Saturday March 14, 2020
I wanted to update everyone on my plans, as of today, to perform infusion services on my patients for the upcoming week.
1. I want to suspend all rituximab NEW infusions immediately and Benlysta ongoing infusions, until further notice. We need B cells at full capacity to mount a viral immune response AND develop a lasting protective immunity to prevent re-infection. If a patient has received their first (of two treatments) of rituximab and is scheduled for their second then I support them receiving their second (in effect, they are already B cell depleted so the benefit of controlling their inflammatory disease is the main objective)
2. All patients 70 and over I would like to individually discuss the risk/benefit of controlling their disease versus coming into the healthcare setting to get treatment.
3. I would like to CONTINUE all patients receiving Actemra infusions or Actemra injections and Kevzara injections. There is actually emerging data the severe pulmonary consequences of COVID-19 are due to a cytokine storm with massive amounts of IL-6 as the leading cause of massive pulmonary edema. Studies are actually in progress looking at these two drugs in ICU settings to treat critical patients. Although this is not science yet, the scientific intuition supports my decision to think that the benefit of these treatments in our patients may actually outweigh the risks.
4. Guidance for patients who call about their other medications: At this point, I do not think patients need to stop oral medications, including methotrexate, leflunomide, azathioprine, cellcept (mycophenolate), sulfasalazine, and especially plaquenil (hydroxychloroquine). Plaquenil may in fact be protective in early reports and science out of China. Because the half-life of plaquenil is so long and the risks are so low and benefits MAY be found it is highly encouraged that patients DO NOT stop this medication. Steroids of 5mg or less can be maintained but should only be increased if necessary. Steroids have not been effective in limiting severe pulmonary manifestations in sick patients. At doses of 5mg or less this is not significantly immunosuppressive. For patients on injectable or oral biologics, including Humira, Enbrel, Simponi, Cimzia, Orencia, Stelara, Xeljanz, Rinvoq, Cosentyx, Oluniant, Talz, Kineret, Ilaris my position is that if they are doing really well and feel that a trial period off their medication would not be a significant problem (their arthritis is in remission or psoriasis is not bad) then it is reasonable to suspend treatments and wait for more guidance. If they feel like they function much better (especially elderly patients) and by extension are more likely to be able to perform AODLs if they get sick then they should continue their meds. When patients get sick they should immediately suspend their medications and then restart them when they convalesce (1-2 weeks). Kevzara and Actemra infections should be continued. Patients on Otezla should continue as well (this is uniquely an immune modulator that directs the immune response to be anti-inflammatory).
I am widely available 24/7. I have heeded my own advice and cancelled travel this coming week. I will be at home, monitoring the national and local situations with you. And I am going to get bored really quickly!
Stay safe and healthy. You are on the front line…of knowledge dissemination now and you will likely be called upon as hands-on healthcare workers to rise up soon.