COVID-19 Live Forum Part II | Frequently Asked Questions

Eileen, did the skin lesions appear to be vasculitis? 

  • COVID fingers and toes appear as a chilblains like lesion or a vasculitic presentation.  In addition, in NYC we are seeing rashes and wounds that are not pressure related.  The coronavirus is causing endothelial and small vessel dysfunction leading to interstitial bleeding, abnormal microthrombi/thrombi, tissue ischemia and sometimes necrosis

 

For patients previously taking DMARDs who have recovered from symptomatic COVID-19, when are you advising them to reinitiate their previous regimen?

  • Non-biologic DMARDs 2 weeks after no fever. Biologics one month.

 

Why all the fever screening when almost half do not develop fevers?

  • Pro to screening: This will catch individuals who have a fever for any cause (will be important as we head back into flu season). Those individuals can be directed away from the general population and hopefully into care. Also, this may help for documentation if community tracing occurs.

  • Con to screening: This gives false sense of security, as we know there is asymptomatic shedding and even in symptomatic patients not all have “traditional” symptoms (fever/cough).

Why isn't hydroxychloroquine being talked about anymore?

  • This is due to negative studies and some showing increase risk of death. We now await randomized control trials evaluating at risk subjects.

 

Tony, what are you seeing in the ED?

  • During the next Live Forum, coming in early June, Tony will be providing an update on the ED.

 

How are people handling new medication starts, moving forward? Particularly for biologics?

  • It’s riskier for someone to walk around with fulminant inflammatory disease than to start a DMARD, including a biologic. So, for active disease, start as usual (possible caveat of not starting a JAK inhibitor until we get more information on if/how they affect the immune response to SARS-COV-2 infection). 

  • I have started biologics, which is safer than steroids, concomitantly educating the patient on COVID -19 safety and monitoring. 

 

Is Colchicine being used or studied?

  • There are a few new studies with colchicine, possibly related to limiting neutrophil numbers and decreasing the cytokine storm. There were a few studies looking at neutrophil/lymphocyte ratio as a marker for worse outcomes. There is an outpatient study in NYC, COLCORONA, enrolling, to study the ability of reducing inflammation, prevent death, hospitalization, and lung involvement.  

With Roche having a FDA approved antibody test with over 98% accuracy against false negatives, is it worth testing our providers, staff and patients? Do we know what antibody positive means?

  • No, we do not know what it means, some patients that had COVID-19 are testing negative. Interpret these antibody test results with caution. The sensitivity and specificity numbers come from small numbers of patients with known disease. How these results should be interpreted in the general population is very much in the air. ​

  • We do not know if a positive test protects from future infection.  Some tests are not validated. It is too soon to tell.  However, if positive, could be a candidate for convalescent plasma donation

Is there a role for JAK inhibitors in the management of COVID-19 patients, if any where?

  • JAK’s keep the virus from replicating in the cell but Dr. Calabrese mentions that is too late in the process.

Have you experienced a shortage of hydroxychloroquine for your patients given the use and hoarding of it during the pandemic?

  • Yes, particularly in NY, patients have to go to different pharmacies and see who has a stock, mail in orders are not so affected.​

  • No shortages in Ohio thank goodness.

  • Initially in NC there were shortages. Now, if the patient has been receiving refills, they will continue. If a new start, a PA is required and if diagnosis of Discoid Lupus, SLE or RA, prescriptions will be filled. 

Have any of you had any experience using Remdesivir in patients who had RA or other inflammatory diseases?

  • Remdesivir is an IV medication and so far, is only being used in people in ICU or in the ED in my hospital.

When do you anticipate getting back to normal clinic operations?

  • As of last week, in NY, we have resumed normal clinic, some patients are coming in, some are opting for tele-health.

  • Ohio is opening up this month. We plan on having more in-person visits starting June 1st. It is proving to be very difficult to work out the logistics - how to keep too many patients from being in the waiting area at once, figuring out how long it will take to clean exam rooms in between patients, etc. We not only have to figure this out for our own patients, but we must communicate with all the other outpatient specialties in our building. It is going to be a long process.

  • North Carolina is starting phase I of opening with extended local restrictions. Currently, continuing TELEMED for follow ups and new consults. Then, scheduling new consults starting June 1st for those that would like to come into the clinic. Infusion patients need to be safe. Will start opening X-ray and DXA with determining cleaning of equipment between the patients. This will be a slow process. Safety is a factor for employees, patients, and visitors to the practice. Logistics should be worked out first. TELEMED will continue as long as the state remains in emergency and is allowed by insurers.

  • Slowly starting this week (early May) with limited providers and patients. The goal is to limit numbers to about ⅓ of normal.  This will be evaluated over next 6-8 weeks, before making more changes.  Tele-visits are still being prioritized.

How will clinics handle resuming face to face visits?

  • We are currently screening the patient prior to the visit with a phone call and using a mask on provider and patient.

  • We will continue screening questions and temperatures, along with masks on providers, staff, and patients. The continuation of limiting visitors will be for a while.​

  • It is still recommended to conduct telehealth visits when possible.  

What are your recommendations for immunocompromised patients and patients on immunosuppressive therapies to begin returning to normal life after the quarantine?

  • The CDC guidelines still recommend that vulnerable populations, including immunocompromised, “shelter in place.” This is a very tough thing for our patients to hear but for now that is the official guidance. 

I am an APP Fellow currently training in Rheumatology. Is there any advice on how best to continue my training during this time?

  • If there is one provider who is doing a lot of virtual visits and doesn’t mind you sitting in (either physically, in the office, with masks, or just being dialed in to the virtual visit which some platforms allow) that could be a valuable learning experience.

  • There are many online educational opportunities popping up. Look not only for rheumatology but dermatology, pulmonary, and other specialties.

  • Academic centers have many virtual learning opportunities posted.

Do you have any suggestions on social distancing in a busy infusion room?

  • No visitors

  • Infusion chairs at least 6 feet apart

  • Everyone wears masks

  • Workstations moved so they are 6’ apart or even out in the hallway (for charting, etc.)

  • If possible, ordering partitions to be placed between chairs

  • Of course, continue screening all patients for symptoms before they come in for their infusion

How are practices dealing with those who use in office certolizumab pegol for those on Medicare? How about those who are on infusions? Are practices changing to oral JAK inhibitors as a result of not being able to infuse? Are labs getting done for those on MTX?

How are you dealing with patients who are not insured or underinsured?

  • My office remained open and infusions were not stopped for patients that chose to come in. We were surprised at the number of patients that did come in, as there were very few cancellations, Some patients have lost their insurance due to losing their employment. For those people on oral of injectables, we were able to supply samples.

  • Our department stayed open for injections and infusions. We are not switching patients from infusables to orals currently. Patients who lose their insurance are directed to patient assistance programs or HCAP (if they are infusion patients).

  • Our office stayed open for infusions and infusions have not been discontinued or changed to other therapy. RNs call patients the day prior. We have had almost 100% compliance. Our lab has not closed. These patients are scheduled for MTX, JAK and osteoporosis labs, come in with masks, escorted in and out of the practice individually. If they live farther out and have had a recent PCP visit with labs, we call and have these faxed to save them a trip. 

  • Our infusion center has remained open.  Some infusions have been postponed if it was safe to do so, but many are still coming in.  We are using samples if needed and exploring patient assistance programs if without insurance.  Sometimes labs have been delayed with MTX, and if patient is stable allowing 1-2 month wait, however if issues with LFTS holding until can get repeat labs. 

  • We are still doing all infusions and Jansen has allowed us to delay in paying for buy and bill if needed. 

Are you using any standardized screening tools to help triage patients for in person and/or telemedicine visits? If so, which assessment tools and how are they being implemented? Which challenges or additional opportunities have you encountered during this process on the part of patients or staff needed to assist this new process. 

  • Our patient reported outcomes were already in an online format before the pandemic, so we continued using that platform. Patients who do not have a MyChart account used to get a tablet when they checked in. Since 85% of our visits have been virtual lately that means the PROs are not getting collected which is a big problem. We are doing everything we can to get patients to sign up for MyChart.                                                       

  • Our screening questions are also on MyChart tablet when arrive.  Also, patients are called and screened prior to coming in for some procedure type appointments 

Any recommendations on performing elective procedures on patients after they have had/recovered from COVID-19?

  • Need to be cautious. I think that would be up to the outpatient surgery department. They should at least have a negative PCR test and normal pOx (and afebrile of course).​

  • This far, I am seeing all providers and patients being required to be tested, prior to procedure.  Also, temperature and screening questions prior to.

Any thoughts or concerns on injectable steroids causing immunosuppression and making a patient more vulnerable to the virus? 

  • This has not been demonstrated for any communicable disease that I am aware of. Not in typical doses for rheumatology, anyway.

How do you see industry best supporting you and your patients in this new normal?

  • Samples, lots and lots of samples

  • Very easy, very rapid, web-based patient assistance programs for patients who lose their insurance.

  • Appreciate the continued availability when needs arise

What are you all doing with the Prolia patients?

  • Prolia patients are on a tight schedule. Looking ahead to their visits in EHR, scheduling TELEMED to do their history, discuss COVID safety and safe practice measures following CDC guidelines to return to office, submit Prolia order. Then, scheduling labs in the office, and also patient’s return to the office for Prolia. At that TELEMED visit they are also given a 6 month follow up so they will not get left off the schedule and lost. I explain at the TELEMED visit the importance of not missing Prolia injection, with risk of QUICK loss of BMD and increased risk of fracture. They have been great about returning and out of hundreds I have had maybe one not return immediately and that was due to a dental visit.

  • We do not recommend stopping Prolia. If patients were very nervous about coming in, we allowed them to stretch their injections out to 7 months, but the evidence shows that is the longest it is safe to go between injections. If patients absolutely refused to come in, we recommend switching to a bisphosphonate.

What are you all doing with IV infusions?

  • In my office in Queens and Long Island, we did not stop infusions.

Are you switching to oral JAK inhibitors to allow for DMARD relief?

  • No, the jury is still out as to whether or not JAK inhibitors can be beneficial or possibly harmful in terms of immune response to SARS-COV-2.

What are you doing with testing with MTX other DMARDS?

  • Continued as usual.​

  • For new/newer starts, continue as usual. If the patient has been on their medication for at least a year with stable labs we allowed them to skip their spring labs but are recommending they restart q3 month labs starting in June.

Are your labs open?

  • Most of our labs remained open. Some were closed if there were other sites very close by (I work for a large hospital system with dozens of locations).

  • I have had access issues to rural labs particularly up Northern Michigan with labs closed but near the capital they are open. 

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