Many patients have been asking what they should do with their arthritis medications during the COVID-19 pandemic.
In the vast majority of cases, the short answer should be – keep taking them.
Patients with inflammatory and autoimmune rheumatic diseases are at increased risk of a range of infections. This is predominantly due to disease factors, rather than treatment, but studies that look at risk of infection in patients taking DMARDs and immunomodulators for rheumatic disease show that azathioprine, cyclophosphamide and, above all, corticosteroids, confer significant risk. Methotrexate, antimalarials and other DMARDs do not appear to increase infection risk significantly.
TNF-inhibitors are responsible for a small increase in risk of serious infection, and the sensible advice is to discontinue these agents during systemic infection and to resume treatment once the infection has resolved.
There are no data to date on the effect of conventional and biologic DMARDs on risk of acquiring or dying from COVID-19. In 2009 the British Society for Rheumatology and the Australian Rheumatology Association both recommended stopping all immunosuppressive and biological therapy for 7 days following exposure to confirmed swine flu. Although this does not seem to be evidence-based, it is at least unlikely to result in a flare of disease.
Death from COVID-19 has been linked to various comorbidities, and the risk seems to be proportional to the number of comorbidities, which may include systemic inflammation. Since corticosteroids increase risk of infection, and these drugs are commonly used to treat flares of rheumatic disease, it would be better to continue DMARDs that confer little or no increased risk of infection than to substitute them with corticosteroids that confer a higher risk.
There have been reports that NSAIDs worsens outcome in COVID-19 infection, which the WHO initially endorsed, but later retracted this endorsement saying that it was not supported by evidence. People with arthritis can continue to use NSAIDs during the current pandemic.
In summary, during the COVID-19 pandemic, patients with rheumatic diseases should:
- Continue treatment with conventional and biological DMARDs.
- Continue to use NSAIDs if required.
- Avoid corticosteroids if possible, or take them at the lowest effective dose.
- Have the seasonal flu vaccine as early as possible, and consider having pneumococcal vaccine (especially the elderly).
- Pay particular attention to hand washing and whatever measures are recommended for their demographic to minimize risk of exposure.
- Attend their rheumatology appointments if possible, but ask about telephone consultations if they are unable or reluctant to attend.
- Discuss any changes in their treatment with the rheumatology service if they develop COVID-19 infection.
Source: New Zealand Rheumatology Association, 2020