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The following guidelines are based on the available knowledge regarding coronavirus (COVID-19) up to 14/3/2020. If new data become available, the information below will be updated. They do not replace medical advice from the treating rheumatologist and may not apply to every patient.

I have been diagnosed with a rheumatic disease. Am I at increased risk of becoming ill from coronavirus (COVID-19)?

People with an autoimmune disease (rheumatic disease) may be at greater risk of developing infections, or their infections may be more severe. This is due both to the rheumatic disease itself and to the medications used to treat these diseases.

Why does my disease make me more susceptible to infections?

To make this easier to understand, we will answer this question simply and perhaps somewhat simplistically.

In autoimmune diseases, our immune system (that is, our defense system), instead of doing only the job it is designed to do (namely, protecting us from microorganisms), attacks our own body. We can think of our immune system as using a great deal of energy to cause our disease and therefore not having enough energy left to protect us fully against microorganisms, bacteria and viruses.

Which rheumatic diseases make me susceptible to infections?

Susceptibility to infections may concern people with any rheumatic disease.

Why do the medications for my condition increase susceptibility to infections?

Medications used for rheumatic diseases put a certain “brake” on our “overactive” immune system. This brake may sometimes slow the immune system down a little too much, causing our body’s response to an infection to be less vigorous.

Do all medications make me equally susceptible?

Not all rheumatologic medications appear to cause the same degree of suppression (immunosuppression) of our immune system.

Hydroxychloroquine probably causes little or no immunosuppression. After all, it is used as an antimalarial drug. Some early laboratory studies even suggest that it may inhibit the activity of coronavirus.

Methotrexate, leflunomide, sulfasalazine and low doses of cortisone (up to 7.5 mg) may cause a mild degree of immunosuppression.

Based on the knowledge available to us, this immunosuppression does not appear to be dangerous.

For example: vaccination against influenza and pneumonia in patients receiving such treatments is capable of producing adequate antibodies despite the small degree of possible immunosuppression caused by these medications. In other words, our immune system appears to respond sufficiently well while we are receiving these treatments. In most cases, we do not discontinue them in the event of an infection.

Biologic agents, however, as well as other medications such as tofacitinib and mycophenolate mofetil, or high doses of cortisone (>15 mg), may cause a greater degree of immunosuppression. This is why we always advise patients to discontinue them for 1-2 weeks in the event of an infection.

I have heard that some rheumatologic medications may be therapeutic in cases of coronavirus infection. Why?

It is possible that in patients with severe infection, the main problem is not the virus itself but rather the intense overstimulation it causes in the immune system. In this sense, some rheumatologic medications may prove useful in the treatment of certain cases of coronavirus infection.

Should I stop taking my medications if I DO NOT have the infection?

What is most important is that you take the necessary measures to avoid becoming infected. Do not stop taking your medications if you feel well. Especially with regard to cortisone, remember that it should never be stopped abruptly if it has been taken for a prolonged period of time.

The risk of stopping your medications is that your disease may flare up. A disease flare may make you more susceptible to infections.

In addition, the result of a flare may be a possible increase in the dose of cortisone, which will likely lead to greater immunosuppression than the medication you discontinued.

Finally, most rheumatologic medications remain in our body for a considerable period of time, and some of them may take weeks or months to be completely eliminated from the body.

Every day we are learning more about coronavirus. For the time being, simply follow the measures you hear about on television. Above all, stay at home.

Should I stop taking my medications if I have a coronavirus infection?

If you have a coronavirus infection, symptoms suspicious for coronavirus infection, or any other infection, you should contact your doctor for specific guidance depending on the severity of your symptoms. If you have shortness of breath, you will probably need to be hospitalized. Follow the same guidance that would apply to someone without a rheumatic disease.

How can I protect myself from COVID-19?

• Stay at home.
• Do not touch your face.
• Wash your hands frequently. Do so for at least 30 seconds.
• Clean and disinfect surfaces and objects that you touch frequently (e.g. your mobile phone, your desk).
• In general, follow the same guidance that everyone should follow, regardless of whether they have a rheumatic disease.

Where can I find more information?

https://www.rheumatology.org/announcements

https://www.rheumatology.org.uk/news-policy/details/Covid19-Coronavirus-update-members

https://www.hss.edu/conditions_rheumatic-disease-and-COVID-19-coronavirus.asp

(some sections are verbatim translations from this source)