Rheumatology in a time of Coronavirus: Lessons from our early experiences
The SARS-CoV-2 pandemic arrived unexpectedly, unapologetically and unwelcomed to modern rheumatology practice. It has and continues to challenge us all; patients, rheumatologists and allied health professionals. Recent advances in the understanding of the immuno-pathogenesis of inflammatory rheumatic conditions has led to improved treatment with biologic agents and synthetic disease modifying anti-rheumatic drugs (DMARDs) that target specific components of the immune system. However, in the face of a pandemic such treatments have left our patients feeling vulnerable and rendered the prescriber’s mind unsettled. Many patients have enquired whether their immunosuppressive medication should be stopped at this time. Doing so could run the risk of flare and a need for greater immunosuppression as a consequence. Early, retrospective analyses of individuals requiring hospital admission for COVID-19 at the original epicentre in Wuhan, China, did not highlight autoimmune disease or associated immunosuppression as a significant risk factor for requiring intensive care treatment or mortality.1, 2 However, the absence of evidence is not evidence of absence. Once the virus was declared pandemic by the World Health Organisation, recommendations from national and international public health and collegiate bodies duly followed. Public Health England offered guidance on ‘shielding’ for those considered extremely vulnerable to COVID-19.3 Specifically, it was advised that individuals ‘on immunosuppression therapies sufficient to significantly increase the risk of infection’ should undertake a period of shielding for at least 12 weeks. This point of guidance, although well-intentioned, also made us debate and discuss: What constitutes a significant increase in the risk of infection?