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Clinical Guide for Rheumatology Patients During the Covid-19 Pandemic

Rheumatology may not seem to be in the frontline with coronavirus, but we do have a key role to play. We have a high percentage of patients who are vulnerable and at increased risk of coronavirus

  1. Am I at risk doctor?

Generally, all Patients with rheumatic diseases have reduced immunity caused by their underlying disease, drugs and related comorbidities. The patients with a higher risk include the following

  • Patients with Co-morbidity includes: age >70, Diabetes Mellitus, any pre-existing lung disease, renal impairment, any history of Ischaemic Heart Disease or hypertension, Rheumatoid arthritis or Connective tissue related lung disease
  • Patients on high doses on drugs to treat rheumatic diseases
  • Patients on multiple combinations of drugs
  • Patients with active disease
  • Pregnant patients
  • Patients on biologic treatment- Biologics include Rituximab, Infliximab, Etanercept, Tofacitinib. For more information on what biologics are kindly consult your primary doctor
  1. Should I stop my current medicine due to the increased risk of infection? 
  • Discuss with each your doctor about the benefits of treatment compared with the risks of becoming infected. Due to the current pandemic your doctor may consider changes to your medicine. The changes include dosage, route of administration and mode of delivery.
  • Patients taking a NSAIDs for a long-term condition eg RA do not need to be stopped.
  • Patients must not suddenly stop prednisolone. This must be only be done in consultation with doctor
  • Patients can continue hydroxychloroquine and sulfasalazine if they are infected with coronavirus.
  • If a patient is infected with coronavirus, they should temporarily stop their conventional DMARD and biological therapy.
  1. What should I do self-isolate or keep social distancing?

After consultation with your doctor, the decision to isolate or not is dependent on a number of factors. Those at high risk need to undergo self-isolation until further advice from the doctor.

The British Society of Rheumatology and NICE recommend the following to undergo self-isolation

  • Cyclophosphamide at any dose orally or within last six months IV
  • Corticosteroid dose of ≥20mg (0.5mg/kg) prednisolone (or equivalent) per day for more than four weeks
  • Corticosteroid dose of ≥5mg prednisolone (or equivalent) per day for more than four weeks plus at least one other immunosuppressive medication*, biologic/ monoclonal** or small molecule immunosuppressant (e.g. JAK inhibitors) ***
  • Any two agents among immunosuppressive medications, biologics/monoclonal** or small molecule immunosuppressants with any co-morbidity****

 

The British Society of Rheumatology and NICE recommend the following patients to self-isolate or maintain social distance at their discretion

  • Well-controlled patients with minimal disease activity and no co-morbidities on single agent broad spectrum immunosuppressive medication, biologic/monoclonal** or small molecule immunosuppressant
  • Well-controlled patients with minimal disease activity and no co-morbidities on single agent broad spectrum immunosuppressive medication plus Sulphasalazine and/ or hydroxychloroquine
  • Well-controlled patients with minimal disease activity and no co-morbidities on a single agent broad spectrum immunosuppressive medication* at standard dose (e.g. Methotrexate up to 25mg per week) plus single biologic (eg anti-TNF or JAKi) ** or ***

* Immunosuppressive medications include: Azathioprine, Leflunomide, methotrexate, Mycophenolate (mycophenolate mofetil or mycophenolic acid), ciclosporin, cyclophosphamide, tacrolimus, sirolimus. It does NOT include Hydroxychloroquine or Sulphasalazine either alone or in combination.

** Biologic/monocolonal includes: Rituximab within last 12 months; all anti-TNF drugs (etanercept, adalimumab, infliximab, golimumab, certolizumab and biosimilar variants of all of these); Tociluzimab; Abatacept; Belimumab; Anakinra; Seukinumab; Ixekizumab; Ustekinumab; Sarilumumab;

*** Small molecules include: all JAK inhibitors – baracitinib, tofacitinib etc

**** Co-morbidity includes: age >70, Diabetes Mellitus, any pre-existing lung disease, renal impairment, any history of Ischaemic Heart Disease or hypertension. Patients who have rheumatoid arthritis (RA) or CTD-related interstitial lung disease (ILD) are at additional risk and may need to be placed in the shielding category. All patients with pulmonary hypertension are placed in the shielding category

  1. What about our clinic appointments and those who receive biologics and need admission to receive the medicine?
  • Low risk patients – continue as usual
    • Space follow up

 

  • High Risk patients – cut non-essential follow-up visits
    • adjust templates to minimize waiting times in department
    • option for telephone or video consultation
      • -unless absolutely necessary to see face to face
    • Stable patients can discuss with their doctors on risk vs benefit of deferring treatment of drugs like rituximab where applicable and possible

 

  • Patients on IV infusions of biologics can also discuss with their doctors of risk vs benefit of switching to oral or subcutaneous routes of administration where applicable and possible

For more information kindly consult your rheumatology doctor. 

Adapted from the BSR and NICE guidelines on patient management during Covid outbreak

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