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Quiz: What RA drugs are under study as possible COVID-19 treatments?
The American College of Rheumatology has issued a series of COVID-19 guiding principles for healthcare professionals who treat patients with rheumatic disease. In this quiz, we highlight a few of the key points the organization, and other healthcare experts, have made in recent weeks.
The American College of Rheumatology has issued a series of COVID-19 guiding principles for healthcare professionals who treat patients with rheumatic disease. In this quiz, we highlight a few of the key points the organization, and other healthcare experts, have made in recent weeks.
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Are patients with rheumatoid arthritis at greater risk of a COVID-19 infection?
a) Yes
b) No
SOURCE: U.S. Department of Health and Human Services, “What to Know About Rheumatic Disease and the COVID-19 Coronavirus”
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Answer: a) Yes
As rheumatoid arthritis is an autoimmune disorder, patients with the condition face a greater risk of COVID-19 infection than the general population and may be at greater risk of complications, such as pneumonia. Use of certain rheumatological treatments, in particular, disease-modifying anti-rheumatic (DMARDs) drugs and immunosuppressants, may heighten that risk of infection further.
SOURCE: U.S. Department of Health and Human Services, “What to Know About Rheumatic Disease and the COVID-19 Coronavirus”
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Should patients with rheumatoid arthritis stop taking their regular rheumatoid arthritis medication as the drugs increase their risk of COVID-19?
a) Yes
b) No
SOURCES:
Favallia EG, Ingegnoli F, De Lucia O et al. “COVID-19 infection and rheumatoid arthritis: Faraway, so close!” Autoimmunity Reviews https://doi.org/10.1016/j.autrev.2020.102523
Rheumatology Network, “Ibuprofen Covid-19 Warning May Be Premature”
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Answer: b) No
Patients should continue taking their rheumatoid arthritis medication as normal unless advised to do otherwise by their rheumatologist. Stopping treatment can lead to flares, requiring corticosteroids which may further increase the risk of viral infection, according to Favallia EG, et al. writing in Autoimmunity Reviews.
Any decision to stop or change a medication should be individualised and made following a discussion with the patient about the risks and benefits of continuing, stopping or modifying treatment.
Rheumatology professionals should consider proactively contacting patients with the most serious disease to discuss their treatment. At the same time emphasising the importance of good hygiene practices, particularly hand washing, and maintaining social isolation.
In some instances, patients may be able to stop their immune suppressive treatment temporarily or reduce their dosing.
There have been a lot of headlines linking anti-inflammatory drugs, in particular, ibuprofen, to greater risk of more serious COVID-19 infections. However, the evidence is limited. While it makes sense for patients with COVID-19 to take paracetamol rather than ibuprofen to reduce fever, most patients experiencing benefit from long-term use of anti-inflammatories for their rheumatoid arthritis should continue to take them.
Prednisolone should not be stopped suddenly, and rheumatology professionals should think carefully about the need for prescribing oral corticosteroids.
SOURCES:
Favallia EG, Ingegnoli F, De Lucia O et al. “COVID-19 infection and rheumatoid arthritis: Faraway, so close!” Autoimmunity Reviews https://doi.org/10.1016/j.autrev.2020.102523
Rheumatology Network, “Ibuprofen Covid-19 Warning May Be Premature”
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According to the American College of Rheumatology, maintaining hydroxychloroquine is most important for which group of patients?
a) Covid-19 patients
b) All rheumatology patients
c) Rheumatoid arthritis patients
d) Systemic lupus erythematosus (SLE) patients
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Answer: d)
Hydroxychloroquine is a drug primarily used to prevent and treat malaria, but it is also used to treat some rheumatoid conditions. Some research has suggested that hydroxychloroquine can effectively treat the COVID-19 virus. The drug is being tested in patients with COVID-19. Excitement surrounding the drug has led to dramatically increased demand, shortages and price hikes.
The American College of Rheumatology (ACR) says that hydroxychloroquine is an essential medicine for patients with systemic lupus erythematosus (SLE) and is also a mainstay of therapy for many patients with rheumatoid arthritis.
While every effort must be made to ensure an adequate supply of hydroxychloroquine for all patients who need it, adequate supplies of hydroxychloroquine should be allocated for patients with SLE, especially pregnant SLE patients and those in whom even brief drug holidays would be reasonably expected to cause a flare of their disease or require a switch to an alternative regimen with less efficacy and/or safety, according to the ACR.
Hydroxychloroquine is the only medication shown to increase survival in lupus patients so should be used in every patient unless it is contraindicated. Withdrawal of hydroxychloroquine from SLE patients for periods even as short as two weeks is associated with flares even in those with previously clinically stable disease.
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Name three drugs for rheumatoid arthritis that are being tested in clinical trials for use in COVID-19 patients.
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ClinialTrials.gov shows there are currently 374 active clinical trials or new trials that are not yet recruiting. At present time, hydroxychloroquine seems to be the most promising, but it has not yet undergone extensive clinical trials testing as trials have just begun. The drug is currently used primarily to prevent and treat malaria, but it is also used to treat some rheumatoid conditions. Clinical trials are taking place with the drug and the Food and Drug Administration has issued an emergency use authorization, allowing hydroxychloroquine to be prescribed by doctors to hospitalized patients with COVID-19 if enrolment to a clinical trial is not available or feasible, according to the U.S. Department of Health and Human Services.
Clinical trials are also taking place with tocilizumab and sarilumab. These are human monoclonal antibodies against the interleukin-6 receptor (IL-6R). Interleukin 6 (IL-6) is a cytokine that plays an important role in immune response.
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Which of the following does the American College of Rheumatology consider a reasonable approach for managing patients with rheumatoid arthritis while shortages of hydroxychloroquine persist?
a) Dose reductions
b) Extended dosing intervals
c) Limiting refills to 30 days
d) Initiations of hydroxychloroquine in outpatients require approval of a rheumatology health professional
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Answer: All options
The American College of Rheumatology says decisions about allocation of hydroxychloroquine should be made locally with input from rheumatology health professionals who are experts in the management of hydroxychloroquine and rheumatologic conditions for which hydroxychloroquine is FDA-approved.
Hydroxychloroquine dose reductions and extended dosing intervals tailored to an individual patient’s needs are reasonable when faced with hydroxychloroquine shortages, it says. Limiting hydroxychloroquine refills to 30 days for patients prescribed hydroxychloroquine prior to the COVID-19 pandemic is reasonable if local circumstances necessitate such action. Restricting new starts of hydroxychloroquine in the outpatient setting, pending approval by a rheumatologist or rheumatology health professional, may be reasonable in settings where rheumatologists and rheumatology health professionals are available to fulfill this role.