Medication, Stress Management in Rheumatology Patients During the COVID-19 Pandemic

Writing in Practical Pain Management, Don L. Goldenberg, M.D., rheumatologist and professor emeritus, Oregon Health Services University, Portland, and the American College of Rheumatology, addresses clinical approaches for managing medications during the COVID-19 pandemic in patients with chronic rheumatic autoimmune disease.

Patients with rheumatic autoimmune diseases should be advised to contact their physician immediately if there is concern of COVID-19 infection. The risk for infection depends on disease status and current medications. During the COVID-19 pandemic, infection-related concerns should be prioritized over routine visits or elective procedures, and physical or occupational therapy should occur via telemedicine, Dr. Goldenberg wrote in the article.

Medication Management

Ongoing immunosuppressive medications should be continued at the current dose, unless an active (COVID-19) infection is present. "Such drugs, including corticosteroids, should never be stopped abruptly,” he wrote.

While there is no data on the impact of immunosuppressive drugs on COVID-19, stopping or switching medications may precipitate systemic disease exacerbations. In cases of disease remission or stable disease, a slow taper of immune suppressant medications can be considered, especially with drugs that primarily affect T cells, but medication should be restarted if the disease flares. However, during an infection, immunosuppressive therapy should be paused until the patient is asymptomatic.

Corticosteroids have been used in patients with COVID-19 infection and severe lung disease, with no reports of clear efficiency. During the pandemic, these drugs should not be injected into joints or soft tissues. Regular intravenous biologic infusions should continue, but clinicians need to inquire about recent fever, cough or exposure. Data regarding the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) has been conflicting, and while there is no evidence that these drugs are unsafe to use during COVID-19 infection, use of NSAIDs or acetaminophen may mask fever and lead to a delay in a COVID-19 diagnosis.

A number rheumatology drugs are currently under study for COVID-19, including antiviral drugs, such as lopinavir-ritonavir and remdesevir, monoclonal antibodies and immunoglobulin derived from the plasma of COVID-19 patients who have recovered. Some biologic immunosuppressive drugs, such as interleukin blockers tocilizumab and sarilumab, and tumor necrosis factor inhibitor adalimumab, may turn out to be effective in managing the cytokine storm evident in severe COVID-19 infections, but more research is needed to determine this with certainty. Moreover, any benefit seen with antimalarial drugs hydroxychloroquine and chloroquine appears to be anecdotal so far. Stockpiling these drugs has made it difficult for patients with rheumatic disease to refill prescriptions.

Stress Management

In patients with rheumatic diseases, stress associated with the COVID-19 pandemic may lead to disease flares, but also anxiety, depression and suicidal thoughts.

“There is an urgent need for clinicians to find innovative ways to offset…emotional and mental states in patients who are already struggling with chronic pain or illness,” Dr. Goldenberg wrote.

Clinicians should assess patients’ levels of despair and offer reassurance that anxiety related to COVID-19 is normal. Telemedicine can be used for patient education and reassurance, and mental health classes have shown potential. If a patient’s sleep is disrupted, due to stress or upset to daily activities, clinicians may advise them to stop watching the news at night and encourage patients to keep to their regular sleep routines where possible.

Healthy lifestyle habits, such as smoking cessation should be encouraged. Smokers may have greater pulmonary complications from COVID-19, while inactivity may increase depression and chronic pain. In light of fitness centers being closed, alternative forms of exercise, such as walking or online yoga, should be recommended to patients. The American College of Rheumatology and Arthritis Foundation have posted free online exercise programs.

“Patients who have not followed lifestyle recommendations regarding smoking cessation, nutrition, and weight management may be better motivated with the added danger of complications from the current pandemic,” Dr. Goldenberg wrote.

REFERENCE

Don L. Goldenberg. “Managing Rheumatic/Immune Diseases During COVID-19.” Practical Pain Management. April 3, 2020.