ACR Releases COVID-19 Clinical Guidance for Pediatric Patients with Rheumatic Disease

Dr. Dawn Wahezi

Those questions were proposed to task force participants—comprising seven pediatric rheumatologists, two pediatric infectious disease physicians, one adult rheumatologist and one pediatric nurse practitioner—during a webinar on May 21. Participants voted anonymously on the initial questions using a 1 to 9 rating scale (1 = disagree; 9 = agree). The statements were refined through two more rounds of voting until consensus was reached. To be approved and included as a guidance statement, the votes were required to fall into the highest third for agreement, representing moderate to high levels of consensus.

Recommendations for Managing Pediatric Rheumatic Patients
The guidance includes general recommendations, such as counseling patients and their families about public health protocols (e.g., hand washing, social distancing, wearing masks) to avoid potential exposure to SARS-CoV-2. Noting that families may be reluctant to bring their children to clinics for regular visits, Dr. Wahezi and her colleagues recommend the use of telemedicine to ensure continued access to care. The recommendations emphasize that it is equally important for physicians to continue non-rheumatic care, such as regular flu vaccinations and in-person ophthalmologic examinations if patients have a history of uveitis or are at high risk for the development of uveitis.

Dr. Mehta adds that during the first few weeks of the pandemic, he and his colleagues were worried their patients on immunosuppression would get very sick and require hospitalization. Although that has not happened, treatment decisions must be individualized for each patient and family, he says, noting “there’s a balance between keeping them safe and keeping them mentally healthy.” The guidance reminds providers that children and caregivers of children with pediatric rheumatic disease could be at risk of anxiety and depression due to the quarantine and other events surrounding COVID-19. Assessments for these risks should be conducted during regular visits.

Ongoing Treatment
The document also addresses ongoing treatment recommendations. For pediatric patients with rheumatic disease and who have not been exposed to or infected with SARS-CoV-2, regular medication regimens should be continued, or new ones initiated, to control underlying disease. For those with stable disease and who might be on stable doses of biologic or traditional synthetic disease-modifying anti-rheumatic drugs, extending laboratory testing intervals to assess for medication toxicity can be considered to reduce the risk of exposure to COVID-19.

For pediatric patients who have close or household exposure to COVID-19, the task force had generally high levels of consensus regarding glucocorticoids. Initiation of high-dose oral or intravenous (IV) glucocorticoids should be delayed by one to two weeks, if safe, only for those patients whose rheumatic disease is non-life or organ threatening. With life- or organ-threatening manifestations, high-dose oral or IV glucocorticoids should not be delayed. Finally, the guidance stipulates specific treatment options for patients with asymptomatic or confirmed symptomatic COVID-19 infection.