Reopening Practices During the Pandemic
Many practices have continued seeing urgent patients via in-person visits during the pandemic, including patients with acute disease flares and those with active, high-risk disease. The ACR has provided guidance for deciding which patients need to be seen in person and which can be accommodated via telemedicine. We have also issued guidance for best practices for necessary in-office infusions, including disinfection, hygiene and screening procedures. We have argued against indiscriminate expansion of home infusions, which pose safety concerns for some patients.
As stay-at-home orders have lifted, many rheumatology practices are beginning to reopen and are scheduling a higher percentage of patients for in-
person and non-urgent visits. Although we lack hard and fast rules for best practices, an advisory document on reopening is now available on the ACR website. In making such decisions, practitioners should consider regional prevalence and new infection rates of SARS-CoV-2 on an ongoing basis. Clinics should also plan for the possibility that scaling back may again be necessary if there is a resurgence of disease locally.
Following guidance from the Centers for Disease Control & Prevention, practitioners may contemplate reopening in stages, screening employees for symptoms, requiring mask use by patients and staff, and employing strict infection-control measures. Many physical arrangements can facilitate appropriate distancing, such as using Plexiglas barriers and having patients wait in their cars for appointments, if feasible. Clinicians may also want to consider proactively developing a plan to be used if an asymptomatic patient tests positive after a clinic visit.
We also recommend clinicians consult the clinical guidance documents provided by the ACR. In addition to a document addressing the care of adult rheumatology patients, two new documents have been prepared by the ACR’s COVID-19 Pediatric Rheumatology Clinical Guidance Task Force. The first addresses the care of pediatric rheumatology patients in during the COVID-19 pandemic. The second document takes on the identification and management of the newly described multi-system inflammatory syndrome (MIS-C) seen in children with COVID-19.
Continued Advocacy & HCQ Recommendations
At the ACR, we have been advocating for our patients for appropriate use of hydroxychloroquine (HCQ) since the drug came to public attention in March. Fortunately, shortages have abated. However, HCQ use in the setting of COVID-19 has brought safety concerns into the public spotlight, particularly regarding possible cardiac toxicity. Providers in clinical practice may be uncertain as to what to tell patients who express anxiety about taking this drug.
Practitioners can highlight that the cardiac risks reported in recent studies are rare in rheumatology patients taking standard doses, although the risk may be higher in COVID-19 patients for reasons including the use of higher dosages of hydroxychloroquine; drug-drug interactions, especially with azathioprine; and the effects of SARS-CoV-2 on the heart. Clinicians should also emphasize that HCQ is the only drug known to reduce death rates in patients with lupus.
