This is the lay version of the EULAR points to consider on the use of medicines traditionally used in
\nrheumatology to treat the inflammation seen in people with severe COVID-19. The original publication can be downloaded from the EULAR website: www.eular.org.<\/p>\n
Alunno A, et al<\/em>. 2021 update of the EULAR points to consider on the use of immunomodulatory therapies in COVID-19. Ann Rheum Dis 2021;80:221\u2013366. doi:10.1136\/annrheumdis-2021-221366<\/a><\/p>\n Introduction<\/strong> What do we already know?<\/strong> Many medicines used in rheumatology are anti-inflammatory or immunomodulatory drugs. They are These findings do not apply to people living with rheumatic and musculoskeletal diseases (RMDs) who are What do the points say?<\/strong> The 12 points to consider focus on immunomodulatory therapy, and how we might use existing medicines Each point is based on the best current knowledge and studies of scientific evidence or expert opinion. The more stars a point has the stronger the evidence is. However, points to consider with limited scientific evidence may still be important, because the experts can have a strong opinion even when the published evidence may be lacking.<\/p>\n One star (*) means it is a point with limited scientific evidence. \u2022 In people with COVID-19 who do not need hospitalisation, there is currently no evidence to severe COVID-19 where there is a severe systemic inflammatory state. Research is looking at anti- \u2022 In people hospitalised for COVID-19 who do not need oxygen therapy there is currently no \u2022 In people with COVID-19 who need supplemental oxygen or ventilation, systemic \u2022 Hydroxychloroquine should be avoided for treating any stage of COVID-19.*** (unchanged)<\/strong> \u2022 In people with COVID-19 who require oxygen or ventilation, combination treatment with \u2022 There is no robust evidence to support the use of anakinra at any disease stage.*** (modified)<\/strong> \u2022 There is no robust evidence to support the use of low-dose colchicine at any disease \u2022 In people with COVID-19 who need non-invasive ventilation or high-flow oxygen, the \u2022 Ongoing trials mean it is not possible to recommend the use of GM-CSF inhibitors in COVID- \u2022 People without hypogammaglobulinaemia and with symptom onset more than 5 days ago \u2022 Monoclonal antibodies against antispike protein should be considered in people at risk of \u2022 There is not enough evidence to recommend the use of other immunomodulators in COVID- Summary<\/strong> Points to consider with just one or two stars are based mainly on expert opinion and not backed up by If you have any questions or concerns, you should speak to a health professional involved in your care.<\/p>\n Disclaimer:<\/strong> This is a summary of a scientific article written by a medical professional (\u201cthe Original Article\u201d). The Summary is written to assist non medically trained readers to understand general points of the Original Article. It is supplied \u201cas is\u201d without any warranty. You should note that the Original Article (and Summary) may not be fully relevant nor accurate as medical science is constantly changing and errors can occur. It is therefore very important that readers not rely on the content in the Summary and consult their medical professionals for all aspects of their health care and only rely on the Summary if directed to do so by their medical professional. Please view our full Website Terms and Conditions<\/a>.<\/p>\n Copyright<\/strong> \u00a9 2021 BMJ Publishing Group Ltd & European League Against Rheumatism. Medical professionals may print copies for their and their patients and students non commercial use. Other individuals may print a single copy for their personal, non commercial use. For other uses please contact our Rights and Licensing Team<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":" This is the lay version of the EULAR points to consider on the use of medicines traditionally used in rheumatology to treat the inflammation seen in people with severe COVID-19. The original publication can be downloaded from the EULAR website: www.eular.org. Alunno A, et al. 2021 update of the EULAR points to consider on the […]<\/p>\n
\nEULAR recommendations give advice to doctors, nurses and patients about the best way to treat and
\nmanage diseases. EULAR has updated the points on the pathophysiology of COVID-19 and the use of
\nimmunomodulatory therapies to treat it. Based on the low level of evidence available for this topic, it was not possible to develop full recommendations, and the work has been presented instead as \u2018points to consider\u2019. Doctors, other health professionals and patients worked together to develop this advice. The patients in the team ensured that the patient point of view was included. The authors looked at the evidence on COVID-19 infection, and the use of different therapies that act on the immune system.<\/p>\n
\nCOVID-19 is the disease caused by infection with the SARS-CoV-2 virus. Since it emerged at the end of
\n2019, this virus has caused a global pandemic. COVID-19 can be mild, or even without symptoms at all. But it can also cause severe disease, leading to respiratory problems, organ failure, and death. Research on the immune mechanisms involved in people with severe COVID-19 has shown that they have widespread inflammation.<\/p>\n
\ndesigned to treat the inflammation caused by autoimmune diseases such as rheumatoid arthritis, where the body\u2019s immune systems attacks its own tissues. New research is looking at how these medicines might be used to treat people with COVID-19. EULAR previously provided a framework to optimize the use of
\nimmunomodulatory therapies for the care of people with COVID-19. The first EULAR-endorsed points to
\nconsider on this topic were developed in 2020. Evidence is changing very quickly, and the points have been updated to include the most recent literature available.<\/p>\n
\ntaking immunomodulatory treatments for their rheumatic disease. Separate recommendations are available
\nfor the management of people with RMDs in the context of the pandemic.<\/p>\n
\nIn total, there are two overarching principles and 12 points to consider. The principles are unchanged from the earlier publication, and stress that the picture of SARS-CoV-2 infection can be very different in different people. Infections range from asymptomatic or mild disease to severe or fatal. People with COVID-19 may need different treatment approaches, including antiviral medicines, oxygen therapy, anticoagulation and\/or immunomodulatory treatment at different stages of the disease.<\/p>\n
\nfrom the field of rheumatology to treat severe COVID-19. Overall, 4 of the 12 points are unchanged from the 2020 version, 4 are modified, and 4 are new. WHO has validated the use of two types of immunomodulators in severe and critical COVID-19: corticosteroids and anti-IL-6 receptor antibodies.<\/p>\n
\nTwo stars (**) means it is a point with some scientific evidence.
\nThree stars (***) means it is a point with quite a lot of scientific evidence.
\nFour stars (****) means it is a point supported with a lot of scientific evidence.<\/p>\n
\nsupport using an immunomodulatory therapy.*** (unchanged)
\nMild or moderate COVID-19 that does not require hospitalisation does not respond to
\nimmunomodulatory medicines. At the moment, the evidence suggests that these work only for<\/p>\n
\nviral medicines to treat people outside the hospital setting.<\/p>\n
\nevidence to support starting immunomodulatory therapy.*** (unchanged)<\/strong>
\nThere is no evidence to support using immunomodulatory drugs in people hospitalised for COVID-19
\nif they do not need oxygen therapy. For those who do need oxygen, there are specific guidelines
\nbelow.<\/p>\n
\nglucocorticoids should be used since they can decrease mortality.*** (unchanged)<\/strong>
\nFor people who are in hospital because of COVID-19 and need to be given oxygen \u2013 or need
\nventilation to help them breathe \u2013 there is evidence that using immunomodulatory glucocorticoids
\ncan reduce the number of people who die. The drug with the most evidence to support this is
\ndexamethasone, which is a steroid that can help to reduce inflammation.<\/p>\n
\nEarly on the in the pandemic, a rheumatology drug called hydroxychloroquine was proposed as a
\npossible treatment. However, the evidence does not support this. It does not look like
\nhydroxychloroquine provides any additional benefit to the standard of care, and could worsen the
\nprognosis in more severe infections, particularly if given with azithromycin.<\/p>\n
\nglucocorticoids and tocilizumab should be considered.*** (modified)<\/strong>
\nA combination of glucocorticoids and tocilizumab can reduce disease progression and mortality in
\nCOVID-19. More data are needed to fully appreciate the effect of other IL-6R inhibitors.<\/p>\n
\nThere has been conflicting evidence about the use of anakinra for people with severe COVID-19,
\nand nothing to support its use in any stage of COVID-19.<\/p>\n
\nstage.*** (new)<\/strong>
\nSince the 2020 publication, there has been new evidence from two trials, but the results were not
\nsolid enough to recommend in favour of colchicine.<\/p>\n
\ncombination of glucocorticoids and baricitinib or tofacitinib could be considered.***
\n(modified)<\/strong>
\nBaricitinib or tofacitinib can decrease the time to recovery and speed up improvement, and can be
\nconsidered in some people with severe COVID-19 who need non-invasive ventilation or high-flow
\noxygen to help them breathe.<\/p>\n
\n19.*** (new)<\/strong>
\nGM-CSF inhibitors (mavrilimumab, otilimab, and lenzilumab) are being investigated in clinical trials,
\nbut there is not yet enough evidence to recommend their use to treat COVID-19.<\/p>\n
\nshould not be given convalescent plasma.*** (new)<\/strong>
\nHypogammaglobulinaemia is a state where a person has low plasma gamma globulins and impaired
\nantibody formation. For people whose COVID-19 symptoms started more than 5 days ago, and who
\ndo not have hypogammaglobulinaemia there is robust evidence against the use of convalescent
\nplasma.<\/p>\n
\nsevere COVID-19 who are seronegative or whose symptoms started less than 5 days ago.***
\n(new)<\/strong>
\nSome new drugs have been developed that target a particular protein on the virus called a spike
\nprotein. These include bamlanivimab, etesevimab, casirivimab and imdevimab. Trial data suggest
\nthese drugs can significantly reduce viral load, but efficacy depends on the virus variant, as well as
\nhow long ago symptoms started.<\/p>\n
\n19.** (modified)<\/strong>
\nThere currently not enough evidence to recommend the use of other immunomodulators to treat
\npeople with COVID-19. This includes interferon alpha, interferon beta, interferon kappa, interferon
\nlambda, leflunomide, nonSARS CoV-2 IVIg, eculizumab and cyclosporine. No recommendation
\neither in favour or against the use of these medicines can be made at this point. Other medicines are
\nbeing investigated, but only those with published evidence are included here.<\/p>\n
\nOverall, the points give guidance on how to use existing anti-inflammatory, immunomodulatory therapies to treat COVID-19. EULAR hopes these will be a useful reference for health professionals involved in the care of people with SARS-CoV-2 infection. They should be used alongside local regulations and guidelines, and information from bodies such as the World Health Organization.<\/p>\n
\nstudies, but these may be as important as those with three or four stars.<\/p>\n