COVID-19 spurs rheumatologists to wear additional 'immunologist, virtualist' hats
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Throughout the COVID-19 pandemic, rheumatologists have experienced a dramatic expansion of their typical roles, taking on attributes of immunologists and virtualists to effectively manage care, according to a presenter here.
“Thank goodness for infectious disease docs, ED docs and intensivists,” Randall Q. Cron, MD, PhD, director of pediatric rheumatology at the University of Alabama at Birmingham, told attendees at the 2021 Congress of Clinical Rheumatology-East. “They have done an amazing job but we as rheumatologists have roles to play as well.”
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Cron noted that during the early days of COVID-19, clinicians began reporting a pattern of inflammation in severe cases of COVID-19 that resembles cytokine storm syndrome, known to occur in certain rheumatologic diseases. Often fatal in both the rheumatology and COVID-19 settings, cytokine storm involvement had set the stage for rheumatologists to step up to the frontlines in the fight against the virus.
“The features that were being recorded, both clinical and laboratory, shared features with other cytokine storms,” Cron said. “It was suggested to some of us that maybe the therapies that we use to treat cytokine storm — that we were more familiar with — may be beneficial for treating the sickest of the sick.”
Bringing that expertise to the table, however, was not without some resistance, Cron noted. “According to the data available in early January/February of 2020, steroids were a no-no,” he said. “I was part of our local efforts to try to come up with treatment plans for our patients and I got a lot of backlash for suggesting that IL-1 blockade or glucocorticoids might help these patients.”
As growing evidence has shown that the drugs used to treat similar features in other cytokine storms may be working in severe COVID-19 cases, rheumatologists have increasingly been brought into the fold for their expertise in a vast armamentarium of therapies, including IL-1 and IL-6 inhibition.
In response to this, Cron urged attendees to “learn as much immunology as you can because that’s what we are. As rheumatologists, we are immunologists, and we understand these drugs because we use them in our patients.”
Additionally, the pandemic has driven rheumatologists to also become “virtualists,” Cron noted, as COVID-19 has forced an otherwise reluctant specialty to embrace the benefits of virtual medicine.
“Before COVID, I was kind of kicking and fighting telemedicine, mostly because like many people I don’t like change, but also because there was data — at least in pediatrics — that people would still have rather driven 6 hours than do it virtually,” Cron said. “As a pediatric rheumatologist — and a rheumatologist in general — I didn’t think we could do great joint exams for example or other parts of our holistic exam virtually, considering we treat patients from head-to-toe. Having said that, I’m a huge convert.”
As University of Alabama at Birmingham is one of the only pediatric rheumatologist clinics in the state, Cron noted that that telehealth made things significantly easier for families who were previously forced to travel 4 to 5 hours for an exam. Although Cron noted some distinct disadvantages to telehealth in rheumatology — “it’s hard to pick up on subtle findings over whatever video device they are using, and as such, I don’t think it’s ideal for new patients” — telehealth has reduced travel times as well as missed days of school and missed days of work for parents of pediatric patients.
“It has definitely opened up access for rare docs like pediatric rheumatologists, or even adult rheumatologists for that matter,” Cron said. “Telehealth is hopefully here to stay, if third-party payers can make it not a monthly question of whether or not they are going to pay for it.”
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Cron RQ. The Role of Rheumatologists in COVID-19. Presented at: Congress of Clinical Rheumatology-East annual symposium; August 12-15, 2021 (hybrid meeting).
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