Immunosuppressants and Coronavirus: Here is What You Should Know

Even during the coronavirus pandemic, physicians are advising patients to stay on their immunosuppressant medications. Here’s why.

People with chronic rheumatic and immune diseases, such as lupus, rheumatoid arthritis, and multiple sclerosis, are helped daily by taking a class of drugs that suppress their immune system. Called disease-modifying anti-rheumatic drugs (DMARDs), these agents purposely affect the immune system to reduce the many problematic symptoms of autoimmune diseases, including pain.

"Nothing takes precedence over the advice of your physician,” says Mahalia Desruisseaux, MD, in the Division of Infectious Diseases at Yale School of Medicine. This means staying on your medications until you’ve received clear guidance from your doctor. (Image: iStock)

But does the benefit of immune modulation or suppression in these individuals become a liability during the novel coronavirus pandemic? Many patients are wondering if they are at increased risk of contracting the COVID-19 infection or at increased risk of more severe illness because of their autoimmune disease or because of the DMARDs they are on to treat it.

The short answer is, no one knows for sure. The longer answer is, in the absence of solid evidence, these seemingly higher-risk patients are not alone to grapple with uncertainty on their own, but they can and should turn to their physician for clear guidance.

“Nothing takes precedence over the advice of your physician,” says Mahalia Desruisseaux, MD, associate professor of Internal Medicine in the Division of Infectious Diseases at Yale School of Medicine in Connecticut. Above all, this means staying on your medications until you’ve spoken with your doctor and received clear guidance about what you should do.

If you are taking immunosuppressant medications to help manage a chronic condition, below are some things you may hear.

Which Disorders and Medications May Be of Concern?  

First, it is important to know the rheumatic/immune diseases and their associated medications may place a person at reduced immunity to fight off a viral infection of any kind. Relevant conditions include:

  • inflammatory disorders such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE), inflammatory bowel disease (IBS), Sjogren’s syndrome, inflammatory myositis, and uveitis
  • connective tissues diseases such as systemic sclerosis and vasculitis (note that SLE is also considered a connective tissue disorder)
  • neurological disorders such as multiple sclerosis (MS) and neuromyelitis optica.

Treatment of these conditions may include a DMARD. These drugs are classified as either conventional or biologic. Methotrexate, leflunomide, teriflunomide, sulfasalazine, and hydroxychloroquine (HCQ, which is being explored as a potential treatment for the novel coronavirus – see beloware among the commonly used conventional DMARDs and are typically the first type of drugs to be used in a care plan. You may hear some of these drugs referred to as "antimalarial" drugs as well. If these medications do not provide effective treatment (ie, they do not reduce disease activity or disease progression), your clinician may prescribe biologic DMARDs. Infliximab, adalimumab, etanercept, rituximab, ocrelizumab, abatacept, tocilizumab, tofacitinib are among these agents. 

Update on HCQ & COVID:  in June 2020, NEJM published data from a randomized controlled trial (RCT) which demonstrated that "after high-risk or moderate-risk exposure to COVID-19, hydroxychloroquine did not prevent illness compatible with COVID-19 or confirmed infection when used as postexposure prophylaxis within 4 days after exposure." Further, the RCT showed more side effects with HCQ use than with placebo. Then, on July 1, 2020, the FDA issued a statement cautioning against the use of hydroxychloroquine or chloroquine for COVID-19 outside of a hospital setting or a clinical trial due to risk of heart rhythm problems. (Stream a video Q&A with PPM's Editors-at-Large on HCQ and other medication/risk questions).

Although no data yet show that patients with rheumatic or immunocompromised conditions, or on DMARDS, are at increased risk of contracting COVID-19, it is known that people with suppressed immune systems are at increased risk for contracting bacterial and other infections and tend to develop more severe infections. For Dr. Desruisseaux, this suggests that immunologically suppressed persons may be at increased risk of developing more severe disease from COVID-19. “There is still a lot about COVID-19 that we don’t know but it stands to reason that if you are on medication that changes your immune system and alters your immune response to different viruses, that you would be at risk of developing severe disease from COVID-19,” said Dr. Desruisseaux.

Doug Roberts, MD, a rheumatologist and assistant professor of medicine at the University of California Davis Medical School, took it a step further. “There are millions of Americans who are at higher risk for COVID-19 simply because they are diagnosed with an illness that suppresses their immune system… That risk is further exacerbated because many of the treatments, such as DMARDs, that suppress the immune system, might put these patients at higher risk for viral infection and then complications from those infections.”

Speaking on behalf of patients with MS, Flavia Nelson, MD, professor of neurology at the University of Minnesota and director of the Multiple Sclerosis Division, echoed the lack of data. “Although we do not have any specific data about the impacts of this illness on people with multiple sclerosis, in most cases we would not expect that the drugs we use to treat it would substantially increase the risk of complications from this virus,” she said. She also stressed that some high efficacy DMARDs increase the risk of infections, so precautionary measures, such as delaying the time between infusions, are being taken at her institution on a case-by-case basis.

She also emphasized that there is a global effort to report cases of patients with MS who are infected with COVID-19 so that more can be learned about the behavior of the disease in these patients. Information can be reported to www.msif.org/covid-19-ms-global-data-sharing-initiative.

In the absence of clear data, what all three experts agree on is the need for patients to discuss their concerns with their physicians and to not stop taking DMARDs without physician guidance.

In General, Stay on Your Medications

“Don’t stop your medications unless you and your physician decide that it is best for you to pull back on those medications,” said Dr. Desruisseaux. This goes for patients with stable disease as welle. “If a patient is stable on their treatment plan, we do not recommend going off their medication during the pandemic without speaking with their physician,” said Dr. Roberts, who also serves as a medical advisor to CreakyJoints and Global Healthy Living Foundation. Why exactly? He emphasized that patients are at risk of relapse or serious flare if they go off their medications, which could lead to complications. This, in turn, said Dr. Desruisseaux, could lead to hospitalization which, at this time, could place you at higher risk of contracting the coronavirus.

Dr. Nelson reiterated that patients with MS should not stop DMARDs. However, she did recommend that patients considering switching to high efficacy infusions, such as ocrelizumab and alemtuzamab, if their non-biologic DMARDs are proving ineffective, should delay switching as long as possible “due to these drugs’ increased risk for upper respiratory tract infections.” She adds that if you are concerned about scheduling delays in the administration of your MS infused (or intravenous, IV) medications, “Delaying an DMT infusion by a month or two should not place patients at risk for a relapse.” 

This advice mirrors that shared by a number of professional medical association and patient support groups. These include the American College of Rheumatology (offering FAQs and Updates), National MS Society (sharing guidelines on disease modifying drugs), and the Creaky Joints and Global Healthy Living Foundation, which are offering a free support program for those with chronic disease. See new guidelines for specific situations below.

Follow COVID-19 Guidance

Important Update: On April 11, 2020, the American College of Rheumatology released draft guidance for the care of adult patients with rheumatic diseases during the COVID-19 pandemic; they updated this guidance on April 29, 2020 and again on July 13, 2020. The guidelines, written for doctors, are available on the ACR COVID webpage. In summary:

  • Regarding general care of individuals with rheumatic disease: The risk of poor outcomes from COVID-19 appears to be related primarily to general risk factors such as age and comorbidity. Preventive measures (eg, social distancing and hand hygiene) should be taken.Measures to reduce healthcare encounters and potential exposure to the virus may be reasonable (eg, reduced frequency of lab monitoring, optimal use of telehealth, increased dosing intervals between intravenous medications). If indicated, glucocorticoids should be used at the lowest dose possible to control rheumatic disease, regardless of exposure or infection status; these medications should not be abruptly stopped, regardless of exposure or infection status. If indicated, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should be continued in full doses or initiated.

  • Regarding individuals with stable rheumatic disease: Hydroxychloroquine or chloroquine (HCQ/CQ), sulfasalazine (SSZ), methotrexate (MTX), leflunomide (LEF), immunosuppressants (eg, tacrolimus, cyclosporine, mycophenolate mofetil, azathioprine), biologics, Janus kinase (JAK) inhibitors, and non-steroidal anti-inflammatory drugs (NSAIDs) may be continued. Denosumab may still be given, extending dosing intervals to no longer than every 8 months, if necessary to 2 minimize healthcare encounters. For those with a history of vital organ-threatening rheumatic disease, immunosuppressants should not be dose-reduced.
  • Regarding individuals with lupus (SLE): In newly diagnosed disease, HCQ/CQ should be started at full dose, when available. In pregnant women with SLE, HCQ/CQ should be continued at the same dose, when available. If indicated, belimumab may be initiated.
  • New – Regarding re-instating treatment in invidivudals after they have had COVID: For patients with uncomplicated COVID-19 infections (characterized by mild or no pneumonia and treated in the ambulatory setting or via self-quarantine), consideration may be given to re-starting rheumatic disease treatments (eg, DMARDs, immunosuppressants, biologics and JAK inhibitors) within 7 to 14 days of symptom resolution. For patients who have a positive PCR test for SARS-CoV-2, but are (and remain) asymptomatic, consideration may be given to re-starting rheumatic disease treatments 10 to 17 days after the PCR test is reported as positive. Decisions regarding the timing should be made on a case-by-case basis.

There are additional ACR guidelines for individuals just recently diagnosed with a rheumatic condition and on what to do in case of COVID-19 exosure or infection. Speak with your provider if you have specific questions about these guidelines and whether they impact you.

In general, persons who may be immunocompromised and taking DMARD medication should aim to reduce their risk of infection by practicing physical distancing, staying home as much as possible, washing hands thoroughly, and avoiding touching your face after returning home from going out in the public, said Dr. Roberts.

Citing guidelines developed by the University of Minnesota for patients with multiple sclerosis, Dr. Flavia further advised that anyone over age 65 or taking more than one immune-suppressive drug to be particularly cautious. She also advised against any travel, but if essential, to avoid mass transit as much as possible and to wear a mask.

People who think they may have been exposed to the virus or have symptoms of COVID-19 should immediately call their primary care physician regarding what to do (many are providing telemedicine so you don’t have to travel to the office to get answers). Patients can stay up to date on recommendations by regularly checking the Centers for Disease Control and Prevention COVID-19 (CDC website). You can also find resources related to pain and chronic illness management on our COVID-19 resource page, including how two immunocompromised sisters are coping.

More on risks regarding COVID-19 for those living with rheumatoid arthritis and lupus, specifically.

 

*Editor's Note: This article was updated on April 13, 2020; on May 5, 2020 and July 24, 2020, to incorporate new ACR clinical guidance for the care of people with rheumatic diseases during and after COVID-19; and on June 3, 2020 and July 9, 2020, to share the latest HCQ data.

 

Updated on: 07/24/20
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How Two Immunocompromised Sisters are Fighting the Coronavirus Quarantine
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