Management of rheumatic diseases in the times of COVID-19 pandemic- perspectives of rheumatology practitioners from India

Latika Gupta; Durga Misra; Vishwesh Agarwal; Suma Balan; Vikas Agarwal

is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.04.03.20048389 doi: medRxiv preprint however, patients with RDs are likely to have heightened risk, as has been seen in the elderly and those with other co-morbid cardiac or lung disease. [9] Disease flares can potentially be induced by the COVID-19, as seen in RDs by most endogenous retroviruses as well as acquired viral infections. [8] Previously higher risk of infections has been reported in those with higher disease activity, and vice versa. [8] While most rheumatologists believed that COVID-19 may trigger MAS, it might be difficult to distinguish cytopenia and hyperferritinemia due to increased disease activity. The consensus was on the use of Tocilizumab in MAS, possibly backed by a case series, which remains to be confirmed in ongoing trials. [10] The feasibility of screening for SARS-CoV-2 before initiation of bDMARDs needs to be explored as previously suggested. [11] There was unanimous agreement on use of HCQ for treatment of COVID-19, with more than two-thirds weighing towards initiating it in patients with otherwise low evidence diseasespecific indications. This may be attributed to less toxic nature, fewer interactions, a wider therapeutic index, greater in-vitro efficacy against the COVID-19 and years of experience of rheumatologists. [12] A prominent national regulatory body has issued an advisory favouring prophylaxis with hydroxychloroquine for healthcare workers and close contacts of patients with COVID-19 [13] However, caution is needed as reports of toxicity have emerged with the use of prophylaxis. [14] The usage of ACEi/ARBs was debateable; there exists little evidence to recommend continuation or discontinuation of either drug. [15] In times of widespread travel bans and jeopardised medical services, there is a felt need for shift to virtual consulting. India recently legalised teleconsultations to the same effect. [16] A pandemic of such magnitude is not without psychologic impact on the treating physicians either. The dominant fears in this situation were mostly related to transmission to family and the patients. The management of the disease was most likely to be affected in the CTD spectrum of RDs, suggesting the need to develop evidence for a triage-in-rheumatology protocol bracing for the times ahead.