Withdraw systemic sclerosis treatment during COVID-19? Expert panel offers advice on patient risk
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In the face of the ongoing coronavirus pandemic, patients with systemic sclerosis should continue immunosuppression to avoid relapses, but should discontinue if they or someone in their household develops COVID-19 symptoms, according to a panel of experts endorsed by the World Scleroderma Foundation in a series of Q&A-style recommendations published in the Annals of the Rheumatic Diseases.
“SSc SARS-CoV-2-infected patients may be at risk for a severe disease course either due to underlying [interstitial lung disease] and/or immunosuppression,” Marco Matucci-Cerinic, PhD, of the University of Florence, in Italy, and colleagues wrote. “Therefore, under the World Scleroderma Foundation (WSF) umbrella, worldwide experts (rheumatology, virology and clinical immunology) have provided answers to the main practical questions that physicians and patients may have when dealing with possibility/presence of SARS-CoV-2 infection (up to date 14 April 2020).”
The panel of experts provided answers to 10 questions, including “Are SSc patients at risk to contract the infection?” and “Should the immunosuppressive treatment be withdrawn in SSc patients?” Among the statements and pieces of advice included in their answers are:
- It is possible that patients who receive immunosuppressive drugs, and/or those with severe interstitial lung disease (ILD), may have an increased risk for a “progressive, rapidly evolving COVID-19,” with much depending on the severity of SSc-ILD;
- Although providers should carefully weigh risk-benefit ratios for each individual patient, immunosuppression should continue in patients to avoid SSc relapse, with any withdrawal considered on a case-specific basis;
- However, if the patient or a member of their household develops COVID-19 symptoms, immunosuppression should be put on hold;
- Diabetes, systemic hypertension, cardiovascular disease and other chronic lung conditions are associated with poor outcomes, and the threshold to recommend hospitalization for patients with these comorbidities should be low;
- Testing for all patients with SSc is not advised, and individuals who are at high risk should follow national, state and local guidelines;
- If a patient with SSc presents with COVID-19 symptoms, a diagnostic test should be performed and, while awaiting results, quarantine for the patient and their close contacts should be advised, with close follow-ups completed online or via phone;
- Antiviral drugs or tocilizumab (Actemra, Genentech) may be used as a rescue treatment in cases where COVID-19 pneumonia is bilateral and severe, due to the high possibility of a rapid evolution to an Acute Respiratory Distress Syndrome.
“The SARS-CoV-2 infection is a global challenge and large initiatives will be of great help,” Matucci-Cerinic and colleagues wrote. “The WSF and European Scleroderma Trial and Research (EUSTAR) group will launch a database dedicated to SSc-COVID-19 patients. It may be intuitive to suspect that immunosuppressed patients may be prone to a more severe infection but currently this remains controversial.”
They added that “SSc patients are a great challenge for the physician to achieve an effective protective strategy or, when infected, to optimize a real-time treatment as suggested by the rapidly evolving guidelines.” – by Jason Laday
Disclosures: Matucci-Cerinic reports grant and personal fees from Actelion, Biogen, Bayer, Boehringer Ingelheim, CSL Behring and Eli Lilly. Please see the study for all other authors’ relevant financial disclosures.
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