Anti-rheumatic in SARS Cov 2: benefit or risk?
Francesco Ferrara 1, Chiara Pelliccia 2, Antonio Vitiello 1
1: Usl Umbria 1, Perugia, Italy; 2: Usl Umbria 2, Terni, Italy
Dear Editor,
About 300 million people worldwide are affected by rheumatic diseases
and over 5 and a half million men and women affected by rheumatological
diseases are present in Italy. These are chronic diseases and therefore
require treatment and diagnostic tests for long periods of time. Patient
needs must be met even in these difficult months marked by the COVID-19
pandemic. The guarantee of therapeutic continuity is important and
increasingly dangerous is the lack of many drugs. This is because many
antimalarial and anti-inflammatory drugs have entered the protocols for
treatment from Sars Cov 2. Without taking these medicines, which for
years have also been used in rheumatology, there is a risk of
reactivating serious diseases including rheumatoid arthritis, ankylosing
spondylitis or systemic Lupus erythematosus.
Anti rheumatic drugs are often associated with viral and bacteriological
infectious events that cause elevated inflammatory states. This virus
induces the activation of immune and anti-inflammatory response
mechanisms that serve to eradicate the virus, but are so intense that
they become pathological, inducing not only bilateral interstitial
pneumonia, but also damage in other body areas, as is emerging from the
autopsies of patients who died for Covid-19. For this reason,
immunosuppressive or powerful anti-inflammatory drugs are used which
have given important results in other pathologies, so it was not
difficult to predict that some drugs used in commonly used Rheumatology
could also be used for Covid-19 Rheumatological drugs currently being
tested in Covid-19 belong to two categories:
1) drugs that can inhibit viral replication (e.g. chloroquine,
hydroxychloroquine)
2) drugs that are able to quell the inflammatory cytokine storm (still
chloroquine and hydroxychloroquine, colchicine and the array of
biotechnological drugs - tocilizumab, IL-6 inhibitor, anti-IL1 and
anti-TNFalpha drugs - and small molecules (e.g. baricitinib ).
At the moment there is no scientific evidence showing a higher risk of
Coronovirus infection in case
of a rheumatological disease so you must not avoid treatment for fear of
possible infections. The administration of immunosuppressive drugs
should only be stopped if flu-like symptoms such as fever or cough
occur. This is a normal medical practice that must be performed
independently of COVID-19. As for the start of new immunosuppressive or
biological drug therapies, in this critical period for the health
system, the choice is up to the rheumatologist. It is preferable to
start these treatments, which present an infectious risk, only in cases
of some pathologies that can have strongly negative effects on health or
cause damage to vital organs.
The due reflection is that antirheumatic drugs risk being a paradox:
they treat the infected and put the uninfected at risk if they make
people more vulnerable to the virus with the risk of infecting more
people than they are saved with the same drugs.
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