Continue or pause immunosuppressive therapy - a decision that currently confronts rheumatologists with a major challenge in the daily practice of many patients. Now a recent study has examined the influence of Covid-19 on the immune system in more detail and gives an overview of how to proceed with the individual antirheumatic therapies until the pandemic is successfully contained.
The spectrum of rheumatic diseases is large and so is the choice of possible antirheumatic treatment concepts. Both are reasons why the data on the effects of the current SARS-CoV-2 pandemic for a large number of rheumatological patients are too limited to make a clear, general treatment recommendation. However, how successful and by when the current vaccination will contribute to the final containment of the virus spread cannot be estimated at the moment.
In a recent study, therefore, the effects of different anti-rheumatic drugs were examined individually and in relation to different situations (without, mild, severe and after infection). From the results, the authors have drawn up the following recommendations for everyday practice.
Without suspicion of and after surviving SARS-CoV-2 infection, there is no evidence of negative effects of the drugs with regard to the disease, and the intake should therefore be continued unchanged. If inpatient treatment is indicated, it is recommended to pause NSAIDs. For cases of suspicion or positive test results without symptoms, the data situation is not clear; decisions must be made on a case-by-case basis.
The same procedure applies to the permanent intake of corticosteroids. Except that these are a fixed component in the therapy of severe courses of Covid-19 - independent of an existing underlying rheumatic disease. The administration of corticosteroids is therefore recommended during inpatient or intensive care treatment.
Even with immunosuppressants, it is recommended to continue the administration unchanged if there is no suspicion of a SARS-CoV-2 infection or if this has already been overcome. In all other cases - suspicion, positive test result or inpatient or intensive care treatment - the intake should be paused, according to the authors of the study.
Based on the data available so far, no clear recommendations can yet be made for all cases regarding the effects of colchicine on the risk of infection and the course of the disease in connection with SARS-CoV-2. The authors also advise continuing the use of colchicine in the absence of suspicion or after the infection has been overcome; in other situations, decisions must be made on an individual basis.
The same applies to DMARDs. The spectrum of preparations available in this substance class is very broad and the procedure differs between the individual drugs. In summary, it is recommended that the type and dosage of the drugs be maintained in the absence of suspicion and after a SARS-CoV-2 infection has been overcome. Chloroquine, hydroxychloroquine and biological (IL-6 based) DMARDs should be continued even with a suspected infection or after a positive test - however, it is often difficult to distinguish between side effects and Covid-19 related symptoms.
The situation is different for methotrexate, sulphasalazine and leflunomide, where continuation of therapy in the case of a suspected or confirmed infection is viewed critically and not recommended. The same applies to JAK inhibitors and biological DMARDs that act independently of IL-6.
Based on the data available so far, the summary recommendation for antirheumatic treatments is uniform: continue the type and dosage if there is no suspicion of a SARS-CoV-2 infection or start again if this has been overcome.
For all other situations, different approaches are recommended for each agent after the risk-benefit assessment to best strike the balance between the two risks - recurrence of the underlying disease and severe Covid-19 disease progression. Until the pandemic is successfully contained, this balancing certainly remains one of the greatest challenges in rheumatology practice.
Reference:
Ladani, Amit P., Muruga Loganathan, and Abhijeet Danve. 2020 Managing Rheumatic Diseases during COVID-19. Clinical Rheumatology 39 (11): 3245-54.