BD and COVID-19 - management advice for clinicians

Suggestions for counselling Behçet’s patients and their families
with questions concerning COVID 19

General aspects

Taking into account the patient’s personal risk factors (eg age, comorbidities, health worker status ± pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout¹⁴), degree of community transmission in the area and the individual testing result for SARS-CoV-2, the main aspects of specific counseling are:

1. To keep social distance with physical distance of at least 4.5feet / 1.5 meters and to stay home when you can. Besides, gatherings with 6 adult people or more in closed spaces should be avoided not only in public, but also privately. Reduce contacts with all non-family members to a minimum.

2. To limit travelling to regions and areas of increased risk for infection, and to ask for telephone consultations instead of physical visits when no urgent need of a medical service is present. In particular, patients from areas with few cases should avoid travelling to areas with high transmission and/or countries with less developed health systems.

3. To keep proper hygiene procedures, frequently hand-cleaning for at least 20 seconds with an alcohol-based hand rub (preferred if hands are not visibly soiled) or soap and water. Hand sanitizers should contain at least 60% alcohol. To avoid touching the face, eyes and nose¹⁴. Also to open windows as often as possible and prefer open-air activities instead of in-room meetings.

4. To regularly clean surfaces in living areas that are touched on a regular basis, using alcohol-based disinfectants¹⁵. To the extent possible, touching high-touch surfaces in public places should be avoided, like elevator buttons, door handles, handrails, handshaking with people, etc. One can use tissue or sleeves to cover the hand or finger if something must be touched.

5. To know about telephone hotlines and how to get medical attention in case of emergency (with the warning signs listed above, especially with pulmonary symptoms). Also everyone should know about local regulations, including (1) self-quarantine in case of suspected close contact with someone tested positive for SARS-CoV-2, (2) isolation in a hospital or at home depending on the severity of the symptoms, and (3) quarantine of sick people as instructed by a physician.

6. To stop medication only with a physician’s advice and to consider comorbidities as risk factors for COVID-19. The pooled odds ratios of hypertension, respiratory system and cardiovascular disease in severe patients were described as 2.36 (95% CI: 1.46-3.83), 2.46 (95% CI: 1.76-3.44) and 3.42 (95% CI: 1.88-6.22) when compared to non-severe COVID-19 patients, respectively¹. If medications are not available, mail-order should be considered for medications.

7. Regarding the use of a mask Current advice is only use a mask if taking care of a person with suspected SARS-CoV-2 infection, or if coughing or sneezing or in public space when advised by local instances¹⁷. However it makes sense for patients on immunosuppressant medication to use a mask if possible, particularly if in hospital or other clinical setting.

Counselling of Behçet’s Disease patients without COVID-19

We still do not know if there is a specific risk of COVID-19 for patients with immune-mediated diseases like BD disease. The following considerations are based on “first principles” and not yet on any scientific evidence:

(1) There is no evidence that BD per se increases the susceptibility to viral diseases in general.

(2) Viral disease may lead to an exacerbation of BD.

(3) Some or all immunosuppressive drugs may increase the risk of acquisition COVID-19.

(4) There are ongoing discussions about immunosuppressive drugs, including biologics, potentially being beneficial for late complications by preventing the cytokine storm responsible for development of complications such as ARDS, the most feared complication of this virus. For more information on this issue, see ..https://www.ncbi.nlm.nih.gov/pubmed/32207680

An individual assessment of existing patients’ risk factors is therefore essential for further decisions on starting, adapting, postponing or even stopping immunosuppression.

Principle 1: Any relapse of BD disease has to be avoided if possible, as it may impose a larger risk compared to the effect of immunosuppression. There is no reason to discontinue local treatment, such as for oral ulcers. With respect to oral or injected treatments:

In low-risk situations (areas with few cases, no known community transmission), immunosuppression should be continued. General recommendations should be communicated - as mentioned above.

In middle-risk situations (areas with many cases / risk of community transmission OR high individual risk for example as a health care worker), treatment with immunosuppressives will depend on a specialist’s decision according to the individual situation.

In high-risk situations (areas with many cases, risk of community transmission, high individual risk for example as a health care worker), reducing immunosuppressive drugs together with the recommendation of postponing biologicals may be appropriate – depending on a specialist’s decision. There is no evidence, and this is only an opinion-based suggestion.

Principle 2: Telemedicine should be used to replace office visits and to avoid unnecessary travelling to the specialists, long waiting times with other immunosuppressed patients and possible contact with virus-contaminated surfaces, as long as COVID-19 is abundant and restricted measures are taken in individual hospitals. Video or telephone consultations can be offered to the patients. Information can be provided either by trained health care workers, or also, as backup for these health care workers, by physicians. Patients’ travelling can be further reduced by having drugs delivered to their home by relatives or courier services.

Principle 3: Consider to reschedule visits if patient has no treatment side-effects but ongoing remission or low-disease activity, to give the physicians time to inform patients with immunosuppressive drugs over-phone about the virus and to assure that patients adhere to the treatment the specialist considers to be the best (with or without changes).

Management of Behçet’s Disease patients with COVID-19

In case of suspected or proven infection with SARS-CoV-2 especially with fever and/or severe shortness of breath, immunosuppressive drugs should be stopped, and a specialist contacted immediately. Discussion with an infection medicine specialist, and management of the patient according to the local authority’s rules will follow, with hospitalization based on symptoms and risk factors.

Decisions have to be made according to an individual risk-benefit assessment, depending on the precise situation, BD disease activity and the medication used. The following aspects can be considered for specific drugs:

Local treatment (like corticosteroids) can be continued, if applied by the COVID-19 patient.

Colchicine There is no information on positive or negative effects of colchicine on COVID-19, so it is recommended not to stop to prevent a relapse of disease (principle 2).

Oral corticosteroids: double prednisolone dose if <10mg daily due to possibly reduced ability to cope with new body stress (ie adrenal insufficiency), but continue same dose if 10mg daily or higher. Low doses of corticosteroids up to prednisolone 10mg, or dexamethasone 6mg for 10 days combined with antibiotic therapy in mild – seriously ill patients that are admitted because of COVID-19 related symptoms are advised.

Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs like Azathioprine, Cyclosporin, Methotrexate, Apremilast, …): In case of fever and/ or dyspnea or ARDS: discontinuation is advised, and a specialist to be contacted immediately.

Biological disease-modifying antirheumatic drugs (bDMARDs), like anti-TNF agents: Continuation of a bDMARD depends primarily on whether it is applied for a serious organ-threatening disease. There may be more evidence coming in the future coming on potential positive effects preventing or treating late complications (eg the cytokine storm).

Management of thrombosis risk

Abnormal coagulation parameters, especially markedly elevated D-dimer and fibrinogen degradation products (FDPs), are indicators of poor prognosis in patients with COVID-19 generally (https://www.ncbi.nlm.nih.gov/pubmed/32073213}, and there is some evidence that anticoagulation improves survival (https://www.ncbi.nlm.nih.gov/pubmed/32220112).

The International Society on Thrombosis and Haemostasis has issued interim guidance on recognition and management of coagulopathy in COVID-19 @ https://doi.org/10.1111/jth.14810.

BD and COVID-19 - management advice for clinicians

Suggestions for counselling Behçet’s patients and their families with questions concerning COVID 19

Suggestions for counselling Behçet’s patients and their families
with questions concerning COVID 19