Leading rheumatologists push for more engagement with long covid research and treatment.
Leading rheumatologists say the specialty is well placed to elevate long covid treatment. However, an Australian expert cautions against making assumptions.
In a comment published in The Lancet Rheumatology, Dr Leonard Calabrese and Dr Cassandra Calabrese posed questions to spark conversation in the rheumatology community about long covid. They identified the challenge created by a nebulous clinical definition of long covid, confirmed its unknown pathology and remarked on the lack of approved drug therapies.
Dr Calabrese and Dr Calabrese said that rheumatologists are well positioned to contribute to clinical research.
“With regards to immune-based therapies, rheumatologists’ extensive clinical trial experience with agents now being considered candidate therapies for long covid make them particularly suited for the task,” they wrote.
Respiratory physician Associate Professor Anthony Byrne, who leads the St Vincent’s Hospital long covid clinic in Sydney agreed, telling Rheumatology Republic “it makes sense” for rheumatologists to get more involved in long covid.
Dr Calabrese and Dr Calabrese raise the question as to whether long covid is unique from other syndromes that occur after acute infectious illness, which unfortunately remain understudied and are a source of frustration for both doctors and patients.
While long covid has relevant similarities with chronic fatigue syndrome, an area with which rheumatologists traditionally have had some interaction as part of fibromyalgia management, Professor Byrne emphasised important distinctions existed as well.
“Yes, it’s a virus that causes the symptom of fatigue. That’s true. But immunological dysfunction in covid and long covid is not the same as chronic fatigue,” he said.
Professor Byrne was also quick to distinguish the unique impact of covid, noting the clear distinction between severity of the initial infection and the extent of ongoing immunological dysfunction.
“It’s highly unusual to not recover from rhinovirus which, as you know, causes the common cold. So, the fact that you’ve got so many of people reporting symptoms beyond three months is highly unusual,” he said.
With many of long covid’s symptoms and manifestations medically unexplained, alongside a lack of consensus classifications or diagnostic criteria, Dr Calabrese and Dr Calabrese pointed to an urgent need for effective laboratory biomarkers.
Professor Byrne agreed, suggesting that researchers could help greatly by establishing phenotyping or sub classification, and then figuring out if there are biochemical differences, or biomarker differences, in those clinically distinct phenotypes.
Associate Professor Peter Wong is head of rheumatology at Westmead Hospital and spent some time last year running a covid ward at the hospital. He said that being a rheumatologist served him well in the ward.
“For acute covid treatment I was uncomfortable managing people who were very short of breath on high-flow oxygen. But I was very comfortable with administering baricitinib, tocilizumab and corticosteroids,” he said.
Regarding long covid Professor Wong said that rheumatologists certainly have value to add.
“A lot of long covid patients have multiple symptoms. We’re diagnosticians, we spend our careers looking at people with lots of vague symptoms,” he said adding that rheumatologists may play a bigger role if certain drugs are proven to be effective for long covid.
“If there’s a role for immunomodulatory therapy, and that’s still uncertain in long covid, we’re experts at this,” he said.
Professor Wong is currently involved in covid research in collaboration with the Kirby Institute.
“I’m looking at effectiveness of covid vaccination in rheumatoid arthritis patients on MTX +/- biologics or JAK inhibitors with follow-up to 12 months post-3rd or 4th dose of Covid vaccine to assess B-cell and T-cell responses,” he said.
