The availability of testing may vary by region and is changing over time. Thus, patients need to discuss advice on testing with their rheumatologist if they are concerned they have been exposed. This may have implications on decisions to temporarily hold treatment with immunosuppressants.
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Explore This IssueMay 2020
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Kevin Winthrop, MD, MPH, professor of infectious diseases, public health and preventive medicine, and ophthalmology at Oregon Health and Science University, Portland, served as a member of the ACR COVID-19 Clinical Guidance Task Force, which released clinical guidance for practitioners caring for patients with rheumatic disease. The purpose of this guidance is to help rheumatologists and other providers manage adult patients safely and effectively in the midst of the COVID-19 pandemic.
Using a modified Delphi process and a rating system of low, moderate and high in terms of consensus, the task force—comprising 10 rheumatologists and four infectious disease specialists—created a set of recommendation statements to help guide clinical decision-making in different situations.
The document includes recommendations for the ongoing treatment of stable adult patients in the absence of SARS-CoV-2 exposure or infection, in the presence of exposure and in the context of presumptive or diagnosed SARS-CoV-2 infection, as well as treatment of newly diagnosed or active rheumatic disease.4 For example, one recommendation is that, for all patients, regardless of exposure or infection status, glucocorticoids, if indicated, should be used at the lowest dose and for the shortest duration necessary. The guidance stresses that uninfected patients should not stop their DMARDs preventively if they are benefitting from them. Dr. Winthrop explains, “We favor maintaining disease control over stopping medications preventively and risking a flare of the underlying rheumatologic disease.”
Dr. Winthrop points out this guidance is meant to assist in clinical decision making, must involve case-by-case discussion between the physician and patient, and should be viewed in the context of new and evolving data on COVID-19.
On the subject of holding medications, the topic of ibuprofen has created quite a bit of potential confusion. In a letter published on March 11 in The Lancet Respiratory Medicine, the authors noted that SARS-CoV-2 binds to target cells through angiotensin-converting enzyme 2 (ACE2), which is expressed by epithelial cells in the lung, intestine, kidney and blood vessels. Conditions in which ACE2 is upregulated, including diabetes and hypertension, also appear to increase the risk of severe infection with COVID-19. Given that ACE2 levels can be increased by ibuprofen, this and other NSAIDs have been discussed widely in the lay press and on social media as potential risk factors for severe SARS-CoV-2 infection.