No additional risk from COVID-19 for people with rheumatic diseases taking biologics and JAK inhibitors

There is no need for withdrawal of DMARDs during the COVID-19 pandemic.

Introduction
COVID-19 is caused by a new type of coronavirus called severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). It was declared a pandemic by the World Health Organization on 11 March 2020. COVID-19 has forced people to change their behaviours to try to limit the spread of infection.

Some people with rheumatic diseases are more likely to get infections. Some people are also more prone to complications when they get an infection. This is partly because of their underlying disease, and partly because some medicines used to treat rheumatic diseases work by suppressing the immune system.

What did the authors hope to find?
The authors wanted to see how the COVID-19 pandemic affected people with rheumatic diseases.

Who was studied?
The study looked at 320 people with rheumatic diseases being treated in Lombardy, Italy. Around two-thirds were female, with an average age of 55 years. 57% had rheumatoid arthritis, while 43% had spondyloarthritis. Most of the people taking part were receiving biologics (abatacept, adalimumab, etanercept, tocilizumab). Around 1 in 10 were receiving Janus kinase (JAK) inhibitors (baricitinib, tofacitinib).

How was the study conducted?
A survey was sent to people with rheumatic diseases, with another follow-up survey after 2 weeks. People were asked to report their health conditions, whether they had been in contact with anyone diagnosed with COVID19, and how the pandemic had affected their attitude towards, and management of their rheumatic disease. The authors also looked at medical records, and reports from other clinics, in addition to the findings from the surveys.

What was the main findings?
The main finding was that people with rheumatic diseases who are diagnosed with COVID-19 do not seem to have an increased risk of complications compared to the general population. The information suggests that biologic and JAK inhibitor medicines do not increase the risk of complications and should continue to be used to manage rheumatic diseases. However, caution is still warranted as these medicines work by suppressing the immune system, and people should continue to be closely monitored by their healthcare teams.

Are these findings new?
Yes. At the time this report was published, there was limited information about COVID-19 in people with rheumatic diseases. This was the first paper to report that people with rheumatic diseases receiving biologics or JAK inhibitors who are diagnosed with COVID-19 have a similar level of risk of complications to that of the general population. Since this report was published, other research groups in different countries have found similar results,(1,2) and many comments have supported the results.(3-6) At the time this article was published, the largest study in people with rheumatic diseases and confirmed or suspected COVID-19 was 86 cases in New York City in the United States, where 72% of people treated with biologics or JAK inhibitors had similar rates of being admitted into hospital or dying from COVID-19, to that of the general population.(2)

What are the main limitations of this study?
The main limitation is that this study was quite small, with only 320 people from one part of Italy.

What do the authors plan to do with this information?
Information is being collected in national and international registries, such as the Italian Society of Rheumatology sponsored registry (COVID-19-RMD), or the European EULAR-COVID-19 Database. The data collected will help to work out what impact COVID-19 has on people with rheumatic diseases.(7,8)

What does this mean for me?
If you are taking a biologic or JAK inhibitor medicine for your rheumatic disease, these results suggest that you are not at higher risk of complications from COVID-19, and there is no need to stop taking your medicine. If you are concerned about the risk of taking your medicine during the pandemic, you should speak to your doctor. It is important that you do not stop taking your medicine by yourself, as this could make your rheumatic disease worse.

Protect yourself from COVID-19 by following the advice of the government in your country, including washing your hands regularly, avoiding touching your face, and following social distancing rules.

References
1. Emmi G, et al. SARS-CoV-2 infection among patients with systemic autoimmune diseases. Autoimmun Rev 2020;102575. doi:10.1016/j.autrev.2020.102575.
2. Haberman R, et al. Covid-19 in Immune-Mediated Inflammatory Diseases – Case Series from New York. N Engl J Med 2020. doi:10.1056/NEJMc2009567.
3. Monti S & Montecucco C. Diagnostic and therapeutic challenges for patients with ANCA-associated vasculitides at the time of COVID-19. Response to: ‘Rituximab for granulomatosis with polyangiitis in the pandemic of COVID-19: lessons from a case with severe pneumonia’ by Guilpain et al. Ann Rheum Dis 2020 Apr 30.
4. Monti S & Montecucco C. The conundrum of COVID-19 treatment targets: the close correlation with rheumatology. Response to: ‘Management of rheumatic diseases in the time of covid-19 pandemic: perspectives of rheumatology practitioners from India’ by Gupta et al and ‘Antirheumatic agents in covid-19: is IL-6 the right target?’ by Capeechi et al. Ann Rheum Dis 2020 Apr 27.
5. Monti S & Montecucco C. Can hydroxychloroquine protect patients with rheumatic diseases from COVID-19? Response to: ‘Does hydroxychloroquine prevent the transmission of COVID-19?’ by Heldwein and Calado and ‘SLE, hydroxychloroquine and no SLE patients with COVID-19: a comment’ by Joob and Wiwanitkit. Ann Rheum Dis 2020 Apr 23.
6. Favalli EG, et al. What is the true incidence of COVID-19 in patients with rheumatic diseases? Ann Rheum Dis 2020. pii:annrheumdis-2020-217615.
7. McInnes IB. COVID-19 and rheumatology: first steps towards a different future? Ann Rheum Dis 2020;79(5):551552. doi:10.1136/annrheumdis-2020-217494.
8. Gianfrancesco MA, et al. Rheumatic disease and COVID-19: initial data from the COVID-19 Global Rheumatology Alliance provider registries. Lancet Rheumatol 2020. doi:10.1016/S2665 9913(20)30095-3.

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Date prepared: May 2020
Summary based on research article published on: 2 April 2020
From: Monti S, et al. Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies. Ann Rheum Dis 2020;79:667–668. doi:10.1136/
annrheumdis-2020-217424

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