Q&A with Dr. Nigil Haroon: COVID-19 and Spondyloarthritis

In this Q&A with rheumatologist Nigil Haroon, M.D., Ph.D., of the University Health Network and Krembil Research Institute at the University of Toronto, we discuss COVID-19 factors specific to patients with spondyloarthritis.

Q:  Are all individuals with spondyloarthritis at an elevated risk of COVID-19?

Chronic inflammatory conditions are considered to decrease our ability to resist infections. Similarly, the complications of COVID-19 seem to be higher in those with chronic conditions. The observational reports currently point to conditions such as lung disease, diabetes, cancer and renal failure resulting in poor outcomes of COIVD-19.

Generally, the risk of infections is considered to be higher in rheumatoid arthritis and lupus compared to ankylosing spondylitis. This could be due to underlying immune pathways but more likely due to the age group of affected individuals and medications such as corticosteroids that are used in rheumatoid arthritis/lupus but not in ankylosing spondylitis.

We do not have information on the differences in susceptibility to COVID-19 in ankylosing spondylitis/ spondyloarthritis versus other rheumatic diseases.

A small proportion of ankylosing spondylitis patients may have lung fibrosis or chest wall involvement resulting in decreased lung volumes. These patients may be at particular risk of complications. Although classic interstitial lung disease may happen, the most commonly reported type of fibrosis in ankylosing spondylitis tends to affect the upper lobes. COVID-19 predominantly affects the lower lobes and this could mean rapid decompensation. Moreover, ankylosing spondylitis patients may be at increased risk of pneumothorax and already, we are recognizing that barotrauma during mechanical ventilation is high in COVID-19.

Long standing ankylosing spondylitis is associated with cardiovascular morbidity and mortality and those patients with a long history of uncontrolled inflammation due to ankylosing spondylitis, should be very careful and strictly observe social distancing and handwashing. They should wear a mask if they really have to go out.

This was the long answer. Short answer is we do not know for sure; caution is recommended.

Q:  Are patients on immunosuppressants at greater risk?

This is still unknown. The chance of acquiring infection may be higher, but we do not know if the complications are.

This is an important question to answer, as I feel the severe manifestations seen with COVID-19 are not virus driven, but rather due to heightened immune responses resulting in lung damage.

Q:  Are patients continuing to attend rheumatology appointments during the pandemic?

Patients come to clinic only if absolutely necessary, for example, for joint injections with severe pain / inflammation.

Telemedicine can and should be used to help our patients at this time of need. Investigations should be minimized, and only absolutely essential monitoring should be done to reduce exposure to COVID-19 in the laboratory.

Q:  Should medication be altered if a patient with spondyloarthritis experiences COVID-19 symptoms?

Patients should inform the rheumatology office and check regarding adjustment of medications especially immunosuppressants. While biologics have to be stopped as we do with any major infections, managing corticosteroids can be tricky. Sudden stoppage of long-term corticosteroids can precipitate adrenal failure with severe consequences.

Q:  Can nonsteroidal anti-inflammatory drugs (NSAIDs) worsen COVID-19 effects?

There is no definitive proof that NSAIDs have an impact on COVID-19. There were some associations reported in observational studies and these are not conclusive. The current advice is to continue NSAIDs if it is required for control of disease as is the case in some spondyloarthritis patients. If patients do not need it on a regular basis and only use it for flares, paracetamol can be taken for minor flares first.

Q:  When will a vaccine become available and will it be safe for spondyloarthritis patients?

Vaccinations are used in spondyloarthritis patients with no issues. If patients are on biologics, live vaccines are avoided. For COVID-19 we will likely have nucleic acid or peptide-based vaccines and it should be safe. However, this is a slow process and if we are successful the best-case scenario is to have a vaccine ready by summer of 2021.

Q:  How will clinical trials be impacted by COVID-19?

New enrollments will likely be very slow due to restricted outpatient activity in the rheumatology clinics. Ongoing clinical trials will continue, and patients should be able to continue receiving the drug as per protocol as these studies have been exempted from restrictions.

Q:  Are you aware of any shortages of these drugs for the community?

There is a backlog of hydroxychloroquine prescriptions. The U.S. Food and Drug Association approved a new application for hydroxychloroquine on April 7 and companies are trying to increase the supply.

Q:  What is the rheumatologist’s role in COVID-19?

Clinical immunologists and rheumatologists who have experience using biologic medications have a major role to play in COVID-19 treatment. The severe form of COVID-19 disease appears to be immune mediated and there is mounting evidence of this not being the usual acute respiratory distress syndrome like lung presentation. A tendency for thrombosis, blood markers and lung patterns that are seen in rheumatic diseases lend support to this possibility.