Expert Perspectives: COVID-19 Considerations for Rheumatologists

Treating rheumatic disease during COVID-19 has presented new challenges for rheumatologists along with opportunities for the advancement of new approaches.

Alvin F. Wells, MD, a rheumatologist with Aurora Health Care in Franklin, Wisconsin, shared his perspectives on recent research during a webinar hosted by Christopher Parker, DO, a rheumatologist with The Austin Diagnostic Clinic in Texas.

The webinar, “Expert Perspectives on Management of Rheumatic Diseases: Post ACR Convergence 2020,” covered highlights from the American College of Rheumatology’s virtual meeting, ACR Convergence 2020, which was held in November.

COVID-19 restrictions left rheumatologists scrambling for ways to evaluate their patients.

“In lieu of a physical exam can we look for other measures to see how patients are responding if they have psoriatic arthritis,” Wells said.

An abstract presented at ACR Convergence 2020, evaluated Routine Assessment of Patient Index Data 3 (RAPID3), which uses patients’ self-reported measures to evaluate disease activity. It included patients in the PALACE 4 study, which assessed the efficacy of apremilast in patients with psoriatic arthritis who haven’t had disease-modifying anti-rheumatic drugs (DMARDs).

The abstract examined trajectories for improving RAPID3 scores along with Clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA).

“The take home message from that abstract shows that, yes, compared to the cDAPSA the RAPID3 score works just as well,” Wells said. “So, fast forward to 2021, I’ve been using that for some of my virtual patients as we see them in the clinic because we’re still not 100% live. I’m about 60% in person, about 40% virtual with my patients in the clinic. So, it’s another tool. Like I said, whether you’re in an academic center or whether you’re in private practice, this is something you can do in lieu of the physical exam.”

RAPID3 includes Health Assessment Questionnaire Disability Index (HAQ-DI) or multidimensional HAQ, pain visual analog scale (VAS) and Patient’s Assessment of Disease Activity (PtGA) VAS.

Wells said physician assistants and nurses play an important role in the assessment, asking questions and collecting information from the patients before he picks up the virtual visit and completes the patient global assessment.

“It can be used in a busy practice and it doesn’t take much time,” he said.

The COVID-19 pandemic also has raised concerns about the risks to patients with rheumatic diseases.

Another abstract presented at ACR Convergence 2020 examined the outcomes of COVID-19 on patients with rheumatic diseases, finding that risk of severe COVID-19 was similar to those without rheumatic diseases in a comparative cohort.

Wells said that while the results were encouraging, the study was small and he encourages patients to submit their names to the Global Rheumatology Alliance patient registry to collect more robust data.

He also noted that prednisone has been found to increase the risk of getting COVID-19 and the risk of hospitalization with the disease, which does not occur with drugs like apremilast, interleukin-6 antagonists or tumor necrosis factor (TNF) drugs.

He encouraged rheumatologists to maintain treatment to reduce the risk of severe COVID-19.

“Because if they flair, to recapture the disease, you’re going to give them prednisone, and when they get prednisone it’s gonna have more side effects,” Wells said. “This is nothing new with the steroids, right? We’ve learned over the years that steroids increase the risk of infections, steroids increase herpes zoster, steroids do a lot of things in addition to all of the other metabolic side effects as well.”

ACR has issued COVID-19 guidance for patients with rheumatic diseases, which Wells called a living document that is likely to change as more data becomes available.

“It gives you all the different scenarios about whether you’re thinking about starting a new therapy, adding a therapy, changing a therapy or somebody who has active infection from that,” Wells said.