppressants, select DMARDs in rheumatic patients with COVID-19
Patients with rheumatic diseases who test positive for COVID-19 should temporarily discontinue all treatments with sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics and JAK inhibitors, according to new recommendations released by the American College of Rheumatology’s COVID-19 Clinical Guidance Task Force.
Approved by the ACR Board of Directors on April 11, the “COVID-19 Clinical Guidance for Patients with Rheumatic Diseases” draft summary states that patients with rheumatic diseases who have been confirmed to have COVID-19 may continue with anti-malarial therapies — namely hydroxychloroquine and chloroquine — and, in select circumstances, IL-6 inhibitors. The organization’s full manuscript is pending journal peer review.
“[Our] Task Force is comprised of experts in infectious disease and in biologic and non-biologic therapies for rheumatic disease,” ACR President Ellen M. Gravallese, MD, told Healio Rheumatology. “Members reviewed and analyzed the existing literature to develop this ‘living document’ using a well-established method of consensus building.”
“However, research into the treatment of patients who are taking medications for rheumatic disease and who contract COVID-19 is ongoing in many institutions and other settings,” she added. “Task Force members will continue to evaluate new data as results of this research becomes available and we will be posting updated versions of this guidance document with date and time stamps as critical new data emerges.”
The draft guidance was developed by a North American task force of 10 rheumatologists and four infectious disease specialists who convened on March 26, 2020. Members collated clinical questions and produced an evidence report based on current knowledge.
According to the ACR, there were two rounds of asynchronous, anonymous voting via email and two webinars attended by the entire panel. Members voted on agreement with draft statements, with the results used to determine “low,” “medium” and “high” consensus for each item. Only items determined to have moderate or high levels of consensus were included in the draft guidance.
The draft’s statements and guidelines include the following general recommendations for patients with rheumatic disease:
- Patients with rheumatic disease appear to be at risk for poor outcomes from COVID-19, primarily due to general risk factors such as age and comorbidity.
- In addition to following all general COVID-19 preventive measures, patients with rheumatic disease and their providers should discuss ways to reduce the number of health care encounters and potential exposure to coronavirus, including monitoring blood work less frequently, using telehealth and increasing the time between doses of intravenous medications.
- For ongoing treatment of stable patients with no coronavirus exposure or infection, hydroxychloroquine or chloroquine, sulfasalazine, methotrexate, leflunomide, immunosuppressants — such as tacrolimus, cyclosporine, mycophenolate mofetil and azathioprine — biologics, JAK inhibitors and NSAIDs may be continued.
- Stable patients without COVID-19 exposure or infection may still receive denosumab for osteoporosis, but the time between doses may be extended to as long as 8 months, to minimize health care encounters and, if necessary, due to limited access to infusions.
- Patients with stable disease who have been exposed to coronavirus but do not have a known infection may continue with hydroxychloroquine, sulfasalazine and NSAIDs, but immunosuppressants, non-IL-6 biologics and JAK inhibitors should be discontinued temporarily, pending a negative test result COVID-19 or after 2 weeks without infection symptoms.
- IL-6 inhibitors may also be continued, in select circumstances, among patients with stable rheumatic disease who have been exposed to coronavirus but have not yet tested positive for COVID-19.
The full list of guidance statements can be found here.
“These statements are not intended to replace clinical judgment,” noted the guideline document. “Modifications made to treatment plans, particularly in complex rheumatic disease patients, are highly disease-, patient-, geography- and time-specific and, therefore, must be individualized as part of a shared decision-making process. 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.” – by Jason Laday