EULAR COVID-19 Recommendations Say Continue Medications, but Vaccinate

The European Alliance of Associations for Rheumatology (EULAR) has issued provisional treatment recommendations for patients with rheumatic and musculoskeletal conditions (RMD) who have contracted SARS-CoV-2 or tested positive for COVID-19.

The guidelines were presented last week at the EULAR annual meeting and published simultaneously in the Annals of the Rheumatic Diseases.

“SARS-CoV-2 is a new virus and COVID-19 a new disease. Scientific knowledge is rapidly accruing, but methodologically robust information from well-controlled trials and experiments is lacking to date. In contrast, we face a flood of unreliable largely uncontrolled studies and even fake news,” Dr. Landewe and colleagues wrote in the journal. “People with RMD appropriately confront their [healthcare provider] with questions about treatment implications and COVID-19-associated anxiety. In turn, [healthcare providers] may feel uncertain about how to advise in the best interest of their patients. Therefore, EULAR decided not to wait until robust scientific knowledge becomes available, but to deviate from their standard operating procedures and to convene a task force of international experts to provide provisional guidance for rheumatologists, health professionals rheumatology and patients with rheumatic and musculoskeletal diseases.”

Initially, it was presumed that autoimmune patients would be more susceptible to COVID-19, but to date, that has not proven to be true, Dr. Landewe said. “There is no evidence that patients with RMD face more risk of contracting SARS-CoV-2 than individuals without RMD, nor that they have a worse prognosis when they contract it,” he wrote.

RELATED: ACR Issues COVID-19 Treatment Guidance for Rheumatic Disease Patients

In as such, patients with rheumatic and musculoskeletal conditions should follow the same preventive measures a the rest of the population.

“According to current knowledge, patients with RMD should not be managed differently than individuals without RMD. It is currently unknown whether a specific RMD or treatment with a specific drug influences the risk (increase, decrease or no change in the risk) of developing COVID-19. While many advisories, including official government bodies in some countries, postulate an increased risk for patients with inflammatory/autoimmune diseases or those using immunosuppressive drugs, since they extrapolate existing data stemming from registries that such patients have increased risk of some infections, it should be stated clearly that such an association for SARS-CoV-2 and COVID-19 has not (yet) been established,” the authors wrote.

A task force of 20 physicians settled on five overarching principles and 13 recommendations, which are similar to COVID-19 treatment guidelines issued by the American College of Rheumatology in April, but with some slight variations.

Some of the EULAR recommendations include:

• Continuation of medication:  Patients should continue NSAIDs, glucocorticoids, sDMARDs, bDMARDs, osteoporosis medications and analgesics, and other medications as originally prescribed unless they have suspected or confirmed COVID-19. By contrast, the American College of Rheumatology recommends extending the time between doses of denosumab to as long as eight months, in part, due to limited access to infusions.

• Regular doctor visits:  Regular face-to-face rheumatology and blood monitoring visits can be postponed if the underlying condition and related drug treatment are stable with no signs or symptoms of drug toxicity. Consider remote visits if necessary.

• Doctor visits:  For patients with active rheumatic or musculoskeletal disease who have just started their treatment for the first timeor their treatment needs adjustment or they have signs of toxicitythe patient and doctor should decide together whether the risk of an in-person visit is warranted.

• Continuation of glucocorticoids:  This treatment should be continued for patients who use them regularly.

• COVID-19 symptoms:  Treatment changes for DMARDs should be discussed on a case-by-case basis in cases when COVID-19 symptoms are present.

• Worsening symptoms:  Patients should immediately seek a consult with a pulmonologist, internist or infectious disease expert.

• Vaccinations: Asymptomatic rheumatic and musculoskeletal patients with should update their vaccination, with a particular focus on pneumococci and influenza

• Pneumonia: Patients with severe lupus, severe Pasculitis or systemic sclerosis, among others, should consider Pneumocystis Jiroveci pneumonia (PJP) prophylaxis in place of cyclophosphamide or glucocorticoids. It was included because this particular pneumonia may be clinically confused with COVID-19 pneumonia. “And since PJP is an avoidable condition, it may be expected that the coexistence of PJP and COVID-19 pneumonia implies a worse prognosis.

“EULAR considers this set of recommendations as a ’living document’ and a starting point, which will be updated as soon as promising new developments with potential impact on the care of patients with RMD become available,” Dr. Landewe and colleagues wrote in the journal.

REFERENCE

Landewé RBM, et al. “EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2,” Annals of the Rheumatic Diseases. 2020;0:1–8. doi:10.1136/annrheumdis-2020-217877