Clinical management of patients with rheumatoid arthritis during the COVID-19 pandemic

ABSTRACT

Introduction: Coronavirus disease 2019 (COVID-19) pandemic raises a great challenge in the management of patients with rheumatoid arthritis (RA), which are generally more susceptible to infection events because of the autoimmune condition itself and the treatment with immunomodulatory drugs. The use of disease-modifying anti-rheumatic drugs (DMARDs), including biologics and targeted-synthetic DMARDs, has aroused particular interest because of both their immunosuppressive effects and their hypothetical potential in COVID-19 treatment.

Areas covered: For this narrative review, a literature search was conducted between December 2019 and February 2021 on PubMed including epidemiological studies, gathering the main evidence available to date about the impact of COVID-19 on RA patients and the influence of anti-rheumatic drugs on patients’ susceptibility to this infection. We also summarize the recommendations from the international guidelines on the management of rheumatic diseases and treatments in this pandemic context, especially focused on RA.

Expert opinion: About a year after the outbreak of the pandemic, we are able to answer some of the most relevant questions regarding patients with RA and their management in this pandemic context. Our efforts must now be directed toward consolidating the currently available data with more rigorous studies and facing new issues and challenges including, foremost, vaccination.

KEYWORDS:

• Clinical management
• coronavirus disease 2019
• disease-modifying anti-rheumatic drugs (DMARDs)
• glucocorticoids
• guidelines
• immunosuppressive treatments
• rheumatoid arthritis

Article highlights

• The incidence and the outcome of COVID-19 among patients with RA is consistent with that of a healthy population, but evidence suggests a higher risk of respiratory failure.

• Risk factors predicting poor outcome include age, comorbidity (such as cardiovascular, lung and renal chronic diseases), and treatment with rituximab or glucocorticoids.

• Rheumatologists’ goal, even in this pandemic context, is to ensure adequate disease control and, contemporarily, to minimize the patient’s risk of contagion.

• The treatment with c/ts/bDMARDs, while safely indicated in the absence of SARS-CoV-2 infection, should be discontinued in case of confirmed COVID-19, with the opportunity to discuss treatment changes on a case-by-case basis

• SARS-CoV-2 vaccination is opening a window of hope and an important field of research and investigation for rheumatic patients.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

Ennio Giulio Favalli and Gabriella Maioli contributed equally

Additional information

Funding

The manuscript was partially supported by the Lombardy Region 2014-2020 Regional Operational Programme under the European Regional Development Fund in the context of the MAINSTREAM project.