ACR Clinical Guidance in Treating Rheumatic Diseases

ACR Clinical Guidance in Treating Rheumatic Diseases

by Kelly O'Neill, RA Warrior

New ACR guidance during COVID-19

The precise risks with COVID-19 for people with autoimmune diseases or who take immune suppressant treatments are not yet known. Last week, the American College of Rheumatology (ACR) published guidelines for the treatment of rheumatic diseases like rheumatoid disease (RD) during the coronavirus pandemic. This guidance is intended to assist rheumatology providers in making treatment decisions with their patients. However, the ACR advises that their guidance is still evolving while evidence about how this virus interacts with rheumatic diseases and treatments is still developing. (More on that evidence below.)

Considering what’s best for you right now

The new recommendations are summarized below. We hope that people with rheumatoid disease (PRD) can be aware of the guidelines and make the best decisions for them with their doctors, based on their own situations. Things that PRD will need to consider include:

  • The totality of your multiple diagnoses (comorbidities and complications are common in RD)
  • Your level of general health and disease activity level
  • Your combination of medications 
  • Whether your job (or location) increases your exposure to the virus
  • Whether you are able to stay home or work from home

The ACR acknowledges that clinical judgment is required along with the guidelines. Even during usual times with guidelines that are well researched, this is the case. As we know, our immune systems are unique, which makes treating this disease especially challenging. Treatment plans must frequently be individualized or adjusted for unique patients. Keep this mind while reviewing the recommendations and talking with your doctor or nurse.

The recommendations

1. The first section is general guidance, which includes common suggestions for infection avoidance. Patients should remain on the lowest possible doses of corticosteroids, but should not be stopped abruptly. Providers should reduce in-person healthcare encounters where possible. Patients should use social distancing and hygiene measures to avoid infection. Use of ACE inhibitors or angiotensin receptor blockers should be continued.

2. The second section addresses patients whose disease is stable and have not been exposed to the coronavirus.

  • For patients with “vital organ-threatening rheumatic disease, immunosuppressants should not be dose-reduced.” 
  • Denosumab (Prolia or Xgeva) dosing intervals should be extended, but no longer than 8 months. 
  • The following treatments should be continued: Hydroxychloroquine (HCQ) or chloroquine, other disease modifying drugs (DMARDs): sulfasalazine, methotrexate, leflunomide, immunosuppressants including tacrolimus, cyclosporine, mycophenolate mofetil, and azathioprine, biologics, JAK inhibitors, and non-steroidal anti-inflammatory drugs (NSAIDs).

3. The next section addresses patients with lupus. HCQ may be initiated in newly diagnosed patients or pregnant women. Belimumab may be initiated if indicated.

4. The ACR then discusses patients with “active rheumatic diseases,” which may include many of our readers or members.

  • HCQ or an IL-6 inhibitor may be continued on patients well controlled by these DMARDs. If HCQ is unavailable, another DMARD should be considered, or another biologic in the case of an IL-6 inhibitor.
  • For patients with moderate to severe disease activity despite other DMARDs, biologic DMARDs may be started.
  • For active or newly diagnosed patients, conventional synthetic DMARDs (non-biologic and non-JAK inhibitor) may be started or switched.
  • If indicated, low-dose steroids (?10mg) or NSAIDs may be started.

5. Patients with other rheumatic diseases with “systemic inflammatory or vital organ-threatening disease” (such as lupus or vasculitis), high-dose steroids or immunosuppressants may be started. Newly diagnosed Sjögren's patients should not be started on HCQ.

6. For treatment of stable patients with exposure to the virus, but no symptoms: HCQ, sulfasalazine, and NSAIDs may be continued. Immunosuppressants, non-IL-6 inhibiting biologics, and JAK inhibitors should be discontinued temporarily, pending a negative COVID-19 test or 2 weeks symptom free. The panel noted uncertainty in suspending methotrexate and leflunomide in this scenario.

7. Disease treatment with a COVID-19 infection is recommended as follows: Patients can continue HCQ, chloroquine, and IL-6 inhibiting biologics, but all other treatments should be suspended. Patients with severe respiratory symptoms should stop NSAIDs.

There was moderate consensus that IL-6 inhibitors may be continued in some patients who are either exposed or infected with the virus. This is likely due to pending results of ongoing studies with IL-6 inhibitors and COVID-19.

A TIME OF UNCERTAINTY

During the past few weeks, I’ve seen numerous PRD saying they’ve delayed or suspended disease treatment on their own. We, the RPF encourage you be informed to make the best possible decisions for you, together with your rheumatology doctor or nurse whenever possible. At this point, there are few published studies and little solid evidence to inform these decisions related to COVID-19. Part of the ACR’s role is to make evidence-based recommendations to doctors (their members). Their COVID-19 recommendations are a result of consensus (votes) of an expert panel with the limited data available. For more information, please see the links below.

To help improve the evidence for rheumatology, we encourage you—if you have not already—to take the patient survey at the COVID-19 Global Rheumatology Alliance, and also continue to help spread the word to your own doctors about the case registry here.  http://rheum-covid.org/

For more information 

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