POS1177 REVAMPING BIOLOGIC THERAPY DURING COVID-19
Authors: S. Ahmed Narikkoottungal, A. Siddiqui, A. Constantin, S. Farrow, K. Ahmed
Journal: Annals of the Rheumatic Diseases (2021)

Background: The COVID-19 pandemic has caught us all by surprise – from governments to individuals; the medical fraternity being no exception. It has affected all walks of life; with its immense contagiosity, diverse and intriguing pathogenesis and manifestations differing from other viruses. It has indeed left humanity in dark, unchartered waters; particularly in the early months of the pandemic. Objectives: This article shares the experience, in a Rheumatology department in a District General Hospital (DGH) in the United Kingdom, of managing patients on Biologic (b) and Targeted Synthetic (ts) DMARDs, in the midst of the COVID-19 Pandemic. Methods: All Rheumatology patients at the Princess Alexandra Hospital (PAH) in Harlow newly started on a biologic or targeted synthetic DMARD between 3rd July and 3rd Oct 2020 were identified. These patients had active inflammatory arthritis. Each patient was discussed in a dedicated Multi-Disciplinary Team (MDT) meeting and a consensus on treatment reached in-line with local and National guidelines. Figure 1. A slide presented at the Essex Rheumatology Association (ERA) meeting explaining the process adopted at the Rheumatology Department at Harlow during the peak of COVID-19 pandemic with new b/ts DMARD patients. Results: Of the 50 patients identified; 39 had Rheumatoid Arthritis, 6 had Ankylosing Spondylitis and 5 had Psoriatic Arthritis. Of these 50 patients, 5 patients decided against treatment during the stage of ‘Enhanced Verbal Consent’. These patients were flaring recurrently and were in regular contact with the department. However, they were afraid to start new Biologic treatment because of the risks of Covid-19. The breakdown of the biologic agents used in the remaining 45 patients were as follows: Adalimumab:11, Rituximab: 10, Etanercept: 9, Tofacitinib: 11, Tocilizumab SC: 3, Tocilizumab IV: 1, Sarilumab: 2, Secukinumab: 1, Infliximab: 1, Baricitinib: 1, Apremilast: 1 Figure 2. Breakdown of the various b/ts DMARD agents newly started in the 45 patients between 3/7/20 - 3/10/20 at PA Hospital, Harlow, UK Conclusion: The over-riding principle that guided the Department during the COVID crisis was: primum non nocere (first, do no harm). The adherence to the Case Based Discussions (CBDs) positively impacted on decision making, ensuring safe initiation of Biologic DMARDs even during the height of the pandemic. This is vital to achieve early disease remission. The MDT meetings comprising Doctors, Specialist Pharmacist and Nurse Specialists ensured prompt risk stratification of individual patients. It gave patients the opportunity to be part of the decision-making - evident in the five of the fifty patients, who opted to defer the start date of their treatments. The choice of the new Biologic agent was based on the latest National COVID-19 guidelines. The agents with the shortest half-life were selected. Moreover, patients for Rituximab were given one pulsed infusion, as opposed to two infusions. Only one of the 45 patients started on a Biologic agent over this period, either was tested positive or had symptoms suggestive of COVID-19. References: [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261974 [2]https://rmdopen.bmj.com/content/6/2/e001314 [3]https://www.nejm.org/doi/full/10.1056/nejmc2009567 [4]https://www.jrheum.org/content/early/2020/05/13/jrheum.200527 [5]https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-care-of-adult-patients-with-systemic-rheumatic-disease [6]www.england.nhs.uk/clinical-guide-rheumatology-patients-v1-19-march-2020.pdf [7]https://www.rheumatology.org.uk/practice-quality/covid-19-guidance [8]https://www.nice.org.uk/guidance/ng167/chapter/4-Treatment-considerations [9]https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent Acknowledgements: We acknowledge the whole Rheumatology Dept at Harlow for their sincere team work during the COVID-19 pandemic – Sabaa Naz (Rheumatology Pharmacist), Mona Kamal Zou (Biologics Nurse Specialist), Lily Robinson (DMARD Nurse Specialist), Mary Surendran (Osteoporosis Nurse Specialist), Janet Bell (Secretary to Dr Ahmed) and Claire Stroud (Secretary to Dr Farrow). Disclosure of Interests: None declared.