ACR’s COVID-19 Clinical Guidance for Adults with Rheumatic Diseases

May 2020

The American College of Rheumatology (ACR) COVID-19 Task Force has developed a “living document” (that will be updated as new information comes in) to help support doctors and patients in the management of adults with rheumatic and autoimmune diseases throughout the COVID-19 pandemic. In the case of exposure to the virus, the document can be used as a tool to help guide risk assessment, infection prevention, and any potential treatment modifications. Due to limited research into how COVID-19 affects those with a rheumatic disease such as spondyloarthritis, we stress that these guidelines are not to be used to limit treatment options available to those with a rheumatic disease, and that individual clinical judgment and shared decision making with patients are highly advised.

The task force consisted of 10 rheumatologists and 4 infectious disease specialists practicing in the United States. Clinical questions were collected, and available evidence and research gathered for review by the task force. The task force members then used a 9-point numeric scoring system to vote on a list of suggested guidelines to answer the clinical questions. Only statements considered moderate to high in importance were included. The initial 77 guidance statements that were grouped into moderate and high importance were later combined to create the 25 final guideline recommendations.

Currently there is not enough data linking rheumatologic treatments and complications of COVID-19. The task force will update the guidelines as new information is released. The guidelines focus on the following three components:

• • Risk Factors: Currently, there is no evidence suggesting that having a rheumatic disease in of itself is a risk factor for severe COVID-19, or poor outcomes from COVID-19. Based on previous studies, poor outcomes with COVID-19 are associated with older age (e.g., >65) and select diseases such as chronic lung disease, hypertension, cardiovascular disease (CVD), chronic kidney disease (CKD), obesity, and diabetes mellitus – which are conditions that tend to be more common in those with rheumatic diseases than in the general population.
  • Infection Prevention: According to the CDC, preventive measures – such as frequent hand washing, social distancing, and wearing a mask in public – are recommended to help reduce risk of infection. This recommendation is the same for those with rheumatic diseases.
  • Rheumatic Disease Treatment: Treatment recommendations are considered based on specific medication type, as well as COVID-19 exposure or infection. Initially, there was much speculation at the start of the COVID-19 pandemic with regards to NSAID use and the possibility of worse outcomes associated with COVID-19; these concerns have yet to be verified. The task force supports the continued use of NSAID medications in most cases, when suggested and deemed appropriate for rheumatic disease, with the exception in those with severe respiratory symptoms caused by COVID-19.

For patients who are not infected with COVID-19, they suggest that following medications may be taken as prescribed; sulfasalazine (SSZ), methotrexate (MTX), hydroxychloroquine or chloroquine (HCQ/CQ), leflunomide (LEF), immunosuppressants (e.g., tacrolimus, cyclosporine, mycophenolate mofetil, azathioprine), biologics (TNF and IL inhibitors), non-steroidal anti-inflammatory drugs (NSAIDs), and if indicated, low-dose glucocorticoids. Further detailed discussion of specific medications and guidance for those who are infected with COVID-19 can be found in the guideline recommendations.

To view a summary of the 25 final guideline recommendations, please visit the following link:

https://www.rheumatology.org/Portals/0/Files/ACR-COVID-19-Clinical-Guidance-Summary-Patients-with-Rheumatic-Diseases.pdf

The full paper can be viewed at the following link:  https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.41301

Find more resources on COVID-19 and spondyloarthritis on our COVID-19 Resource Page.

References:

Walsh, N. (2020, May 6). ACR: Do’s and Don’ts During the Pandemic. Retrieved May 12, 2020, from https://www.medpagetoday.com/infectiousdisease/covid19/86315?xid=nl_popmed_2020-05-06&eun=g1454080d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=CoronaBreak_050620&utm_term=NL_Daily_Breaking_News_Active

Mikuls TR, Johnson SR, Fraenkel L, Arasaratnam RJ, Baden LR, Bermas BL, et al. American College of Rheumatology guidance for the management of adult patients with rheumatic disease during the COVID-19 pandemic. Arthritis Rheumatol doi: https://onlinelibrary.wiley.com/doi/abs/10.1002/art.41301. E-pub ahead of print.