Rheumatologists Challenged in the Era of COVID-19

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Although they are not at the very front line of most medical care that is directly related to the COVID-19 crisis, rheumatologists and people with rheumatic diseases are facing several unique challenges.

The leading challenge is that individuals who have rheumatic diseases are probably at higher risk for complications from infection with SARS-CoV-2 because of their underlying illness or immunosuppressive medications. This may cause anxiety for providers and patients about COVID-19, as well as concerns about rheumatic disease management.

The Medication Challenge

Rheumatologists and patients are faced with difficult decisions about whether to taper or hold immunosuppressive medications in order to potentially reduce the risk for COVID-19, and specifically whether to delay infusions in order to lower the exposure risk created by coming to an infusion center.

There are also questions of whether the risk of contracting COVID-19 may be reduced by tapering or discontinuing other agents, such as injectables or oral disease-modifying agents. These choices must be weighed against controlling an underlying autoimmune disease that itself could cause substantial morbidity or mortality if a flare develops.

Furthermore, deciding which medications to taper or stop if COVID-19 develops is challenging, as well as knowing how long to alter therapy after infection, especially because the timing of viral clearance after clinical infection is not yet clear.

Perhaps all agree that tapering corticosteroids to the lowest dose possible is beneficial for a variety of reasons related to infection risk and other side effects (eg, osteoporosis), although the choices around continuing rheumatic disease medications is complicated by emerging yet limited findings about these risks.

Several medications for rheumatic disease may be helpful for treating COVID-19. These medications include but are not limited to corticosteroids, anti-cytokine therapies, Janus kinase inhibitors, chloroquine, and hydroxychloroquine.

It has long been standard practice to taper or discontinue rheumatic disease medications during severe infections, and that may be the right approach with COVID-19. However, additional studies are needed to determine which, if any, rheumatic disease medications may be reasonable to continue in someone who has developed COVID-19.

Of importance, although robust studies demonstrating the benefit of these medications have yet to be completed (many well-designed studies are under way), rheumatologists and patients may now have difficulty accessing these drugs.

In particular, hydroxychloroquine, a mainstay of treatment for systemic lupus erythematosus (SLE), is in short supply because of its use (and stockpiling for use) in COVID-19. Many healthcare systems across the United States and beyond are restricting access to new starts of hydroxychloroquine, and individuals who have been chronically receiving this medication are reportedly unable to get it.

The possible benefit of these medications for a potentially devastating illness such as COVID-19 must be considered, but it is also important that they continue to be available for individuals with the rheumatic diseases for which they have been proven effective, and in particular for patients with SLE, for which hydroxychloroquine has an established mortality benefit.

Because of these issues, many organizations and agencies, including the American College of Rheumatology (ACR), are petitioning such entities as the US Food and Drug Administration, pharmaceutical companies, and insurance providers to help patients maintain access to hydroxychloroquine and other medications by increasing production; reducing barriers, such as prior authorization; and preventing hoarding. Furthermore, the ACR and others are also providing guidance to rheumatologists and patients on the use and possible shortages of these medications.

Because of the potential role of these medications in treating COVID-19, individuals with rheumatic diseases who are taking them may believe they will protect against infection. This is not proven, and individuals taking these medications for rheumatic disease should be assumed to be at higher risk for COVID-19 and counseled to take appropriate steps to avoid infection, including social distancing, avoiding contact with anyone who is ill, careful hand washing, and not touching their faces.

Furthermore, they should maintain contact with healthcare providers if symptoms of COVID-19 or other infections develop, working together to determine a personalized approach to tapering or discontinuing their rheumatic disease medications. We hope that clear guidelines on how to manage these medications in the setting of COVID-19 will be forthcoming.

The Telemedicine Challenge

Individuals with rheumatic disease are often evaluated by a rheumatologist every few months. Thus, getting appropriate follow-up care while minimizing exposure to high-risk settings, such as medical centers, and optimizing the effectiveness of stay-at-home orders is a challenge. To address this, telemedicine has been catapulted to the forefront of medical care in the setting of the COVID-19 crisis.

Telemedicine is challenging on many fronts, including billing, medical malpractice coverage, and interstate practice regulations. These issues are rapidly being addressed at the healthcare system and governmental levels.

Perhaps the most immediate challenge of telemedicine, however, is implementing a visit. This can prove difficult for rheumatologists, their office staff, and patients, who may not be familiar with some the technical aspects of a telemedicine visit, such as scheduling and use of a video interface.

Furthermore, there is little specialty-specific experience about when to appropriately use telemedicine, and what the visits should entail in terms of clinical evaluations or the implications of the limits of clinical evaluations. For example, the physical joint examination, a mainstay of rheumatologic care, cannot be accomplished through current telemedicine applications.

Should ancillary staff be trained to be an onsite extension of the remote rheumatologist? These issues, all of which need to be answered in a systematic way, are particularly important for new patients with disease manifestations, such as joint inflammation, which may not have previously been identified by a rheumatologist and may be crucial for diagnosis.

As such, while exposure restrictions are in effect, rheumatologists may have to rely largely on patient-reported symptoms and what can be gleaned through video imaging. However, it is hoped that these issues will spur the development and implementation of new methods to remotely evaluate patients and that these may benefit the field even after the COVID-19 crisis has resolved. Moreover, these new methods may be broadly beneficial, especially in the face of a predicted workforce shortage in rheumatology.

A further challenge in clinical care is obtaining the laboratory tests that are critically important for making diagnoses in rheumatic diseases and are needed to evaluate medication efficacy and toxicity. To address this, some medical centers have developed laboratory collection facilities that maintain high levels of protection for healthcare providers and patients and are separate from facilities evaluating individuals with suspected COVID-19. There remain concerns about the impact of asymptomatic carriers on these models, given that the safety of these sites is typically predicated on symptom-based screening when specific testing for the virus is not widely available.

We hope that such facilities will soon be more widely available, and that best protocols will be validated. In addition, the effects of COVID-19 restrictions may ultimately lead the rheumatology field to reevaluate the optimal type and frequency of laboratory evaluations or develop new approaches, such as "collect-at-home" laboratory tests.

The Non–COVID-19 Crises Challenge

Outpatient evaluation of patients with rheumatic diseases who may have non–COVID-19 infections presents additional challenges. Patients with rheumatic disease are still at risk for bacterial and other processes. Given that many health-care systems are asking individuals with infectious symptoms (eg, fever) to stay home unless their symptoms are severe, it may be that non–COVID-19 processes are being missed. Although there are limited resources in the face of COVID-19, ultimately we may need a wider use of clinics that can rapidly evaluate any infectious symptom to identify non–COVID-19 processes that may require specific therapy.

Additional challenges relate to the inpatient care of patients who have severe rheumatic disease. There has always been concern about side effects of therapy in patients with rheumatic disease, especially in very sick individuals who need high doses of steroids or cytotoxic therapy (eg, cyclophosphamide). The COVID-19 crisis lends new concerns over a hospitalized individual with a rheumatic disease who may require aggressive therapy and thus may be at increased risk for COVID-19 exposure and complications.

Furthermore, COVID-19 may mimic rheumatic disease. Individuals with rheumatic diseases, such as granulomatosis with polyangiitis, may have fever, sinus symptoms, and pulmonary infiltrates, either as a primary manifestation or a flare of existing disease. Rapidly determining COVID-19 status in these individuals is currently a challenge that can only be addressed with more widespread availability of accurate and rapid COVID-19 testing.

Finally, because of the potential increased risk for COVID-19 infection and complications in patients with rheumatic diseases, and the high visibility and impact that this crisis has had on the world's psyche, anxiety may run high in rheumatologists and individuals with rheumatic diseases. There is no easy answer here. Nevertheless, an awareness of this anxiety and a willingness for rheumatologists, patients, and other healthcare providers to work together using resources, such as the ACR, will help providers and patients through the process.

Summary

Many of the challenges of the COVID-19 crisis will create unique opportunities to advance the field of rheumatology through remote evaluation of patients with rheumatic disease (eg, telemedicine), and new modes of care delivery that may reshape practices and help with workforce shortages and asymmetric distribution of providers. Furthermore, the field will probably gain insights into how rheumatic disease therapies can be used to address dysregulated inflammatory responses that may be associated with the morbidity and mortality that are seen with COVID-19, as well as other illnesses.

With efforts from stakeholders, including patients with rheumatic disease, rheumatologists, healthcare systems, and others, let us plan on making meaningful, positive advances in the setting of this COVID-19 crisis.

Kevin D. Deane, MD, PhD, and Duane W. Pearson, MD, are associate professors of rheumatology at the University of Colorado at Denver Health Sciences Center in Aurora, Colorado.

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