Should DMARDs Be Stopped Preemptively?
In further discussion, Jean Liew, MD, MS, assistant professor of rheumatology at Boston University School of Medicine, described the hypothetical case of a 46-year-old man with stable RA, taking etanercept and methotrexate, who is concerned about COVID-19 exposure because he is a nurse in an outpatient clinic. Should he stop his medicines preventatively? If not, what if he gets exposed?
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Overall, Dr. Liew said, the evidence suggests that conventional DMARDs should not be stopped preemptively, although some evidence from observational, registry-based data suggests sulfasalazine may be associated with higher odds of a poor outcome for someone who gets COVID-19.3,4 Not enough information for a hard conclusion exists, Dr. Liew said.
Regarding biologics and targeted small molecule drugs, the infection risk likely depends on the drug class. Tumor necrosis factor inhibitors have been found to be associated with lower odds of hospitalization.3 But is this a true protective effect?
“We cannot come to causal conclusions using these observational data,” Dr. Liew said. “We really need the results of ongoing trials.”
The picture surrounding Janus kinase inhibitors remains complicated: Baricitinib has been linked with a shorter time to recovery when used along with the antiviral remdesivir, compared with remdesivir alone, according to information on the ACTT-2 trial released by the manufacturer, although that phase 3 trial continues.5 Concern lingers about the effects on the interferon response and the infection risk, as well as the risk of thrombosis in those with COVID-19, she said.
Data collected through the registry has helped point the way forward, identifying suitable treatment options & vulnerable populations.
Big-picture messages, Dr. Liew said, are for patients with rheumatic and musculoskeletal diseases to continue their medications if their disease is under control and they do not have a COVID-19 diagnosis or exposure, and to use the lowest glucocorticoid dose possible.
For patients with exposure to SARS-CoV-2, patients should hold conventional DMARDs other than hydroxychloroquine and sulfasalazine, along with biologics, targeted synthetic drugs and other immunosuppressives, while they wait for test results. Patients diagnosed with COVID-19 should hold all medications other than hydroxychloroquine.
Those are the recommendations from the ACR COVID-19 Task Force, updated in July and based on the evidence available then.
Physicians should also remember that quarantine can contribute to higher disease activity and worse physical and mental health by decreasing activity levels and leading to sedentary behavior, Dr. Liew said.