Rheumatology & COVID-19

Topics

Hydroxychloroquine

Hydroxychloroquine is an important medication for many patients with autoimmune diseases. It has also been widely used to treat COVID-19 even though we haven’t been clear about the risks and benefits. A study was just published online in the New England Journal of Medicine that looked at 1,376 patients hospitalized in New York City for COVID-19. Unfortunately, patients treated with hydroxychloroquine did not have a lower risk of dying or needing to be put on a breathing machine. Randomized trials are underway, but this study doesn’t suggest that hydroxychloroquine is helpful for treating COVID-19.

Do medications used to treat common rheumatic conditions increase this risk of COVID-19 infection?

Physicians from New York City recently published their experiences with 86 patients with COVID-19 and autoimmune disease (published on-line in the New England Journal of Medicine NEJM.org). These were people with conditions like rheumatoid arthritis or psoriatic arthritis, and they were being treated with a variety of medications. They looked at whether the medications that they were on affected their chances of being hospitalized for COVID-19. Encouragingly, most of the medications that we use to treat autoimmune conditions did not seem to increase the chances of having a severe case of COVID-19. There were a few medications, including prednisone, methotrexate and hydroxychloroquine, that were associated with a modestly increased risk of hospitalization. This information is preliminary, but is reassuring for those patients who require medications to control their chronic autoimmune condition. As always, ask your provider about how this information may or may not apply to your specific case. Never stop or change your medications without first having a discussion with your rheumatologist.

Anakinra (Kineret)

Respiratory failure is the leading cause of death related to COVID-19. This is often due to an excessive amount of inflammation from the immune system rather than from the virus itself. This “cytokine storm” leads to fever, low blood counts, and failure of many organs including the kidneys, lungs, and heart. When this happens, very high levels of inflammatory proteins are found, and it is thought that this overactive immune response is primarily responsible for many of the problems of severe COVID-19.

There are many medications that rheumatologists use to suppress the immune system by blocking these inflammatory proteins. Studies are underway to see if using these medications could be helpful at treating severe COVID-19 infections. It is important to understand that these medications may not prevent the infection itself, but they may be helpful at treating the inflammation that can result after an infection.

Anakinra (Kineret) is a biologic medication that blocks an inflammatory protein called IL-1. A recent study published on May 7 in Lancet Rheumatology reported improved survival in patients receiving anakinra. After 3 weeks, 73% of patients on anakinra were alive and not on a ventilator (compared with 50% of patients not receiving anakinra). This was a small study (45 patients) and patients were not randomized. We know from the initial reports of hydroxychloroquine that small studies can be misleading and don’t always hold up, but this study of anakinra is certainly encouraging.

https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30127-2/fulltext

Hydroxychloroquine in COVID-Positive Patients

Another study was published online on May 11 in the Journal of American Medical Association (JAMA) that looked at 1438 hospitalized patients with COVID-19 in 25 hospitals in New York. In this study, patients who received hydroxychloroquine were not more likely to survive than patients who did not get the medication. The combination of hydroxychloroquine and azithromycin also did not improve survival, and these patients were twice as likely to have a heart attack while in the hospital. What is concerning about this study is that it looks like these medications not only do not help, but the combination of the two may actually cause harm.

https://jamanetwork.com/journals/jama/fullarticle/2766117?resultClick=1

Immunosuppressive Medications and COVID-19

Because medications that suppress the immune system can increase the risk for some infections, we have been cautious about using them during the SARS-CoV-2 pandemic. A recent study published in the Annals of Rheumatic Diseases was reassuring, however. They followed 600 patients with rheumatic diseases who had a positive test for SARS-CoV-2 to see what happened to see whether certain diseases or medications could lead to more severe cases of COVID-19. Being on prednisone at a dose of 10mg or greater did seem to increase the risk of being hospitalized due to the virus, but the other medications we use did not. Being on a biologic medication actually reduced the risk of being hospitalized by more than 50%, which is very reassuring. This will need to be followed closely, but it looks like the biologic medications do not increase the risk that people with COVID-19 get so sick that they need to be in the hospital.

Gianfrancesco M, Hyrich KL, Al-Adely S, et al. Ann Rheum Dis 2020;79:859–866.

Arthritis Foundation - Coronavirus and Arthritis: What You Need to Know
American College of Rheumatology - Announcements


Language Assistance Available