NEW YORK (Reuters Health)—The German Society for Rheumatology (DGRh) has updated its guidelines to reflect the recent impact of the pandemic, noting among its key changes that immunosuppressive medications should not be changed solely for fear of SARS-CoV-2 infection.1
The update is based on evidence from scientific data from registries, cross-sectional studies, case reports and case series published through June 15, 2020. Dr. Hendrik Schulze-Koops of Ludwig-Maximilians University Munich, Germany, and colleagues reported the society’s key recommendations in Rheumatology. These include:
- Patients with an inflammatory rheumatic disease (IRD) do not have a higher risk of contracting SARS-CoV-2;
- IRD patients should follow the same behavioral and precautionary measures as the general population;
- Digital tracking, such as the Corona-Warn-App, should be used to help prevent SARS-CoV-2 transmission;
- There is no reason not to work solely based on an assumed risk of infection due to an underlying rheumatic disease;
- Immunosuppressive medications should not be discontinued, delayed or changed solely for fear of SARS-CoV-2 infection;
- If an IRD patient tests positive for SARS-CoV-2 , consider pausing or delaying tsDMARD or bDMARD therapy for the duration of the incubation period; csDMARDs should not be discontinued; and
- Continue long-term glucocorticoid therapy, though tapered dosing may be needed.
Dr. Hendrik Schulze-Koops did not respond to requests for a comment, but US experts comments by email to Reuters Health.
Avis Ware, MD, professor and director of the Division of Immunology, Allergy and Rheumatology at the University of Cincinnati College of Medicine, says many of the recommendations overlap with guidance from the American College of Rheumatology and the European League Against Rheumatism (EULAR), “especially in relation to behavioral and precautionary measures.”2
“One important distinction is that the ACR and EULAR do recommend the use of telemedicine and other measures to reduce personal contact overall,” she says. “This current (update) does not, due to the lower overall risk of infection in Germany at the time of publication.”
“The DGRh is less restrictive in its recommendations regarding postponing or stopping anti-rheumatic therapies in the setting of contact with a SARS-CoV-2 individual compared with the ACR,” she says. “In particular, the German society suggests pausing treatment only if the person has clear symptoms of infection or a positive test result. The ACR recommends pausing many anti-rheumatic therapies for up to two weeks if there is even exposure to an infected individual.”
“There is no convincing evidence—with the exception of corticosteroids/glucocorticoids—that [immunosuppressive medications] increases the risk of severity of COVID-19 infections,” she adds. “The exception is in those patients whose underlying disease is poorly controlled.”
Anca Askanase, MD, PhD, director, Columbia University Lupus Center and associate professor of Medicine at Columbia University College of Physicians and Surgeons, New York City, notes, like Dr. Ware, that the DGRh update “is very much in line with the guidance from the ACR.”
“The main difference,” she says, “is more detail in regards to medication used and recommendations about adjusting several medications in the setting of either documented or presumptive COVID-19 diagnosis.”
“The key message,” she adds, “is that this is a rapidly evolving field and that we all need to keep up with the information and help our patients make preventive, therapeutic and lifestyle decisions on a regular basis.”
Rheumatologist Gary Firestein, MD, director of the Clinical and Translational Research Institute at University of California,San Diego Health, noted, like Dr. Askanase, that guidelines for COVID-19 are constantly evolving. “Decisions on therapy should be individualized for each patient and depend on the severity of their rheumatic disease and COVID-19 symptoms,” he says. “Transient adjustment or suspension of therapy is a goal, but should be tempered by the need to keep the rheumatic disease under control.”
“Most drugs that we use appear safe in patients with COVID-19, and some are even being explored as (COVID-19) treatments. So the likelihood that these agents will do serious harm seems relatively low,” he concluded.
References
- Schulze-Koops H, Krüger K, Hoyer BF, et al. Updated recommendations of the German Society for Rheumatology for the care of patients with inflammatory rheumatic diseases in times of SARS-CoV-2 – methodology, key messages and justifying information. Rheumatology (Oxford). 2021 Jan 27;keab072. Online ahead of print.
- Mikuls TR, Johnson SR, Fraenkel L, et al. American College of Rheumatology guidance for the management of rheumatic disease in adult patients during the COVID-19 pandemic: Version 3. Arthritis Rheumatol. 2021 Feb;73(2):e1–e12. Epub 2020 Dec 5.
