New interim guidelines for rheumatic and musculoskeletal diseases management in the context of COVID-19

01 Sep 2020

During the EULAR 2020 e-congress, Dr. Robert Landewé, MD, Ph.D., Professor of the Amsterdam Rheumatology Center at the University of Amsterdam, and chair of the Department of Rheumatology at the Zuyderland Medical Center Heerlen, the Netherland, shared his perspective on the provisional EULAR recommendations for patients with rheumatic musculoskeletal disease (RMD) and their caregivers during the COVID-19 pandemic.

Dr. Landewé started the webinar by summarizing the highlights of the five overarching principles of the 13 updated recommendations. He noted, “There is no indication that patients with RMD have a higher risk of contracting [COVID-19], or that they fair worst.”

Dr. Landewé continued, “For the second overarching principle, we as a task force think that when it comes to managerial discussions, such as whether or not to stop or start treatment, rheumatologists should be involved. Immunosuppressive drugs are often stopped by medical specialists involved in the care for COVID-19 that lack expertise in treating patients with RA, and we should avoid that situation. The third highlight is that when we are talking about treating COVID-19, the current situation is a situation in which we may face potential shortages of synthetic disease-modifying antirheumatic drugs (DMARDs).”

Per recommendation, the off-label use of DMARDs for COVID-19 should be discouraged. Furthermore, the management of COVID-19 should be a multidisciplinary approach led primarily by a pulmonologist or an infectious disease specialist. The rheumatologist's expertise for the usage of immunosuppressive drugs is also critical.1

The 13 recommendations are categorized into four themes. The first theme relates to the general measures for preventing virus infection. These recommendations include advising RMD patients to strictly adhere to the same safety measures as those without RMDs. RMD patients without COVID-19 are to continue with their RMD regimens.1

The second theme pertains to patient management during the COVID-19 pandemic. Dr. Landewé said, “First, the task force advises RMD patients to avoid visits to the hospital or the office. Task forces agree unanimously that remote monitoring is safe.” However, if RMD patients experience signs or symptoms of drug toxicity or require drug dosing adjustments, the EULAR recommendation states that the importance of a clinical visit is to be determined by risk assessment by both the rheumatologist and the patient.1

Nonetheless, if a physical visit is required, hospital staff and rheumatologist are to comply with the preventions and control guidelines for COVID-19. Furthermore, the experts agreed that patients with rheumatic disease exhibiting symptoms of COVID-19 are recommended to continue treatment for their chronic RMD conditions while being tested for COVID-19.1

Consequently, if the RMD patients are positive for COVID-19, the third theme revolves around the recommendations for the management of COVID-19 in the context of RMD. RMD patients in close contact with COVID-19 positive individuals are recommended by the task force to test for COVID-19 infection.1 Rheumatologists are to proceed accordingly with glucocorticoids regimen for RMD patients with COVID-19 symptoms: RMD patients with mild COVID-19 symptoms is defined by EULAR as nasal congestion, elevated body temperatures (<100.4°F), and sore throat, are to receive tailored treatment regimen on a case by case basis; RMD patients experiencing mild but worsening COVID-19 symptoms should consult experts specializing in treating COVID-19.1

Finally, the fourth theme pertains to the prevention of infections other than COVID-19. Particularly, there is a need to avoid confusion between COVID-19 and phenotypical mimics. For RMD patients treated with cyclophosphamide or glucocorticoids, pneumocystis jiroveci pneumonia prophylaxis should be considered as the clinical symptoms may be confused with COVID-19 pneumonia. Also, rheumatologists should update their RMD patients on vaccination status, namely pneumococci and influenza, to avoid severe morbidity due to neglected coexisting infections.1

In essence, Dr. Landewé emphasized that although the current evidence is extremely sparse and fragmented, he believes that these strategies are imperative for managing patients with RMD during this COVID-19 pandemic.

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