The first thing to say is that the pandemic is rapidly evolving, and our understanding of COVID and rheumatic disease is developing, so this article is a snapshot and the data may have changed by the time you read it.
The newly formed COVID-19 Global Rheumatology Alliance registry collected data from March to April 2020 and found that hospitalisations were twice as common in those taking prednisolone at over 10 mg a day. They also found that hospitalisations were 60% less frequent in those taking anti-TNF inhibitors. Conventional disease-modifying therapies like methotrexate were not associated with increased or reduced hospitalisation.
In a further analysis of their data looking at death rates rather than hospitalisations, COVID-19 related death was more common in the known risk factors - older age, males, high blood pressure, lung conditions – but also was higher in those with moderate or high disease activity and those who had particular drugs such as rituximab and sulfasalazine. This may reflect those with more severe diseases who are more unwell – it may not be a direct effect of the drug at all.
In a large US study of 32 thousand cases of COVID, methotrexate and anti-TNF were not associated with more hospitalisation or death.
The American College of Rheumatology published the 3rd version of their guidance in December. They are generally in favour of starting the treatments one would usually start. During COVID infection, they recommend stopping immunosuppressants other than IL-6 inhibitors (such as Tocilizumab and Sarilumab) and generally restarting therapies 7-14 days after the end of symptoms if the course of COVID was not severe, and for individual decision making in more severe cases. They recommend keeping the corticosteroid dose as low as possible to maintain control of the rheumatic disease. And of course, general measures such as hand washing, social distancing and mask-wearing, and reducing potential exposure to COVID-19.
So, the take-home message? It’s important that we continue to treat and control rheumatic diseases. Patients with severe diseases requiring intense immunosuppression are more vulnerable and should take particular care. It’s great to avoid large doses of corticosteroids at the moment where possible, even though dexamethasone reduces mortality in patients with COVID-19 requiring oxygen.
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