Public health

Rheumatologists urged to get involved in COVID-19 treatment discussions: EULAR

The first expert recommendations on the management of rheumatic diseases during the COVID-19 pandemic has urged rheumatologists to involve themselves in multidisciplinary discussions on patient management.

Presenting the preliminary recommendations to the EULAR 2020 virtual congress, Professor Robert Landewè, a Professor in rheumatology at the Academic Medical Center at the University of Amsterdam, the Netherlands, said that while it was not the place of the rheumatologist to diagnosis and treat patients with COVID-19, they should be involved in patient management discussions on whether to stop or start treatments for rheumatic diseases (RMDs).

“I mention this because I know that in practice something that happens very often is that immunosuppressive drugs are stopped by medical specialists who are involved in the care of COVID-19 but without any expertise in treating patients with rheumatic diseases… we should try to avoid that situation,” he told delegates attending the virtual congress.

The EULAR COVID-19 recommendations are based on five overarching principles that all received high agreement from the 15 member taskforce:

  1. To date there is no evidence that patients with RMD face more risk of contracting SARS-CoV-2 than individuals without RMD, or that they have a worse prognosis when they contract it (level of agreement (LOA*) 84%).
  2. The diagnosis and treatment of COVID 19 in patients with RMD is the primary responsibility of an expert in treating COVID-19, such as a pulmonologist, an internist or a specialist in infectious disease, dependent on local circumstances (LOA 84%)
  3. Rheumatologists are the leading experts for the immunosuppressive treatment of their patients and should be involved in the decision to maintain or discontinue them. (LOA 89%)
  4. The knowledge about immunosuppressive treatments, including sDMARDs and BDMARDs for the treatment of severe COVID-19  is rapidly evolving. In view of their expertise, rheumatologists should make themselves for local-hospital, regional  or national guideline committees for COVID-19. The use of immunosuppressive drugs for the treatment of COVID-19 should be a multidisciplinary decision. (LOA 84%).
  5. Availability of, and distribution of, and access to, sDMARDs and bDMARDs for the treatment of RMDs as well as for patients with COVID-19 (but without RMD) is a delicate societal responsibility. Therefore, the off-label use of DMARDs in COVID-19 outside the context of clinical trials should be discouraged. (LOA 89%)

*The level of agreement (LOA) was the number of members who voted 8 out of 10 or more

The recommendations also capture four themes: general measures and prevention of SARS-CoV-2 infection; management of RMD patients during the pandemic; management of patients with RMDs who have COVID-19; and the prevention of other pulmonary infections in patients with RMDs.

According to Prof. Landewè one of the highlights from the recommendations included advice that glucocorticoids should be continued for patients who have come into contact with COVID-19, but at the lowest possible dose.

But for patients with mild COVID-19 the situation was not so clear, with the taskforce unable to reach a consensus.

“It depends a little bit on the country you live in… but because it was impossible to reach consensus the task force actually agreed to disagree and decided that it was best to leave the decision to the patient and the physician in a one-to-one encounter, so on a case by case basis,” Prof. Landewè said.

“If a patient feels safer by temporarily discontinuing the drug so be it, if the doctor does not want to continue the drug because he/she feels safety stopping the drug, then do that”.

If a rheumatology patient had worsening COVID-19 symptoms the best advice was to seek expert advice immediately and follow local treatment recommendations.

“The rheumatologist is not the expert to treat COVID-19, that belongs to the pulmonologist, the infectious disease specialist, or maybe the intensive care doctor,” he stressed.

Professor Landewè concluded that current evidence was sparse and fragmented which meant the task force was largely ‘flying blind’.

“We have to cover many jurisdictions within Europe with many conflicting opinions so updates are truly necessary but we have to wait a while,” he added

The recommendations are published  in the Annals of the Rheumatic Diseases. For a full text copy click here.

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