EULAR & ACR COVID-19 Recommendations: How to Manage Patients During the COVID-19 Pandemic

The task force underscored the importance of disease-modifying anti-rheumatic drugs (DMARDs) remaining available for rheumatic and musculoskeletal disease patients, including hydroxychloroquine, which has drawn interest for COVID-19 use after publicity, despite a lack of strong evidence that it is effective in preventing or treating the virus.

“The off-label use of DMARDs in COVID-19 outside the context of clinical trials should be discouraged,” the group wrote.

Dr. Landewé said it’s crucial to stay in touch, even as the pandemic continues for a long period, because patients need the support and the encouragement to stay on top of their disease management.

“Don’t lose contact with those patients,” he said.

Dr. Mikuls

According to the ACR
The ACR’s published clinical guidance for the care of adult patients with rheumatic diseases during the COVID-19 pandemic is mostly in concert with EULAR’s recommendations, which is encouraging, said Ted Mikuls, MD, a member of the ACR task force that developed the guidance and the Umbach Professor of Rheumatology at the University of Nebraska Medical Center, Omaha, where he also serves as vice chair of research for the Department of Internal Medicine.²

“We’re approaching the unknown from very different parts of the world and arriving in a very similar place,” Dr. Mikuls said.

The ACR guidance offers more specific suggestions in cases of suspected exposure, recommending clinicians stop immunosuppressants, non-interleukin (IL) 6 biologics and JAK inhibitors for patients who are stable after an exposure to the virus, while hydroxychloroquine, sulfasalazine and non-steroidal anti-inflammatory drugs should be continued. With documented or presumed COVID-19, the guidance recommends hydroxychloroquine should be continued with appropriate cautions in place, but sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics and JAK inhibitors should be stopped or held.

In response to a question about JAK inhibitor use, Dr. Mikuls said the panel was uncertain about what to recommend for COVID-19 patients, saying task force members “didn’t necessarily vote against that, but weren’t ready to endorse that strategy.”

He pointed out that high-dose JAK inhibition has been linked with thromboembolic events, and this has been seen with COVID-19, too. “I think that’s given folks pause,” he said.

Despite the recent attention paid to hydroxychloroquine, and data pointing to cardiotoxicity, Dr. Mikuls said the drug’s benefits have to be kept in mind.

“We have good data that, optimally dosed, … hydroxychloroquine reduces morbidity, reduces mortality, related to lupus,” he said. “I don’t think we can lose sight of that.”