Rare diseases

Stop arthritis treatments in patients exposed to coronavirus, ACR advises


Therapies for rheumatic disease such immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily for patients who are exposed to COVID19, according to new guidance issued by the American College of Rheumatology.

And in the case of documented or presumptive COVID-19 infection all rheumatic disease treatment except for hydroxychloroquine and possibly IL-6 inhibitors should be stopped, according to the advice for adult patients compiled by an ACR Task Force comprising 10 rheumatologists and 4 infectious disease specialists.

Overall, the guidance recommends no changes be made to ongoing treatment of stable patients in the absence of infection or SARS-CoV-2 exposure.

Therapies such as sulfasalazine, methotrexate, leflunomide, immunosuppressants, biologics, JAK inhibitors and NSAIDs may be continued, it advises

The ACR guidance warns against stopping glucocorticoids in the absence of infection, though it says steroids should be used at the lowest dose possible to control rheumatic disease, regardless of exposure or infection status.

Similarly immunosuppressants should not be dose-reduced for patients with a history of vital organ-threatening rheumatic disease.

The ACR guidance suggests that patients unable to access HCQ should switch to a different conventional synthetic DMARD (either as monotherapy or as part of combination therapy).

In the context of the COVID-19 pandemic, the ACR advises that conventional synthetic DMARDs may be started or switched in patients with active or newly diagnosed inflammatory arthritis. Biologics may also be started in patients who have moderate to high disease activity despite optimal csDMARDs, though the ACR panel notes uncertainty regarding the use of JAK inhibitors in this situation.

For patients who have been exposed to SARS-CoV-2 the ACR advises that immunosuppressants, non-IL-6 biologics, and JAK inhibitors be stopped temporarily, pending a negative test result for COVID-19 or after 2 weeks of symptom-free observation. HCQ, sulfasalazine and NSAIDs may be continued but there is uncertainty around temporarily stopping methotrexate or leflunamide, the ACR says. It advises that IL-6 inhibitors may be continued “in select circumstances, as part of a shared decision-making process.”

In the case of documented or presumptive COVID-19 infection the ACR advises that sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped or held.

The panel advises that NSAIDs be stopped in patients with severe respiratory symptoms, NSAIDS but could not agree on advice about stopping NSAIDs in the absence of severe symptoms.

“In select circumstances, as part of a shared decision-making process, IL-6 inhibitors may be continued,” it advised.

The ACR cautions that the guidance statements  are not intended to replace clinical judgment. and that any changes to treatment must be individualised as part of a shared decision-making process.

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