Guidance from the American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients during the COVID-19 Pandemic: Version 3
(Part 7)
We now continue with our discussion of the use of conventional synthetic disease modifying antirheumatic drugs (csDMARDS) for the treatment of rheumatic disease (RD) for patients who are at risk of getting infected with the SARS-CoV-2 virus, which is the contagion that causes the Coronavirus disease (Covid).
The American College of Rheumatology (ACR) task force recommends the temporarily withholding of hydroxychloroquine (HCQ)/ chloroquine (CQ) following SARS–CoV-2 exposure or infection. This is a change from the prior guideline issued by the ACR for patients with RD.
The change is due to the potential for cardiotoxicity that could be exacerbated in the context of Covid and the receipt of other similar agents that are commonly used among hospitalized patients.
Protocols insist for the need for cardiac monitoring in order to reduce the potential of adverse cardiac events that could be linked to HCQ/CQ,in the context of severe Covid infection.
Knowing the nature of antimalarial drugs, such monitoring may be implemented in high-risk patients with Covid even in circumstances where the use of these kinds of drugs has been withheld.
As with sulfasalazine (SSZ), the task force believes that temporary halting of the use of these drugs would be unlikely to result in significant risk of RD flares.Biologics, immunosuppressants, and Janus kinase (JAK) inhibitors are linked with an heightened risk of serious infection compared to conventional DMARDs.
Pieces of information have focused on the risk of bacterial and other kinds of infections. Less attention is given to viral respiratory infections. There is an observation about the increased risk of herpes zoster with the use of JAK inhibitors.
Studies done in the context of RD, the tapering or discontinuation of biologics or JAK inhibitors suggest that a large percentage of patients experience RD flare. This is significant because inflammation or disease activity are known as a risk factor for infection.
These data provide support for the task force’s recommendation to continue all immunosuppressants in patients with stable RD in the absence of Covid exposure.
We will continue next week as we discuss the next installment of the use of csDMARDs for those people with RD in the face of Covid exposure.