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COVID-19 and inflammatory rheumatic disease: some key issues

Presented by
Prof. G. Burmester, Charité University Hospital, Germany
EULAR 2020
Undoubtedly highly anticipated during this year’s EULAR were the updates and recommendations concerning COVID-19. In a joint effort, experts aimed to gather the latest insights and solutions to the global pandemic. The currently available data suggests that patients with inflammatory rheumatic conditions do not exhibit an increased frequency of COVID-19 infection or a more severe course of the disease in general. General risk factors –such as older age, obesity, cardiovascular conditions, chronic lung conditions, hypertension, and diabetes– seem to be much more important in this respect.

During a unique virtual press conference, Prof. Gerd Burmester (EULAR Public Affairs Officer; Charité University Hospital, Germany) addressed some issues regarding medication, inflammatory rheumatic disease, and COVID-19 infection [1]. He emphasised that discontinuing immunomodulatory medication is not a good idea, as patients with inflammatory rheumatic diseases do not have an increased frequency of infection with COVID-19, nor do they experience a more severe course of the infection. Moreover, stopping therapy may trigger a relapse of the disease, which may lead to an unfavourable immunological situation or subsequent increased administration of cortisone, which has its specific hazards.

Prof. Burmester subsequently debunked the myth on the use of hydroxychloroquine in COVID-19 prevention or treatment, stating that either some studies that investigated the drug were uncontrolled or participants were given the drug with concomitant medication. Also, hydroxychloroquine was administered in patients with pre-existing conditions and cardiovascular comorbidities; these results can therefore not be transferred to the common situations when treating autoimmune disorders. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, were initially thought to pose a danger to patients with COVID-19, but this has found not to be the case. Thus, NSAIDs can continue to be used.

Similarly, it is important to know that angiotensin-converting enzyme (ACE) inhibitors, which are frequently used to treat hypertension for patients with a condition such as rheumatoid arthritis, are safe for patients infected with COVID-19. Moreover, current discussion focuses on a potential beneficial effect of these drugs on this condition.

Prof. John Isaacs (Newcastle University, United Kingdom) addressed the increased risk for COVID-19 in rheumatic patients who are suffering from venous thromboembolism (VTE). The reason that COVID-19 patients are susceptible to VTE may be related to the inflammation as well as the fact that the virus may infect the endothelium of the blood vessels. As it is known that antirheumatic drugs such as tumour necrosis factor (TNF)α inhibiting drugs, interleukin (IL)-6 blockers, and Janus kinase (JAK) inhibitors reduce thrombotic risk by lowering inflammation, they are being studied in hyperinflammation in COVID-19 and may be able to reduce the side effects of the disease, according to Prof. Isaacs [2].

Reassurance about recovery from COVID 19 was at hand from Prof. Pedro Machado (University College London, United Kingdom), who conducted a study assessing rheumatic patients or those with musculoskeletal diseases who had been infected with COVID-19: “Most of them recover from the virus, regardless of which medication they receive for their rheumatic condition.” In total, 600 COVID-19 patients from 40 countries were included in the study; 46% of patients were hospitalised and 9% died. Those who were treated with TNF inhibitors were found to be less likely to be hospitalised for COVID-19 (odds ratio [OR] 0.40; 95% CI 0.19-0.81). Contrary, prednisone dose ≥10 mg/day was associated with higher odds of hospitalisation (OR 2.05; 95% CI 1.06-3.96). The use of conventional disease-modifying anti-rheumatic drugs (DMARDs) alone or in combination with biologics/JAK inhibitors was not associated with hospitalisation (OR 1.23; 95% CI 0.70-2.17 and OR 0.74; 95% CI 0.37-1.46, respectively). Neither NSAID use or  anti-malarial use were associated with hospitalisation status (OR 0.64; 95% CI 0.39-1.06 and OR 0.94, 95% CI 0.57-1.57, respectively) [3].

Recommendations for managing rheumatic and musculoskeletal diseases in the COVID-19 era

A set of recommendations on the management of patients with rheumatic and musculoskeletal diseases has been developed by EULAR [4]. These recommendations focus on prevention of COVID-19; managing patients in general; and managing patients who have been infected or have been in contact with a COVID-19 patient. The recommendations were simultaneously published in the Annals of the Rheumatic Diseases [5]. Despite the sparse evidence combined with the tremendous time pressure under which these recommendations were made, EULAR was able to develop a preliminary set of recommendations on the management of patients with rheumatic and musculoskeletal diseases in the COVID-19 era. Prof. Robert Landewé (Academic Medical Center Amsterdam and Zuyderland Medical Center Heerlen, the Netherlands) emphasised that they are indeed preliminary and that updates are eagerly awaited. “However, for the time being, it will have to do.” The 13 recommendations are based on 4 themes outlined in the Table [4,5].


Table: The 4 themes on which the EULAR recommendations for COVID-19 are based [4,5]

Full recommendations can be found online.

Editors Note: In a fast-changing evolving field, the UK OpenSAFELY cohort of 17 million records has since showed a very marginal increased mortality in RA/SLE/psoriasis combined groups compared with a 50-59-year-old reference group [6].  Secondly, pulmonary immunothrombosis secondary to viral alveolitis rather than active pulmonary endothelialitis appears to be a key mechanism of thrombosis given the reported efficacy of corticosteroids from the RECOVERY trial [7,8].


    1. Burmester GR. Immunosuppressants, Analgesics and Anti-Inflammatory Drugs: Three common myths COVID-19 and Medication Used in Rheumatology – Current Findings. EULAR E-Congress, 3-6 June 2020.

    1. Isaacs J. COVID-19 - an update. EULAR E-Congress, 3-6 June 2020.
    2. Gianfrancesco M, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry.
    3. Landewé RBM. Provisional recommendations COVID-19. EULAR COVID-19 Recommendations. EULAR E-Congress, 3-6 June 2020.
    4. Landewé RBM, et al. EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2. Ann Rheum Dis. 2020;annrheumdis-2020-217877.
    5. Williamson EJ, et al. Nature 2020. Doi:10.1038/s41586-020-2521-4.
    6. McGonagle D, et al. The Lancet Rheumatology 2020;2(7):E437-E445.
    7. RECOVERY Collaborative Group. N Engl J Med. 2020. DOI: 10.1056/NEJMoa2021436.


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