IMPACT OF THE COVID PANDEMIC ON RHEUMATOLOGY PATIENTS IN NORTHERN IRELAND - A WEB BASED CROSS-SECTIONAL SURVEY OF PATIENT REPORTED OUTCOMES.

Editor,

Concern for the susceptibility of rheumatology patients to severe COVID-19 illness has been raised since the start of the pandemic. Rheumatic disease and their immunosuppressant therapies placed many patients into the ‘clinically extremely vulnerable’ group when the UK’s shielding guidance commenced on 23 March 2020. The impact of DMARDs/glucocorticoids/biologics on COVID-19 remains under investigation1. A recent study suggested caution may be required with rituximab and sulfasalazine in COVID-19 patients 2.

The objective of our study was to evaluate the impact of the COVID-19 pandemic on rheumatology patients in Northern Ireland by assessing treatment, disease progression, shielding advice, access to primary & tertiary care, overall anxiety and incidence and severity of COVID-19 infection.

A web-based cross-sectional survey was completed in Northern Ireland between 23rd November 2020 and 22nd January 2021. The questionnaire included medication history, comorbidities, disease course, patient experience, shielding advice, COVID-19 illness, hospitalisation and effects on mental health. The survey was publicised by sending 6,032 Belfast Trust NHS patients a link via SMS and via NHS/Versus Arthritis social media platforms.

There were 2,615 responses and of these 2,539 had been completed and were suitable for analysis. The majority of respondents were aged 45+ (78.27%) and female (N=1819). Rheumatoid arthritis (41%) and psoriatic arthritis (29%) were the most common diagnoses. Just over one third (35.27%, N=896) of patients were on biological drugs. Most patients were taking methotrexate (28.04%) followed by hydroxychloroquine (15.20%) and adalimumab (12.52%). The majority (79.6%) continued treatment during the pandemic as recommended. There was evidence of disease ‘flaring’ in 30.75% of those patients who had stopped treatment. Of the respondents surveyed 7.8% (N=198), tested positive for Covid-19 and of these 77.55% reported that they had received adequate shielding advice. Less than one third of patients testing positive for COVID-19 had been treated with biological drugs (30.3%, N=60). Cardiovascular disease was the most prevalent comorbidity. Only 11.11% (N=22) of those who tested positive for Covid-19 required hospital admission and 2 patients required intensive care support. Both patients requiring ICU were not on immunosuppression. Of the 22 patients hospitalised with COVID-19, 13.64% (N=3) were on solitary sulphasalazine therapy, 13.64% (N = 3) were on solitary anti-TNF therapy, 18% (N = 4) were on methotrexate alone and one patient was on combination methotrexate and anti-TNF therapy. Anxiety and loneliness to varying levels was reported in the majority of patients.

The survey showed low levels of COVID-19 hospitalisation despite most patients continuing DMARD/biologic/ glucocorticoid therapy. This has been replicated in other studies1,2 however data continues to be gathered on the safety of some biologic drugs particularly rituximab 3. Many patients expressed overwhelming anxiety and fear of mortality. This coupled with stringent restrictions and social isolation led to a detrimental effect on their well-being. Concern over the mental health of the rheumatology community within this pandemic has already been well recognised, and this current data highlights again the need for us as physicians to be proactive 4. Our survey results also indicated high concordance with continuing prescribed treatments but highlighted the negative impact of interrupting treatment on disease control. Future data will inform our decision making regarding the safety of continuing with certain drugs 5.