'Flying blindly:' EULAR offers recommendations for COVID-19
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Under extreme duress, EULAR has offered a preliminary set of recommendations for the management of rheumatic and musculoskeletal diseases in the COVID-19 setting, according to data presented at the EULAR 2020 E-Congress.
“The evidence is extremely sparse,” Robert Landewé, MD, PhD, professor in rheumatology at the Academic Medical Center/University of Amsterdam, and chair of the department of rheumatology at Zuyderland Medical Center Heerlen, in the Netherlands, said in his presentation. “There were many conflicting opinions. Updates are truly necessary, but we have to wait a while.”
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Landewé highlighted the unusual and urgent nature that the development of the document required. “Usually, a process like this takes 12 to 18 months,” he said, noting that the group presented the full data set in 3 months. “In addition, we did it with no usual meetings.”
It should be noted that the first key element of any guideline document development process was conspicuously absent from the current procedure: literature review. “It is very obvious that we can forget the first steps when it comes to the COVID-19 crisis,” Landewé said. “We don’t have the literature.”
This is why Landewé stressed that the current recommendations are provisional and will grow as the scientific literature on the virus increases. The document was designed to be living, with the April 2020 version “hopefully” giving way to an October or November version as the data allow.
With that, Landewé ran through the four general themes that informed the 13 recommendations.
The first theme pertains to “general matters of prevention” of COVID-19, according to Landewé. Hand-washing, mask-wearing and social distancing were the cornerstones of preventing spread of the virus.
“There were high levels of agreement,” Landewé said, noting that the guidelines were developed by experts with a heterogeneous group of countries treating a heterogeneous group of patients.
The second theme deals with management of patients during the pandemic. The experts agreed that if a patient with a rheumatic disease has symptoms of COVID-19, they should be tested, and treatment for their chronic condition should continue, according to Landewé. Hospital or doctor visits should be via telehealth unless there is absolute urgency for an in-person consultation.
The third theme covers management of patients who have been in contact with someone with COVID-19 or who have contracted the virus.
Given that 80% of individuals who contract COVID-19 are asymptomatic or experience mild disease, patients should remain safely at home if, or until, more severe symptoms occur. “When it comes to mild disease, we could not reach a consensus,” Landewé said. “The task force agreed to disagree. The task force said it was best to leave the decision to the patient and managing physician on a case-by-case basis.”
Symptoms of more severe disease can range from fever, hypoxia and other respiratory complaints to what Landewé called the “famous cytokine storm, or cytokine release syndrome.” In those patients, biomarkers such as serum ferritin, D-dimers, C-reactive protein and IL-6 can be “sky high,” he said. “As our understanding evolves, biomarkers may be found” for patients who are likely to progress to more severe disease.
Landewé also stressed that, while rheumatologists may have useful understanding of the systemic nature of severe COVID-19, if a patient is rapidly worsening, they should be referred to an intensivist, infectious diseases specialist or pulmonologist who may have more expertise and experience in managing the virus.
The fourth theme addressed pulmonary complications that Landewé called “COVID-19 mimics.” He urged clinicians to be aware of this phenomenon, and to enlist the help of a pulmonologist when appropriate.
“I have summarized first expert-based recommendations of COVID-19 in RMDs,” Landewé concluded. “We as a task force are, sad to say, flying blindly.”
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