Clinicians managing IMIDs offer insights into pandemic as new COVID-19 cases mount
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Clinicians who manage patients with immune-mediated diseases can offer useful insight into the management of COVID-19, according to presenters at a roundtable discussion at the 2020 Interdisciplinary Autoimmune Summit.
“It is clear that the U.S. has become an outlier, continuing to break records of new case counts every day,” Cassandra Calabrese, DO, of the Cleveland Clinic, said in her presentation. “Schools reopened in other parts of the world. COVID-19 is not going anywhere. We need to continuously think and talk about how we can counsel our patients and families on best practices and infection prevention.”
Cassandra ran down the boilerplate list of prevention protocols, from wearing masks to maintaining 6 feet of distance to not speaking face-to-face with someone for more than 15 minutes. “But for patients with immune-mediated diseases, there are still a lot of gray areas and still a lot of unknowns,” she said. “We do not know when it is safe for our patients to return to work or the clinic.”
While there are no formal recommendations for these patients to resume normal life, Calabrese urged clinicians to review CDC guidelines for the general population, which stipulate a return 72 hours after symptom recovery, and “add a 2-week buffer onto that.”
Leonard H. Calabrese, DO, chief medical editor of Healio Rheumatology, and professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, opened his presentation by urging all clinicians who manage patients with rheumatic or immune-mediated diseases to register COVID-19 cases to the Global Rheumatology Alliance registry.
“It takes 5 minutes,” he said, and noted that every bit of information can be valuable in fighting the infection.
With that, Leonard highlighted a number of drugs in the rheumatology and immune-mediated diseases armamentarium — including IL-1, IL-6 and IL-17 inhibitors, TNF inhibitors, and JAK inhibitors, among others — are in COVID-19-related clinical trials.
“These are our drugs,” he said. “We know how to immunosuppress patients. All of our drugs have a natural place at the table in the COVID-19 response.”
For Stephen B. Hanauer, MD, professor of medicine at Northwestern University in Chicago, deeper understanding of the pathogenesis of COVID-19 can inform which treatment approaches are likely to have the most utility. “Historically, these viruses have entered the nose, mouth and upper respiratory tract,” he said. “But, similar to SARS, this virus attaches to the angiotensin converting enzyme 2 (ACE-2) receptor, which is also present in the gastrointestinal tract.”
Understanding whether the GI tract is also a source of infection and contagion is critical to containing and managing the disease, according to Hanauer. That said, he stressed that the data thus far show that GI comorbidities of COVID-19 are largely “transient and mild.”
Hanauer then zeroed in on IBD and encouraged clinicians to register patients to the SECURE-IBD registry. To date, data for 470 hospitalizations and 54 deaths among 1,629 international IBD patients with COVID-19 have been recorded.
“The patterns of COVID-19 illnesses in IBD patients appear similar to those in the general population,” he said. Meaning, increased morbidity and mortality have been reported among IBD patients who are older or who also have diabetes mellitus, hypertension and obesity. “But we are still trying to figure out whether so-called immunosuppressed patients [with IBD] are at greater risk for developing COVID or severe comorbidities if they acquire it.”
Joel M. Gelfand, MD, MSCE, director of the psoriasis and phototherapy treatment center at the University of Pennsylvania Perelman School of Medicine, looked at the bigger picture.
“We have seen a lot of parallels in all of our fields,” he said, suggesting that underlying comorbidities are driving poorer outcomes in patients across the immune-mediated disease spectrum. “For example, patients with psoriasis who get COVID often have a flare of skin disease. It may prompt a flare of psoriatic arthritis, as well.”
But beyond the particulars of disease outcomes and treatment paradigms, Gelfand encouraged vigilance across the clinical community. “It is really important for physicians to be involved and engaged,” he said.
To that end, Gelfand offered a quote from John M. Barry’s book, “The Great Influenza: The Story of the Deadliest Pandemic in History,” about the 1918 influenza pandemic “Those in authority must retain the public’s trust,” he quoted. “The way to do that is to distort nothing, put the best face on nothing, to try to manipulate no one.”
In closing, Gelfand offered a comment of his own. “We must keep our eyes on the literature and our minds open,” he said.
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Calabrese C, Calabrese L, Gelfand JM, Hanauer S. Roundtable: Impact of COVID-19 on Autoimmune Diseases. Presented at: Interdisciplinary Autoimmune Summit; July 10-12, 2020 (virtual meeting).
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