American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic:
Version 3 (Part 3)
We now continue our discussion on the guidelines of the American College of Rheumatology (ACR) for the management of rheumatic disease (RD) amid the Coronavirus disease (Covid) pandemic.
The ACR task force recognizes the need of physical distancing for all patients, including in the workplace when it is possible.
This is particularly important for vulnerable patients at increased risk of poor Covid outcomes such as the elderly and those with comorbidities. This is also critical to the medical frontliners.
There is a need to wear appropriate personal protective equipment (PPE), to minimize the spread of infection and these should be made available to the frontliners.
We know that angiotensin-converting enzyme 2 (ACE2) receptors are the gateway used by the Covid virus to enter the cells. Therefore there are concerns which have been raised regarding therapies known to increase ACE2 expression.
After acute lung injury, ACE2 levels are down-regulated in local tissue, which may lead to excessive activation of the renin–angiotensin–aldosterone system and worsen underlying pneumonia. This has led to the opposing conjecture that ACE inhibitors could be beneficial in the fight against an active infection. To date, however, there are insufficient clinical data to support the notion of either detrimental or beneficial effects of these ACE2 receptor drugs with respect to Covid.
The American Heart Association, Heart Failure Society of America, and American College of Cardiology have recommended continuation of ACE inhibitors for all patients who have been prescribed these agents, with careful deliberation preceding any change in these treatments. A cohort study shows that among patients with hypertension hospitalized with Covid, the use of ACE2 inhibitors as linked with significantly level of recovery.
The task force recommended continued use of ACE inhibitors per standard of care in rheumatic disease patients who are most likely to benefit from these drugs.
We will focus on other drugs that should be continued or not for patients with RD in our next column.