11 March 2020

Immunocompromised patients worried about COVID-19

Communicable Diseases

Patients who are taking immunosuppressive drugs may need to take extra precautions if COVID-19 spreads more widely in the community, rheumatologists say.

There were no specific data on COVID-19 for patients with rheumatic disease yet.

But these patients were at increased risk of infections in general so one would suspect that COVID-19 could pose a greater risk to this group, said Associate Professor Alistair Reid, an infectious diseases specialist and rheumatologist in Wollongong.

“It looks like the way coronavirus may be causing severe outcomes is through secondary bacterial infection and you could postulate that our patients would be more at risk for that,” he said.

At present, the main advice for patients with rheumatic disease was to practice good hygiene, such as hand washing and avoiding shaking hands, said Professor Reid on 4 March.

“Anything I say today might be completely different in two weeks’ time because that’s how fast this is evolving,” he said.

If COVID-19 person-to-person spread becomes common in Australia, Professor Reid said he might start to advise his patients to avoid public areas with limited airflow.

“I’m certainly not advising that our patients avoid public areas at this stage,” he said. “I think that would be premature but, in the future, that might be some of the public health advice that we give our patients.

“Unfortunately, it’s a little bit unsatisfying at the moment because we have so many unknowns.”

The risk of infection is approximately double in patients taking 10 to 20 mg of prednisone, and is slightly increased in patients taking biologics or conventional DMARDs like methotrexate.

However, the risk of infection was even greater in patients with uncontrolled rheumatic disease, so patients should continue taking their medications, said Professor Reid.

While the risks of COVID-19 infection in patients taking spondyloarthritis drugs is currently not known, these drugs do change a patient’s risk of infection in general, according to a blog published by The Spondylitis Association of America.

High doses of prednisone increase infection risk in general, TNF inhibitors increase the risk of mycobacterial infections like tuberculosis, IL-17 inhibitors increase the risk of fungal infections such as Candida, and JAK inhibitors increase the risk of herpes zoster, the blog states.

However, people who are HLA-B27 positive demonstrate increased natural immunity toward a number of viral infections, such as HIV-1, hepatitis C and influenza, although whether this natural immunity carries over to coronavirus has not been studied, the blog reads.

“Most people who come down with coronavirus will do well – in fact, they are best cared for at home in self-quarantine, with treatment focused on rest, not getting dehydrated, good nutrition and treatment of symptoms,” the blog states.

The global death rate from COVID-19 infection is 3.4% compared with 1% for influenza, according to the WHO. The elderly and people with high blood pressure, chronic lung disease, diabetes and smokers are at greatest risk of severe COVID-19 infection.

Dr Irwin Lim, a rheumatologist based in western Sydney and the editor of Rheumatology Republic, has received numerous queries from patients about COVID-19, including questions about where to source face masks and whether to travel.

In response, his clinic has sent out three emails about COVID-19 to patients who have consented to receiving such communications over the past few weeks.

Signs have also been put up around the clinic asking people wait until their flu symptoms have resolved before coming in for an appointment, or to consider wearing a face mask if they are unwell and still need to attend the clinic.

In relation to travel, Dr Lim said, “we don’t really know the risk so the best advice at the moment is to avoid any travel that you consider unnecessary”.

“I am cancelling my own family’s school holiday trip to Japan even though we are not immunocompromised,” he said.

“Our personal reason is the fear of needing quarantine for two weeks more so that the absolute risk of catching the virus.”

Naomi Creek, the national coordinator of patient group CreakyJoints Australia, said patients were feeling worried about COVID-19, particularly about the potential disruption in medication supply due to factories closing in China.

While items like toilet paper might go into temporary shortage due to panic shopping, there could be no run on prescription medications because people needed a script to buy the product and would only be given a few months’ supply at a time, said Professor Reid.

The US branch of patient group CreakyJoints published a blog in late February on COVID-19 facts for patients who have a chronic illness and are immunocompromised. CreakyJoints US also hosted a Twitter forum on COVID-19 on 6 March, which can be followed by searching for “#CreakyChats”.