American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 3
(Part 8)
We now continue our discussion on the use of conventional synthetic disease modifying antirheumatic drugs (csDMARDs) in the face of possible infection from Coronavirus disease (Covid) among patients of rheumatic disease (RD).
Emerging data suggest that some immunosuppressants, biologics, and/or Janus kinase (JAK) inhibitors could may mitigate the impact of Covid. This means, these agents are favored for continued use in the management of RD.
Mycophenolate mofetil (MMF), is linked with improved potential of recovery from Covid infection, according to data. The use of this agent is linked with improved survival following Middle East Respiratory Syndrome (MERS-CoV) infection. It has been known that cyclosporin (CSA) may reduce the growth of the virus based on in vitro studies.
Baracitinib, which is a JAK inhibitor, may interfere with cellular endocytosis and may slow down the possibility of cellular entry of the virus, which is responsible for Covid.
It is not totally known if these drugs may indeed have an impact with the risk of infection as the studies so far have been small.
The use of tocilizumab was linked with huge improvement of patients infected with Covid.
Hyperinflammation and cytokine storm may play a huge role in the severe symptoms of Covid. For this reason some cytokine suppressants with glucocorticoids and other targeted small molecules) are pushed as potential treatments for patients with RA and infected with Covid.
However, randomized control trials (RCT) are being done to ascertain the ability of these agents to help people with Covid.
The task force of the American College of Rheumatology recommended to continue all non–interleukin (IL)-6 biologics, immunosuppressants could be continued in the midst of Covid infection.
Similarly, the task force have approved some recommendations of restarting the treatment that were discontinued following the diagnosis of a Covid infection.
The task force did not favor the use of polymerase chain reaction (PCR) test or Covid virus antibody testing to guide the restart of halted RD treatments due to infection.
PCR results in some patients have remained positive for periods nearly 30 days, which is well after patients are known to be infectious.
The need for a negative PCR result before restarting treatment could therefore lead to unnecessarily long delays. It may also result in higher risk of RD flare.
Longer delays in restarting the treatment may be possible in patients who test positive but remain asymptomatic.
In patients with severe Covid, which are those which require hospitalization, the task force understands decisions regarding restart of RD treatment should be made on a case-by-case basis.
We shall continue with our discussion on this topic next issue.