Sign up to receive posts from The Exchange
Posted By: Richard S. Pope, PA-C, MPAS
October 09, 2020
Since COVID-19 will continue to be with us for some time, patients on disease modifying antirheumatic drugs (DMARDs) may discontinue therapy on their own due to warnings about "those who are immunosuppressed" having a higher purported likelihood of COVID-19 infection. Several patients have admitted to me that they had held their medications without notifying their practitioner due to fears of contracting the virus and beliefs that their DMARD would put them at increased risk of infection. To date, management strategies that rheumatologists have taken for those who are at higher risk for COVID-19 include spreading out the dosing frequency while still attempting to control the rheumatoid arthritis (RA).
A more detailed approach is available from the American College of Rheumatology (ACR), which has proposed recommendations for adult patients with RA taking DMARDs in the context of COVID-19. The ACR recommendations encompass two main categories: Those who have been exposed to SARS-CoV-2 and those who are documented or presumed positive for SARS-CoV-2.
According to the recommendations, patients exposed to SARS-CoV-2 may continue to take hydroxychloroquine (HCQ), chloroquine (CQ), sulfasalazine (SSZ), and nonsteroidal anti-inflammatory drugs (NSAIDs). The panel was uncertain about continuing methotrexate and leflunomide; the use of these two medications should be decided based on individual patient risk factors. Those who were exposed to SARS-CoV-2 and who have been taking biologics and targeted synthetic DMARDs—including tumor necrosis factor inhibitors, abatacept, anakinra, rituximab, and Janus kinase (JAK) inhibitors—should temporarily halt their medications until a negative COVID test is returned, or after 2 weeks of being symptom free. The interleukin (IL)-6 inhibitors tocilizumab and sarilumab may be continued as a part of a shared decision-making process in light of IL-6 inhibition being recently employed as a management option for the cytokine storm associated with COVID-19 in some patients.
For those with documented or presumptive COVID-19, regardless of severity, HCQ and CQ may be continued, but SSZ, methotrexate, leflunomide, biologics, and JAK inhibitors should be stopped. In patients with severe respiratory symptoms, NSAIDs should be stopped. Here again, IL-6 inhibitors may be continued as part of a shared decision-making process between the clinician and the patient.
You may already have fielded questions on this issue from adult patients with RA who are on DMARDs and will likely do so in the future as we continue with this pandemic. Most often, rheumatologists or NPs and PAs working in rheumatology will answer these questions, but it is always helpful to know what goes in to making these decisions. You can access these recommendations about RA and other rheumatic diseases in the context of COVID-19 here.
- American College of Rheumatology. ACR updates: COVID-19. www.rheumatology.org/announcements. Accessed October 9, 2020.
- Mikuls TR, et al. American College of Rheumatology guidance for the management of rheumatic disease in adult patients during the COVID‐19 pandemic: Version 2. Arthritis & Rheumatol. 2020;72:e1-e12.