The global coronavirus disease 2019 (COVID-19) crisis is rapidly accelerating pressure on health systems, especially in the high-income countries that make up most current hotspots. The routine management of chronic conditions, including rheumatic diseases, diabetes and HIV, is beginning to feel the strain. In response, rheumatologists have had to rapidly pivot toward virtual patient care (telemedicine), consider adjusting patients' medications, and provide advice on the potentially increased risks to patients with rheumatic diseases.
Like many cities and countries worldwide, New York has been placed under lockdown as COVID-19 cases surge there. “We are very concerned for our patients, as it is likely that patients with immune-mediated diseases such as lupus or rheumatoid arthritis may be more likely to develop COVID-19 or more severe complications of COVID-19, as they do with other infections,” says Mary (Peggy) Crow, Chief of the Division of Rheumatology at Hospital for Special Surgery and New York-Presbyterian/Weill Cornell Medical Center, NY, USA. “So far none of our patients infected have required hospital care,” she adds, “Time will establish if the course of disease is more serious in these patients.”
At the hospitals where Crow practices, there has been a rapid shift toward telemedicine in an effort to curb the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The transfer has lengthened patient visits, says Crow, mostly due to staff learning a new system, but she is confident that efficiency will improve with time. “For patient care and patient satisfaction, we will need more time to assess this,” she adds.
Recognising the widespread governmental advice to avoid in-person medical visits, on March 17, the US Centers for Medicare & Medicaid Services expanded access to telehealth appointments, promising reimbursement for telehealth visits at no additional cost; physicians who use Skype and FaceTime—not usually permitted under US regulations for telehealth care—will not face any penalty for doing so during the COVID-19 pandemic.
The UK has also seen a rapid shift toward telemedicine in response to SARS-CoV-2. Peter Taylor, professor of musculoskeletal sciences at the University of Oxford (Oxford, UK), says that “the impressively fast adoption of telemedicine outpatient care has been designed to maintain best levels of disease control for our patients and to provide advice most appropriate to an individual's treatment regime while promoting avoidance and spread of SARS-CoV-2 infection.”
Taylor says this transition has gone well for the majority of follow-up appointments. For new patient appointments, telemedicine allows for in-depth triage so that individuals that need to be seen urgently can be fast-tracked safely to the most appropriate environment. He says that clinical trials in Oxford have also been temporarily suspended so that facilities can be prioritised for patients who need hospital-administered therapies. He adds that rheumatologists are being called on to contribute to urgent research into the role of cytokine modulation in the management of patients with severe COVID-19, in whom treatment with certain cytokine blockers has shown potential.
An unanswered question in the fast-moving environment of the SARS-CoV-2 outbreak is whether patients' treatment regimens should be modified as a result. In the absence of routine testing for SARS-CoV-2, which has yet to be implemented in New York and many other places globally, one approach has been to assume patients could be infected. “Many rheumatologists might consider discontinuing or decreasing the dose of some of the immunosuppressive medications on a temporary basis,” says Crow.
However, guidance issued by the European League against Rheumatic Diseases (EULAR) cautions that stopping immunosuppressant drugs could lead to a flare-up of rheumatic conditions, saying not enough is yet known about the effects of these medications on COVID-19. As such, EULAR recommends that patients should not stop or reduce their medication unless their physician advises it for a specific reason. The guidance also recommends the postponement of any non-essential rheumatology appointments if these can be safely delayed; for any appointments that go ahead, patients should have virtual consultations if possible. The British Society of Rheumatology has also issued guidance, providing a risk stratification tool to guide the amount of shielding and isolation required for patients on different immunosuppressant medications.
Given that severe cases of SARS-CoV-2 can involve potentially fatal respiratory dysfunction, a major concern is patients with systemic sclerosis who are vulnerable to interstitial lung disease. “Patients with systemic sclerosis fall potentially into the highest risk group—on immunosuppression and with heart, lung, and kidney disease,” explains Christopher Denton, professor of experimental rheumatology and consultant rheumatologist at University College London (London, UK). “We have contacted all our patients with this condition to advise strict isolation or shielding, especially if they are on immunosuppression or have lung fibrosis,” he says, noting that it is too soon to comment on any systemic sclerosis-specific issues caused by COVID-19. He adds that data collection exercises have been developed that will address this in time, including new international registries.
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