COVID-19 Drove Significant Changes in Rheumatoid Arthritis Patient Treatment Regimens

Kaleb Michaud, PhD (UMNC)

The coronavirus 2019 (COVID-19) pandemic’s effect on medicine reaches far beyond the means of viral transmission and progression of disease in infected patients. It has greatly influenced every field of medicine since first becoming a major outbreak in the US in early March.

In the field of rheumatology, it even influenced treatment regimens.

New data presented at the American College of Rheumatology (ACR) Convergence 2020 showed patients with rheumatoid arthritis made “substantial changes” to their medication use in the early months of the pandemic. What’s more, nearly half of decisions to decrease or discontinue disease-modifying therapy treatment were made without the guidance of their prescribing clinician.

Investigators, led by Kaleb Michaud, PhD, of the University of Nebraska Medical Center and FORWARD, the National Databank for Rheumatic Diseases, sought to understand the changes made by patients with rheumatoid arthritis to their medical and clinical care regimen during March-May 2020—the first 3 full months of the COVID-19 pandemic.

Initial concern to the inflammation-targeting mechanism of the virus led to greater discussion early into the pandemic that therapies including disease-modifying antirheumatic drugs (DMARDs) could make patients more susceptible to severe COVID-19 outcomes.

Michaud and colleagues observed data provided by adults with rheumatoid arthritis participating in the FORWARD observational registry. The pool of patients had answered questions on baseline characteristics and general medication use in 2019, and then answered questions centric to COVID-19’s effect on their status in May and June of this year.

Investigators compared the reported medication changes by pre-pandemic DMARD exposure in logistic models first without adjustment—and then with adjustment to various factors:

• Age
• Sex
• Cardiovascular and pulmonary comorbidities
• Education
• Health insurance
• Rheumatoid arthritis activity (per PAS-II)
• Polysymptomatic distress (PSD)

Rates of medication change were also examined from before and after the first COVID-19 treatment guidelines from ACR were published in April.

Among 734 database respondents, investigators observed a 30% (n = 221) rate of reported medication changes during the early COVID-19 pandemic. Patients more likely to change their regimen more frequently used glucocorticoids (33% vs 18%) and less frequently used DMARDs over than hydroxychloroquine (49% vs 62%) prior to COVID-19.

Patient JAK inhibitor use was associated with change in investigators’ bivariate analyses (OR, 1.9; 95% CI, 1.0-3.4). However, just glucocorticoids were a strong factor of rheumatoid arthritis treatment change during early COVID-19 spread in multivariable models (OR, 3.0; 95% CI, 1.9-4.9).

Among patient factors, changes in care were most associated with their having pulmonary disease (OR, 2.9; 95% CI, 1.3-6.5) and using glucocorticoids (OR, 1.6; 95% CI, 1.0-2.5).

Incidence of medication change before and after April 15, the midpoint of their assessment, was approximately the same. But patient-initiated changes due to COVID-19 were actually twice as likely to occur before April 15, while physicians were more likely to advise change after the date—marking a disparity in clinician-informed versus pandemic-reactionary regimen strategies.

“Our findings confirm US patients with RA made substantial changes to their medication use during the first 3 months of the COVID-19 pandemic,” investigators concluded. “Almost half of DMARD decrease or discontinuations were made without physician guidance, and all types of medication changes after ACR recommendations were made with increased physician guidance.”

Though Michaud and colleagues could not confirm a direct causation of this trend in changed rheumatic care, the findings overall provide evidence toward their recommendation of adherence to the ACR guidance.

The study, “DMARD Changes for Patients with Rheumatoid Arthritis in the US During the First Three Months of the COVID-19 Pandemic,” was presented at ACR 2020.