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Mediterr J Rheumatol 2020;31(Suppl 2):295-8
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Management of Patients with Inflammatory Diseases during the COVID-19 Pandemic
Theofanis Apostolou1, Ioannis E. Koutroubakis2, Spilios Manolakopoulos3, Gerasimos Mantzaris2, Dimitrios Rigopoulos4, Konstantinos Triantafyllou5, Dimitrios Vassilopoulos6
Authors Information
1. President of the Hellenic Nephrological Society (HNS)
2. President of the Hellenic Study Group for Inflammatory Bowel Diseases (EOMIFNE)
2. Board Member of the Hellenic Study Group for Inflammatory Bowel Diseases (EOMIFNE)
3. President of the Hellenic Society for the Study of Liver (HASL)
4. President of the Hellenic Society of Dermatology and Venereology (HSDV)
5. President of the Hellenic Society of Gastroenterology (HSG)
6. President of the Greek Rheumatology Society & Professional Association of Rheumatologists (EPE-EPERE)
Full Text

PURPOSE OF THIS POSITION STATEMENT

The pandemic of the novel SARS-CoV-2 coronavirus has created a number of practical day-to-day problems in patients with inflammatory diseases undergoing treatment with different anti-inflammatory agents. These include patients with inflammatory diseases of the gastrointestinal tract (inflammatory bowel disease, IBD), liver (autoimmune hepatitis), skin (psoriasis, blistering skin disorders), kidneys (glomerulonephritis, glomerulopathies), and musculoskeletal-connective tissues diseases (rheumatoid arthritis, systemic rheumatic diseases such as Systemic Lupus Erythematosus, vasculitis, myositis, scleroderma, Sjögren’s Syndrome, etc.).

The purpose of this joint position statement is to provide up-to-date guidance for better management of patients with inflammatory diseases during the COVID19 pandemic. This text does not include recommendations for transplanted patients (kidney, liver) for whom there are special instructions from the Greek National Organization of Public Health (EODY).1

For the development of this joint position statement, the general recommendations of EODY1 as well as the most recent Specific Recommendations/Guidelines of the respective Greek2-4 and International5-15 Scientific Societies were taken into account. These statements do not replace the individual diagnostic and therapeutic decisions of treating physicians, and may be modified over time with the emergence of new scientific data.

 

A. GENERAL STATEMENTS

1. Patients with inflammatory diseases (whether receiving immuno-suppressive/modulatory therapies or not) should follow the updated Guidelines and Recommendations of the National Organization of Public Health (EODY).

2. Up to date, there is no data to suggest that patients with inflammatory diseases are at higher risk of COVID-19 infection compared to the general population.

3. Although data on the course of COVID19 disease in patients with inflammatory diseases are still limited, recent findings from international databases of patients with IBD16 and rheumatic diseases17 show an increased hospitalization rate of these patients (31-46%), especially those receiving glucocorticoids.

                Based on these data and the recent Guidelines/Recommendations of International Health Organizations18-19 and Academic Hospitals,20-21 patients with inflammatory diseases undergoing moderate to high risk anti-inflammatory treatment (see Annex) might be considered as an increased risk group for severe COVID-19 and appropriate measures should be taken in order to protect them.

4. Most specifically, regarding:

                A. The home isolation of working patients and/or

                B. The continuation, temporary or permanent discontinuation of theirtherapies,

the following factors should be taken into account:

                                - the severity of the underlying inflammatory disease (mild, moderate, severe, vital organ- and/or life-threatening)

                                 - patients’ comorbidities (age> 65 years, chronic respiratory or cardiovascular disease, chronic kidney or liver disease, diabetes mellitus)

                                - the risk of exposure to SARS-CoV-2 (working-home environment, administration of IV therapies in a hospital setting)

                                - the type of their anti-inflammatory therapies (see C and D, Annex)

 5. In the Interdisciplinary Teams caringforpatients with inflammatory diseases (who receive or not immuno-suppressive/modulatory therapies) who develop COVID19 infection, the inclusion of the respective specialists (gastroenterologists, dermatologists, hepatologists, nephrologists, rheumatologists) is mandatory.


B. INITIATING THERAPY IN PATIENTS WITH ACTIVE INFLAMMATORY DISEASES WHO HAVE NOT BEEN EXPOSED TO OR INFECTED WITH SARS-CoV-2 VIRUS

                1. For patients with active disease, the choice of initiating anti-inflammatory therapy should be based primarily on the severity of the underlying disease (mild, moderate, severe, vital organ- and/or life-threatening)

                2. Therapeutic decisions should take into account:

                                - the type of treatment (low vs. moderate - high risk, see Annex) and

                                - the risk of exposure to SARS-CoV-2 in patients receiving such treatment (IV treatment in a hospital setting vs. pos/subcutaneous treatment at home, potential virus exposure at work or home)


C. THERAPY OF PATIENTS WHO HAVE NOT BEEN EXPOSED TO OR INFECTED WITH SARS-CoV-2 VIRUS

1. Glucocorticoids

                Glucocorticoids should not be discontinued abruptly but caution must be taken to taper their dose to the lowest possible one that achieves adequate control of the underlying inflammatory disease.

2. Non-biologics/biologics/targeted-synthetic agents

                In the absence of SARS-CoV-2 exposure or COVID-19 infection, discontinuation of non-biologics, biologics or targeted-synthetic agents (see Annex) is not recommended.


D. THERAPY OF PATIENTS WHO HAVE BEEN EXPOSED TO OR INFECTED WITH SARS-CoV-2 VIRUS

1. Glucocorticoids

a. It is recommended to taper glucocorticoids to the minimum possible dose required to control the inflammatory activity of the underlying disease.

b. In special cases, following a decision from the Interdisciplinary Team, glucocorticoids can be administered as treatment for the COVID19 infection.

c. In patients with mild to moderate IBD, conventional glucocorticoids may be substituted by budesonide (controlled ileal-release or multimatrix extended-release) to control the underlying inflammatory disease.

2. Non-biologics

a. It is recommended to stop or postpone their administration until patients are asymptomatic from COVID19 infection and the molecular viral tests become negative.

b. An exception is the administration of 5- Aminosalicylic acid (5-ASA, in patients with IBD) to control the underlying inflammatory disease which can be used safely, if necessary, at the maximum permitted dose and in all forms (orally and/or rectally).

c. In special cases, following a decision of the Interdisciplinary Team, hydroxychloroquine (in patients with systemic lupus erythematosus or rheumatoid arthritis) could be continued.

3. Biologics/targeted-synthetic agents

a. It is recommended to stop or postpone their administration until patients are asymptomatic from COVID19 infection and the molecular viral tests become negative.

b. In special cases, following a decision of the Interdisciplinary Team, the following agents may be continued:

- Vedolizumab (in patients with active IBD) to control the underlying inflammatory disease and if necessary

- Tocilizumab, for the control of their underlying inflammatory disease (in patients with rheumatoid arthritis or giant cell arteritis) and/or the treatment of COVID19 disease (according to existing National Guidelines for the treatment of COVID-19).

Annex.Risk categorization of anti-inflammatory therapies for severe COVID19.
 

References
  1. Guidelines from the Greek National Organization of Public Health (EODY).Accessed at:https://eody.gov.gr/neos-koronaios-covid-19/
  2. Hellenic Dermatological and Venereological Society (HDVS): Recommendations in patients with Dermatological diseases under systematic treatment,. Accessed at: http://www.edae.gr/pdf/covid19_odigies.pdf
  3. The Greek Rheumatology Society and Professional Association of Rheumatologists (ERE-EPERE): Recommendations Regarding COVID19 Infection in Rheumatic Patients in Greece. Mediter J Rheumatol 2020;31;6-7.
  4. Recommendations of the Hellenic Study Group regarding the management of patients with IBD during the course of the COVID-19 pandemic (EOMIFNE). http://eomifne.gr/New/images/2020/COVID_19_2020_03_26.pdf
  5. ERA-EDTA: Information for nephrologists and other professionals on prevention and treatment of COVID-19 infections in kidney patients. Accessed at: https://www.era-edta.org/en/covid-19-news-and-information/   
  6. American Association for the Study of Liver Diseases (AASLD): Clinical insights for hepatology and liver transplant providers during the COVID-19 pandemic. Accessed at: https://www.aasld.org/sites/default/files/2020-04/AASLD-COVID19-ClinicalInsights-4.07.2020-Final.pdf  
  7. European Association for the Study of the Liver (EASL): Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper. Accessed at: https://easl.eu/wp-content/uploads/2020/04/EASL-ESCMID-COVID-19-Position-Paper.pdf    
  8. American Academy of Dermatology: Guidance on the use of biologic agents during COVID-19 outbreak. Accessed at: https://assets.ctfassets.net/1ny4yoiyrqia/PicgNuD0IpYd9MSOwab47/07b614658aff5fc6ccc4c0bd910509a3/Biologics_and_COVID_19_FINAL_V2.pdf   
  9. American College of Rheumatology (ACR): COVID-19 Clinical Guidance for Patients with Rheumatic Diseases. https://www.rheumatology.org/Portals/0/Files/ACR-COVID-19-Clinical-Guidance-Summary-Patients-with-Rheumatic-Diseases.pdf   
  10. European League Against Rheumatism (EULAR): EULAR Guidance for patients COVID-19 outbreak. Accessed at: https://www.eular.org/eular_guidance_for_patients_covid19_outbreak.cfm   
  11. International Organization for the Study of Inflammatory Bowel Disease (IOIBD): Rubin DT, Abreu MT, Rai V, Siegel CA; International Organization for the Study of Inflammatory Bowel Disease. Management of Patients with Crohn's Disease and Ulcerative Colitis During the COVID-19 Pandemic: Results of an International Meeting. Gastroenterology 2020;159:6-13.
  12. American Gastroenterology Association (AGA): Rubin DT, Feuerstein JD, Wang AY, Cohen RD, AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary. Gastroenterology. 2020;159:350-57.
  13. National Health System (NHS) -UK: Clinical guide for the management of rheumatology patients during the coronavirus pandemic (16 March 2020 Version 1). https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/clinical-guide-rheumatology-patients-v1-19-march-2020.pdf    
  14. National Institute for Health and Care Excellence (NICE) - UK: COVID-19 rapid guideline: rheumatological, autoimmune, inflammatory and metabolic bone disorders. Accessed at: https://www.nice.org.uk/guidance/NG167# (published April 3, 2020, updated July 2, 2020)   
  15. British Society for Rheumatologists (BSR): COVID-19: guidance for rheumatologists. Accessed at: https://www.rheumatology.org.uk/news-policy/details/covid19-coronavirus-update-members (updated July 29, 2020)
  16. Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD): Accessed at: https://covidibd.org/
  17. COVID-19 Global Rheumatology Alliance. Accessed at: https://rheum-covid.org/
  18. CDC: Groups at Higher Risk for Severe Illness. Accessed at:  https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html (revised July 17, 2020)   
  19. Public Health England: Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19. Accessed at: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 (updated September 4, 2020)
  20. Massachusetts General Hospital (MGH): COVID-19 Treatment Guidance. Accessed at: https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/mass-general-COVID-19-treatment-guidance.pdf (updated July 1, 2020)
  21. Massachusetts General Hospital (MGH): Risk Factors for COVID-19 Disease Progression. Accessed at: https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/risk-factors-for-severe-COVID-19.pdf