Assessing the Pandemic’s Impact on DMARD Use Among Patients With RA

The COVID-19 pandemic led nearly one-third of patients with rheumatoid arthritis (RA) to make substantial changes to their use of disease-modifying antirheumatic drugs (DMARDs) in the crisis’ initial months, with or without physician guidance, according to survey results.

Of 734 respondents, 221 (30.1%) reported making medication changes from March through May 2020, according to a study published in Arthritis Care & Research, with fear of COVID-19 as the primary reason reported (39% reported this concern). Those taking the more commonly prescribed glucocorticoids (GCs) tended to decrease their usage once COVID-19 hit (33% vs 18%), while those on nonhydroxychloroquine conventional DMARDs increased usage (49% vs. 62%).

Furthermore, 10% of RA users of hydroxychloroquine, touted without evidence by former President Trump as a treatment for COVID-19, reported they were unable to get the medication.

After the American College of Rheumatology (ACR) published recommendations on April 13, 2020, changes were more often made with increased guidance, researchers said. However, the changes were not statistically significant.

The study was the first to track changes in DMARDs use in individuals with RA during the pandemic, according to the study. Data were provided by adults with RA participating in a national observational registry. Individuals with rheumatic and musculoskeletal diseases (RMDs) found themselves at greater risk of COVID-19 infection due to immune dysregulation, comorbidities, and immune-modulating treatments. Those with medication changes were more likely to be younger and have worse patient-reported outcomes.

Meanwhile, with hydroxychloroquine and GCS—as well as interleukin (IL)-1, IL-6, and Janus kinase (JAK) inhibitors—being tested to prevent or treat COVID-19, there was considerable confusion and concern among patients on actual risks and how to treat their conditions. A survey on the first 2 weeks of the pandemic found almost half of patients with RMDs said their rheumatology care was significantly disrupted, including reports of postponed appointments and self-imposed or physician-directed changes to medications.

Fear of COVID-19 was the most reported reason for medication changes, the authors said. Most changes were physician-approved (90% adding a new medication, 66% for changing dosage), but only 53% (P<.001) of patients who said they stopped medication received doctor approval.

The study found those who changed medication were 3 times more likely to be taking GCs in addition to DMARDs, possibly reflecting efforts to reduce the perceived risk of infections due to the steroids as well as to try and lower risk of contracting COVID-19. ACR recommendations acknowledged those controversies, stating GCs should be used at the lowest possible dose for rheumatic disease, regardless of exposure or infection status, although not abruptly stopped. The ACR also said patients with RA with documented or presumptive COVID-19 cases were recommended to use only hydroxychloroquine and IL-6 biologics.

A majority of those initiating GCs reported flares of their RA, but the role of the pandemic is unclear, the authors said. The authors recommended future investigations into this issue and speculated stress and lifestyle changes could be implicated.

Change in care was significantly associated with pulmonary disease, with a 3-fold increase in risk (odds ratio [OR] 2.9 [95% CI, 1.3-6.5]) observed. The authors speculated the change was because COVID-19 itself is a pulmonary disease. Both pulmonary disease and GC use are associated with mortality in RA, and recent studies find them similarly associated with COVID-19 case mortality when RA activity was controlled.

The study also found care changers were more likely to have worse RA activity (OR 1.1 [95% CI, 1.0-1.1]) and use GCs (OR 1.6 [95% CI, 1.0-2.5]).

Those with medication changes in the pandemic’s initial months were more likely to have worse disease and a higher exposure to DMARDs, but no statistical difference was found in comorbidities, according to the study. Patients on biologic DMARDs and JAK inhibitors were more likely to discontinue their drugs in comparison to those on conventional synthetic DMARDs (16-18% vs <8%).

The survey also assessed how patients with RA were affected economically and behaviorally. It found those who changed medications were more likely to have experienced a negative economic impact than those who did not (23% vs 15%). In addition, nearly all patients responded to the pandemic by washing their hands, using hand sanitizer, and wearing a mask more often. Other behavioral changes, particularly canceling travel, occurred less frequently.

Reference

Michaud K, Pedro S, Wipfler K, Agarwal E, and Katz P. DMARD changes for patients with rheumatoid arthritis in the US during the covid‐19 pandemic: a 3‐month observational study. Arthritis Care Res. Published online March 30, 2021. doi:10.1002/acr.24611