Therapeutic management of chronic inflammatory rheumatic diseases in times of pandemic COVID 19

Conoravirus 2019 or Covid-19 disease (acronym for COronaVirus Infectious Disease 2019) is an emerging highly contagious infection caused by the coronavirus strain SARS-CoV-2. In March 2020 it has been declared a pandemic by the World Health Organization (WHO). The rheumatologist is therefore faced with a challenge: an optimal management of COVID patients who are immunosuppressed not only by the disease but also by the immunosuppressive treatments they take. In fact, some of these drugs seem , oddly, to have antagonist effects on viral response and therefore are investigated in COVID treatment. Severe COVID-19 originates from a cytokine storm caused by increased levels of a number of cytokines and chemokines resulting in a multiorgan failure. The management of this cytokine storm is one of the major challenges regarding COVID-19 infection. Several pathways are investigated including drugs known to be efficient on rheumatology field (especially NSAIDs, corticosteroids, Disease Modifying Anti Rheumatic diseases (DMARDs): biological or synthetic ones such as methotrexate, salazopyrine, leflunomide and Hydroxychloroquine). Given these facts, this review aimed to summarize the existing data that may support the therapeuting decision making of rheumatologists in this pandemic context. Glucocorticoids should be used at its lowest necessary dose regardless of exposure or infection status if needed to controlee underlying disease. They should never be stopped precipitously . Stable patients with no COVID 19 infection or exposure should continue their treatment either NSAIDs or immunosuppressants (CsDMARDs, TsDMARDs or bDMARDs) with no modification or dose reduction in case of life threatening organ lesion. Anti malarial drugs is to not discontinue them, considering the antiviral efficacy and the immunomodulatory rather than immunosuppressive effect. The anti Il 6 is also not to be stopped given their action on the inflammatory reaction caused by COVID19. In case of confirmed COVID 19 infection it is recommended to temporarily stop other immunosuppressive treatments. That guidance does not replace clinical judgment of the rheumatologist based on clinical severity of the infection or the ARD. Mostly guideline panel recommends underlying general preventive measures, e.g., social distancing and hand hygiene, reducing exposure of patients with minimizing health encounters.