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The past several weeks have been unprecedented in our lifetime. Social distancing, sheltering in place, and overburdened hospitals are disconcerting for anyone. Add in managing rheumatoid arthritis on top of trying to protect yourself from the novel coronavirus (COVID-19), and things can feel even more challenging.
Are you at greater risk if you have RA? Should you keep taking your RA medications? These are the questions members of myRAteam are asking now. We reached out to Dr. Siddarth Tambar, a rheumatologist and leader of Chicago Arthritis and Regenerative Medicine, and asked him what people with RA need to know in the era of COVID-19.
This article addresses:
In a March 27, 2020 interview with myRAteam, Dr. Siddharth Tambar talked about the risks of COVID-19 for people facing rheumatoid arthritis. Dr. Tambar explained:
“The nature of any sort of chronic active condition is that it makes you more susceptible to any other kind of infectious issue,” Dr. Tambar said. “From the standpoint of having worse outcomes, however, if a condition is under control, we think that the risk [of contracting COVID-19] is really the same as the general population.”
According to the National Rheumatoid Arthritis Society, “It is important to keep your RA as well controlled as possible. If you come off your medication, you have a very high likelihood of going into RA flare.”
Flares are not only hard on your body, but also might require that you visit a congested hospital or doctor’s office — putting you at greater risk for infection. Given how overextended health care services can get during pandemics, it is a good idea to avoid unnecessary appointments. Contact your doctor via phone and telemedicine first about any questions or concerns.
People with RA are generally prescribed medications from a few different categories. Common treatments for RA include:
Dr. Tambar advises continuing to take your medications if you can and if your doctor feels that is the right strategy for you. He noted, “While there's a little bit higher risk being on the medication, the benefits are that your immune system is under control.” That is preferable to “having a ragingly active condition, which on its own puts you at higher risk for infections."
The antimalarial medication Plaquenil (Hydroxychloroquine) has been in the news lately. After President Trump cited these medications as a potential treatment for COVID-19, many people with RA began to have trouble filling their prescriptions. And on March 29, the Food and Drug Administration (FDA) gave emergency approval to distribute this drug to hospitals for COVID-19 care.
Dr. Tambar noted that some of his patients are beginning to experience a shortage in Plaquenil and its generic, Hydroxychloroquine. “What I'm hearing from patients, what I'm hearing from pharmacies,” he said, “is that either they're not being given a full prescription — let's say a full 90 days [and] maybe they're only getting 30 days. In some cases, only 20 days. Or they're being told, ‘Hey, we just don't have the medication on hand. You're going to have to wait.’”
He continued, “It's challenging because we have a legitimate reason for [using Plaquenil] in a subset of our autoimmune patients. And definitely, I am starting to hear that there is some limitation in supply.”
As a result, manufacturers have recently committed to ramping up production of Hydroxychloroquine to meet the expected increase in demand. If you are concerned that shortages of Hydroxychloroquine may affect you, talk to your pharmacy and health care providers.
Keeping your RA under control with medications may help you avoid having to take corticosteroids. According to Dr. Tambar, corticosteroids may be problematic for people with RA. “Steroids, at a high dose for a prolonged period of time, put you at risk for a dramatically higher risk for infections than just the meds that we're using routinely for these autoimmune conditions,” he said.
The American College of Rheumatology reminds individuals with RA to talk to their rheumatologist or a rheumatology professional prior to discontinuing any of their medications. Certain drugs, such as steroids, that have been used on a long-term basis cannot just be stopped. People have to slowly taper off of them, and this process requires their doctor’s medical input. In an article in Creaky Joints, Dr. Nilanjana Bose warned, “Prednisone at higher doses [20 milligrams or more] can be severely immunosuppressive but they cannot be tapered off fast.”
Again, it’s important to speak with your doctor about what, if any, changes you should make.
Disease-modifying antirheumatic drugs (DMARDs) have risks of infection associated with them. However, when evaluating the risk of COVID-19, Dr. Tambar believes that an individual’s overall health matters more than the infection risk of taking a DMARD. He recommends people living with RA consider these questions:
The British Society for Rheumatology reminds people to consult with a doctor before making any changes to their treatments. Before stopping any medication, you will want to develop a transition plan with your doctor.
NSAIDs are often used to treat RA. Rumors have circulated that people with COVID-19 should not take Ibuprofen, a nonsteroidal anti-inflammatory drug. Both the World Health Organization and the European Medicines Agency have debunked this myth.
Dr. Tambar cautioned that people with RA should consult their primary care physician or rheumatologist, as always, before making any changes or starting any new medications.
People with RA may need to consider whether they have to leave home to receive medications. Some treatments, such as Remicade (Infliximab), may be given by infusion at a clinic. If that is the case for you, it is important to check with your doctor to see if there are other options available. Take precautions in advance of any upcoming appointments, including monitoring your own health, considering how you will physically get to your appointment (your own car or public transportation), and practicing social distance by leaving space between yourself and other people at a clinic.
Dr. Tambar mentioned some of the best practices in his own clinic, including minimizing routine in-person follow-up appointments, rotating staff so they are not working in the clinic for as long, and not filling the entire infusion room. These are practices to consider asking your health care provider about before your appointment.
The U.S. Centers for Disease Control and Prevention (CDC) recommended that individuals in high-risk groups avoid attending public events. The advice from the CDC is changing on a daily basis. You can find the latest updates and guidance from the CDC about COVID-19 here.
In general, if you have a fever or you are unsure if you’re experiencing symptoms of COVID-19 — or if you have any questions about how you are feeling — make sure you reach out via telephone or online portal to your health care provider. Medicare is now covering telehealth services to treat COVID-19 (and "other medically reasonable purposes").
In addition to safety measures to protect one’s health, people with RA may want to develop a contingency plan in case they are unable to leave their home. Steps to consider include:
Members of myRAteam are talking about COVID-19. Join the conversation:
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