Rheumatologists move 'front and center' in fight against COVID-19
Evidence showing an increasing number of associations between rheumatologic conditions and COVID-19 has put rheumatologists in a key position to fight the infection, according to findings presented during a webinar hosted by United Rheumatology.
That said, the evidence is overwhelming and occasionally contradictory, often creating more questions than answers, according to presenter Leonard H. Calabrese, DO, RJ Fasenmyer chair of clinical immunology at the Cleveland Clinic. “It is like drinking water from a fire hydrant, with over 4,000 articles published in peer review,” he said during the “On Survival and Resilience: Managing A Rheumatology Practice Through the COVID-19 Pandemic” webinar. “The data are coming out almost by the minute.”
Leonard and Cassandra Calabrese, DO, associate staff in the departments of rheumatic and immunologic disease and infectious disease at the Cleveland Clinic, aimed to make sense of these data and field questions they are generating from both patients and fellow clinicians. The purpose was to arm rheumatologists, as best as possible, for the fight.
“The most frequently asked question is whether our patients with immune-mediated inflammatory conditions are at increased risk for acquiring the infection, or for increased severity of infection if they do acquire it,” she said. “The short answer is: We don’t know.”
Regarding acquisition, Cassandra Calabrese stressed that social distancing is working, and that converting as many patient visits as possible to telehealth consultations is part of that equation. But when it comes to treatment decisions to potentially reduce the severity of infection, the picture becomes more complicated.
“Should patients risk coming to the clinic to receive biologic infusions?” she said. “We take this on a case-by-case basis.”
Leonard Calabrese addressed approaches to managing the cytokine storm that is seen in many of the most severe patients. “What is now becoming clear is that in many of the most severe patients, they are not dying of viremia, they are dying of damage mediated by an over-exuberant integrated immune response,” he said. “This is cytokine release syndrome, also called cytokine storm syndrome.”
He was careful to note that the cytokine storm seen in COVID-19 is fundamentally different from those seen in hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS) that may be familiar to rheumatologists. “It has its own unique fingerprint we are just starting to understand,” he said.
But evidence is beginning to show that the drugs used to treat those other storms may be working in severe COVID-19 cases. “In dealing with these most severe patients with COVID-19, we as rheumatologists can use the armamentarium that we use in these other syndromes, including IL-1 and IL-6 inhibition, along with interferon gamma,” he said.
Another key question about the rheumatology armamentarium pertains to growing shortages of hydroxychloroquine. Cassandra Calabrese suggested that patients using this medication for lupus or other conditions may decrease daily doses to extend supplies.
Both Calabreses noted that while these recommendations may hold true today, emerging data may change the landscape in a matter of days, or even hours. But Leonard Calabrese is certain that one thing will remain consistent: “We in the rheumatology community have a front and center place in the fight against COVID-19,” he said. – by Rob Volansky
Calabrese C, Calabrese LN. Stay on Your TIM. Presented at: United Rheumatology webinar “On Survival and Resilience: Managing A Rheumatology Practice Through the COVID-19 Pandemic”; April 17, 2020 (virtual meeting).
Disclosures: Leonard Calabrese reports consulting relationships with AbbVie, Centecor Biopharmaceutical, Crescendo Bioscience, GlaxoSmithKline, Horizon Pharma, Janssen Pharmaceuticals, Pfizer, Regeneron Pharmaceuticals and UCB. Cassandra Calabrese reports no relevant financial disclosures.