By Tammi L. Shlotzhauer, M.D.
These are alarming times for everyone. If you have Rheumatoid Arthritis, there are some additional concerns. With RA, as well as other autoimmune diseases, your immune system responds differently to triggers in our environment. As yet, we do not know how the new coronavirus will affect your immune system with RA. We do know that RA patients, in general, are at higher risk for infections and complications of infections. In addition, many people with RA are on medications intended to regulate an “overactive” immune system by suppressing it, thereby controlling the symptoms of RA. However, in that process, other important protective parts of the immune system are not functioning normally. This weakening of the immune system makes you at risk for a more severe infection if contracted. You may not consider yourself compromised given that with our effective RA medications, you may be functioning quite normally in this world. In addition, your suppressed immune system is invisible to friends, family, and employers. So, the following represents some advice for the special case of RA in this pandemic.
Stay Home as much as possible
Because you have a chronic condition and possibly are on immune-suppressing medications, this directive is very important to you. Avoiding exposure to coronavirus is imperative and is the key strategy for preventing COVID-19. This may involve discussion with your employer if you are in an essential occupation that exposes you to infected people. Because immune compromise is invisible, they may not understand that you at risk for more serious complications if exposed.
Consider using services that are available:
-Home grocery/supplies delivery or have friends or family shop for necessities.
-Home medication delivery with effort to get 3-month prescriptions if possible.
-Home blood draws if you are on a medication that requires routine surveillance laboratories.
-Telehealth services with your doctor if available (it helps if you have a blood pressure cuff and home oximeter).
Double down on personal protective behaviors:
-Keeping all surfaces clean and disinfected.
-Hand washing or hand-sanitizing frequently.
-Avoid touching your eyes, nose, and face.
Housemates and family must exert special caution
Your cohabiters will need to be very conscious of your infection risk and act accordingly. Because individuals can be infectious without symptoms, the safest course of action is for them to behave as if they are infected in your presence. This includes:
-Wearing a mask.
-Remaining outside of your 6-foot personal space.
-Avoiding person-to-person contact.
-Avoiding touching surfaces/objects that you share or disinfecting them after each use.
-Using separate bathrooms if possible since the virus has been noted in feces of some infected individuals.
If those you live with are working outside the home, asking them to remove and wash their clothes upon entering the home would be helpful.
What to do with your medications
Many people with RA ask if they should stop their immune-suppressing medications temporarily. These medications include some disease-modifying anti-rheumatic drugs (DMARDS), biologics, small molecules, and corticosteroids. Always consult your physician before making any change in your oral or self-injected medications. Some biologics are given in an infusion center and you will want to work with your rheumatologist regarding specific guidelines during this crisis. Even though it might appear to make sense to temporarily hold these medications, being ill with a bad flare of RA can also make you at risk for more severe illness with COVID-19. That said, your rheumatologist may consider a slow taper of immunosuppressive medications if your condition is very stable.
Should you develop any symptoms of actual infection (fever, chills, cough, shortness of breath, etc.) call your doctor immediately. If the responding health professional is unfamiliar with your case, make certain that they understand that you have RA and are on medications that affect the immune system. He or she will likely ask you to hold the RA medications that lower the immune system and give you directions on next steps, depending on the severity of your symptoms. Corticosteroids must never be stopped abruptly. It is, no doubt, a “balancing act” but you can rely on your physician to help you with this.
A second medication concern involves the use of non-steroidal anti-inflammatory drugs- NSAIDs (such as ibuprofen and naproxen) during a coronavirus infection. Several news outlets have reported anecdotal reports of increased disease severity of COVID-19 in NSAID users. Initially, the World Health Association (WHO) recommended that people with COVID-19 symptoms avoid taking ibuprofen. After a lack of specific evidence, the WHO reversed this decision. Although there is no proven evidence of an adverse effect of NSAID use with the coronavirus, a discussion with your prescribing physician would seem prudent, particularly if you develop symptoms of infection.
There was early discussion regarding the possible efficacy of one of our frequently used DMARDS, hydroxychloroquine, to treat (or even prevent) COVID-19 infection. However, further study has found this is incorrect, and the FDA has cautioned against the use of the drug. It is integral that you do not take these medications for preventative measures, or to try to treat an infection at home without a professional’s assistance.
Still, private and corporate stockpiles of the drug continue to exist, so it is very important to alert your pharmacist that you are taking these medications for your RA. Most pharmacies are giving priority to current patients taking these for rheumatic conditions. Be sure to call well before you run out of medication so that they can help locate a supply for you.
It is very important in this time of crisis to follow the evolving advice that comes to us each day, but to remain calm. Stress, poor quality sleep, and unhealthy behaviors will have their own negative effects on your RA. It is very well known that excess stress can increase pain and precipitate RA flares in many people. Exercise is very important. Since your regular options may not be available, consider on-line programs or walking, being mindful of social distance recommendations. Make healthful diet choices and avoid excessive alcohol. Stay positive but informed, and be prepared.
Tammi L. Shlotzhauer, M.D., is a practicing rheumatologist at Rheumatology Associates of Rochester and associate medical director at Rochester Clinical Research, where she directs clinical research trials involving arthritis. She is the author of Living with Rheumatoid Arthritis, third edition.