Managing rheumatologic diseases during pandemic

The current Covid-19 pandemic has changed the equation of healthcare in India to a great extent. Patients with rheumatologic (autoimmune) diseases such as rheumatoid arthritis, lupus, vasculitis, scleroderma, psoriatic arthritis and others, are facing many unique challenges.

These patients have diseases that are chronic and need long-term care, frequent visits to the specialist, periodic laboratory tests to monitor disease activity and safety of medications. In addition, a majority of the patients are on immunosuppressive medications and some are on steroids, which may be a cause of anxiety for them.

Social media is abuzz with misconceptions about the outcomes of Covid-19 infection in rheumatologic patients and the impact of arthritis medication on Covid-19 and the vaccines. The concern about worse outcomes on patients with rheumatologic diseases contracting the infection have been addressed through many clinical research studies.

The mere presence of an underlying autoimmune disease does not predict worse outcomes for patients following Covid-19 infection. It emerged from the first wave that patients having other factors such as pre-existing co-morbidities like diabetes, age, presence of underlying lung disease (which is not uncommon in various rheumatologic diseases) and those who were taking steroids, such as prednisolone more than 10mg daily, were more likely to require hospitalisation for severe Covid-19. However, patients with rheumatologic diseases should still continue to practise strict precautionary measures such as social distancing, use of masks and sanitizers etc. especially more so in the wake of the second wave where younger people are being affected equally. It is advisable to withhold immunosuppressive drugs for a period of up to three weeks when arthritis patients contract Covid-19 and then safely restart their medications.

Those with chronic rheumatologic diseases have faced numerous problems during the pandemic. The lockdowns, closure of out-patient services at hospitals and clinics, lack of transportation, unfamiliarity with online or teleconsultation, poor access to the internet and fear of visiting hospitals for scheduled appointments have left patients without follow-up on their disease and medications.

In a recent study of scleroderma patients from the Indian Systemic Sclerosis registry, it was noted that 92.3% of the patients missed their scheduled out-patient appointments and 22.3% skipped their prescription drugs. 22.3% of the surveyed patients reported that a family member lost their job.

Since a majority of patients with rheumatologic diseases are women in the child-bearing age group, a carefully planned pregnancy and ante-natal care is required.

This has become a challenge in the current context. In addition, both pregnant and lactating mothers are not eligible for the currently available Covid-19 vaccines. This puts them at a higher risk of contracting the infection and the ensuing complications.

During the pandemic, access to medications that are regularly used by patients with rheumatologic diseases has become difficult. Hydroxychloroquine sulphate (HCQS) is regularly used by patients with lupus and rheumatoid arthritis. During the first wave, it was widely believed that HCQS had an important role in the treatment and
prophylaxis of Covid-19. This resulted in a major shortfall in the supply of this essential drug to a large number of arthritis patients, in turn, resulting in their disease flares.

In the current wave, the focus is again on another drug called Tocilizumab (actemra), which is used for the treatment of rheumatoid arthritis, arthritis in children (juvenile arthritis) and temporal arteritis. Tocilizumab (actemra) is currently being recommended for the treatment of Covid-19 patients with moderate to severe lung disease.

The sudden increase in the number of Covid-19 cases and the ensuing increased demand for Tocilizumab (actemra) has created a shortage of the drug. This has in turn made it difficult to access the drug for many of the patients who were dependent on it for the control of their arthritis. Baricitinib (Olumiant) is another arthritis drug that is also being used to treat severe Covid-19 infection. This has likewise created a difficult situation to procure the drug for patients with arthritis. Both these drugs are still not generic, hence are not manufactured in India and have to be imported. This in turn has compounded the problem of availability.

Finally, arthritis patients who suffer from lung disease are facing a huge challenge with their regular supplies of oxygen or concentrators much like others. Women with long-standing arthritis may have joint deformities rendering them less capable to carry out their daily chores.

Likewise, those with inadequately controlled disease are in constant pain. Inability to get domestic help, carers and support during the pandemic compounds their struggle to keep up with daily household chores, making it an arduous task.

Vaccination is our only hope to contain the pandemic. Doubts were raised about the safety of vaccination in patients with autoimmune rheumatologic diseases especially for those who were on immunosuppressive drugs. Recent recommendations from the American College of Rheumatology suggest that it is safe for patients with rheumatologic diseases to receive Covid-19 vaccination irrespective of the underlying disease status.

Minor alterations will be made to existing medications to facilitate vaccination. Drugs such as methotrexate, mycophenolate, baricitinib and tofacitinib are better withheld for a week after vaccination. This is done in order to facilitate a better immune response from the body post-vaccination.

The timing of infusion of more potent drugs such as cyclophosphamide and rituximab are to be likewise modified. Although this temporary cessation of medications might cause a small flare of the underlying rheumatologic disease, it shouldn’t be difficult to manage them.

(The writer is a Consultant Rheumatologist at a Bengaluru hospital)