Uprooting the rules of RA management during COVID
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The term “game-changer” is thrown around freely in the English language vernacular. But it is unlikely that anything in the near future will change the game of rheumatology practice — and, consequently, the management of rheumatoid arthritis — as much as COVID-19.
Perhaps the best way to understand the changes in RA management brought about by the pandemic is to examine the adjustments seen in most other specialties and compare them with those that are unique to the disease. For example, like most other fields, rheumatology saw a significant uptick in telemedicine in the early days of COVID, and that trend continues.
“I had reservations about converting to telemedicine in rheumatology for obvious reasons,” Cassandra Calabrese, DO, of the department of rheumatologic and immunologic disease at the Cleveland Clinic, told Healio. “The physical exam was the elephant in the room. How can you see someone with rheumatologic joint problems without putting your hands on them? Our specialty is rooted in the physical exam.”
In addition, social distancing and sanitation have become an integral part of everyday medical office environment operations. “You have to go to great lengths to keep the physical office safe,” Grace C. Wright, MD, PhD, president of the Association of Women in Rheumatology, and president & CEO of Grace C. Wright, MD, PC, said in an interview. “Every touch point — doorknobs, countertops, exam tables, computers and keyboards, touch screens, everything — has to be sanitized 100% after every visit.”
But if there is one key difference between rheumatology and other specialties, it pertains to therapeutic options to treat COVID-19. The specialty saw drug shortages that struck fear into the hearts of many patients. While hydroxychloroquine garnered the brunt of that attention, RA therapies targeting the interleukin (IL)-1 and IL-6 pathways, among others, have shown efficacy against the virus, raising the specter of potential shortages if therapeutic paradigms involving those drugs solidify.
The final piece of the puzzle is misinformation. Conflicting and inaccurate messages surrounding COVID-19 and its impact on patients with rheumatologic diseases like RA can be found in many corners of the internet and in the mainstream media alike. Clinicians have had to face this head on, often chewing up valuable minutes in a brief visit.
Healio takes a deeper look at some of these changes in rheumatology practice and how practitioners managing RA can make the most the hand COVID-19 has dealt the field.
Elephant in the room
Like many rheumatologists who were skeptical of telemedicine early on, what Calabrese learned is that seeing patients in their homes — and, consequently, seeing the furniture, stairs and other obstacles that present daily difficulties in arthritis — allowed her to tailor recommendations and interventions to that space.
“Patients can do maneuvers while I watch on the phone,” she said. In addition, visual communications allowed her to see rashes and other topical manifestations.
The ability to see maneuvers is of the utmost importance in RA, according to Wright. “What happens when an arthritic person doesn’t move?” she said. “Everything hurts. So, when we reconnected with patients on the phone or online, we encouraged them to get moving.”
If there is another important consideration for the future of telemedicine in RA, it has less to do with severely impacted or immobile patients than it does with those in stable condition. Given the shortage of rheumatologists around the country, many patients are forced to spend considerable time, money and effort just getting to appointments. For RA patients with regular access to medications who are doing well physically and mentally, telehealth solves those problems. They can check in with their doctor without leaving home.
To that point, for Wright, it is important to treat patients with RA holistically and understand the moment, particularly as the pandemic drags on. “Patients feel lonely, isolated and disabled,” she said. “They are not having family members come to take care of them.”
Telemedicine has allowed clinicians, at the very least, to help these patients tread water through lockdowns and quarantines. “When I appear on their screen, they say to me, ‘I’m just so happy to see your face,’” Wright said.
As difficult as COVID-19 has been, this may exemplify one of the lasting impacts Wright believes the virus will ultimately have on RA practice. “We are no longer taking things for granted.”
Therapeutic questions
Both Calabrese and Wright acknowledged that drug shortages have not been an issue since the initial run on hydroxychloroquine. While IL-1 and IL-6 inhibitors are undergoing rigorous investigation in COVID-19 patients, it may be best to simply take a wait-and-see approach.
“There are hundreds of trials on ClinicalTrials.gov,” Calabrese said. “All the drug shortage questions are apt to change pending data from these trials.”
That said, it is important that clinicians managing patients with RA understand the playing field. The issue is that the same IL-1 and IL-6 inhibitors used in RA have shown efficacy in mitigating the cytokine storm or cytokine release syndrome, which has proven fatal in many COVID-19 patients.
Regardless of whether a patient has active disease or is under control with medications and healthy living, there is widespread concern that having RA predisposes patients to COVID-19 infection and causes more significant morbidity and mortality in the case of infection. Data thus far have shown that infection rates and outcomes in RA populations are more or less comparable to those seen in the general population. But the research community is still learning.
Wright is a strong believer in the power of that research community. She regularly shares information from the COVID-19 Global Rheumatology Alliance and other such data sets with her patients. “I tell them, ‘We are getting information from around the world for people just like you,’” she said. “People are comforted by the fact that their doctor is thinking proactively about their situation and trying to access the information that is available out there.”
Managing misinformation
If there is one other important role that clinicians treating RA have had to fill since the pandemic began, it is in managing the round-the-clock barrage of information and misinformation available to patients.
For Calabrese, calm is the key. But a persistent calm. “I tell my patients, it is going to be ok, here is what you can do,” she said. “Then I share recommendations from the CDC or those that we have come up with at the Cleveland Clinic.”
Calabrese keeps the lines of communication open and assures patients that she will answer any and all questions, regardless of whether they pertain social distancing at the gym or how to manage their arthritis at home.
“If they are concerned about coming in for a visit, I try to tell them that it is definitely safer in here than it is to go out to dinner,” Calabrese said.
Wright ultimately encouraged clinicians treating RA to get back to basics and focus on the positive as patients slowly make their way back to routine in-office visits. “With our masks on, we can’t see each other’s facial expressions,” she said. “You have to look at their eyes. Eyebrows can be expressive. You can’t have patients talk to your back or talk to you while you are entering information into the computer. We have to learn how to communicate differently.”
For more information:
- Cassandra Calabrese, DO, can be reached at 9500 Euclid Ave., Desk A50, Cleveland, OH 44195.
- Grace C. Wright, MD, PhD, can be reached at 345 East 37th Street, Suite 303C, New York, NY 10016; email: gcwright.md@gmail.com.
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