How and why are rheumatologists relevant to COVID-19?

The unprecedented health crisis at COVID-19 mobilised all of our medical forces, with emergency physicians, intensivists, infectious diseases specialists and internists at the forefront, in which rheumatologists had to and were able to find their place.

The current state shows that old and new perspectives are opening up for anti-rheumatic drugs in the treatment of this pandemic [1], [2]. A search on clinicaltrials.gov conducted on April 23, 2020 identified 363 phase I to IV interventional clinical trials for the Management of the COVID-19 Pandemic (Fig. 1 ), involving a total of 170 treatments. Importantly, 143 trials (39%) involve treatments used daily by rheumatologists: 10 for NSAIDs and corticosteroids, and 133 for DMARDs (88 hydroxychloroquine, 14 chloroquine, 14 tocilizumab, 8 sarilumab, 6 colchicine, 4 anakinra, 3 baricitinib, 1 tofacitinib, 1 methotrexate, some trials testing several molecules at the same time in different arms). In addition, 46 trials (11%) are evaluating targeted therapies that are well known to rheumatologists because they are used in other indications (cancer immunotherapy or conventional immunosuppressants, n  = 9) or are under development in inflammatory diseases (n  = 37). Rheumatologists are thus experienced with drugs involved in more than 50% of the COVID-19 trials. Trials of specific anti-viral treatments (n  = 30) or evaluating vaccines (n  = 14) account for just over 10% of the trials (n  = 44). Forty trials evaluated cellular therapies (n  = 22) or plasma transfusions from immunised patients (n  = 18). Twenty-one trials are evaluating oxygen therapy modalities or inhaled treatments. Seventeen trials are evaluating vitamin or dietary supplements. Finally, 52 are evaluating a wide variety of treatments, including angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, anti-aggregants, anticoagulants, antibiotics and other treatments or support therapy.

Fig. 1

Ongoing clinical trials in COVID-19 from clinicaltrials.gov and classification of these trials according to the modes of action of the drugs tested.

The covid-nma.com website is a quick and useful tool for all clinicians looking for quick information on current research and those with published results. It is a “living mapping of ongoing research”. On this site on April 23, 2020, 339 randomised trials (excluding traditional Chinese medicine trials), including 163 RCTs currently recruiting, were identified.

At the onset of this pandemic, we feared for our patients with chronic inflammatory diseases treated with immunosuppressive drugs. The lack of data in this population in China raised concerns about susceptibility to severe forms in our patients. More recent European data now suggest that they should not be at such a higher risk [3]. Of note, these reassuring data are subject to bias because these patients may have been confined earlier, more strictly and may protect themselves better than the general population. It is therefore our duty to continue to register these patients, describing severe forms, of course, but also benign or pauci-symptomatic forms, in order to build up a reliable database on this potentially at-risk population. Although discontinuing immunosuppressive therapy in the event of infection is logical and commonly done by patients themselves, the question of restarting it, once the COVID-19 infection has been cured, remains unknown. Is there not a risk of viral reactivation by inhibiting the anti-viral response? Therefore, barrier measures should be emphasised as much as possible. Our patients must also be informed of the clinical signs that justify medical consultation (fever and respiratory manifestations). It is therefore important that they can easily contact their rheumatologist [4].

Our rheumatologist experience in clinical trial design, the inclusion of patients in these trials and our knowledge of many of those potential treatments have allowed us to make ourselves useful during this pandemic when no one would suspect a rheumatologist of having a significant role to play in such a health crisis. In addition, monitoring our at-risk patients during this pandemic, identifying cases of infection and reporting them to our registries is also an important task during this crisis.

Disclosure of interest

The authors declare that they have no competing interest.