Panel 1: Key Recommendations for Managing Patients With Rheumatic Diseases During The COVID-19 Epidemic

Potential risk factors for SARS-CoV-2 infection in patients with rheumatic diseases

• On immunosuppressive agents
• Chronic kidney disease e.g. lupus nephritis
• With lung involvement e.g. interstitial lung disease
• Elderly patients
• Frequently visiting medical clinic
• With underlying health conditions, such as smoking, obesity, hypertension and diabetes
• Who are pregnant

Medication for patients with rheumatic diseases #

• Continue current treatment if disease is stable, and contact your doctor for suitable medicine if disease has flared
• Use of hydroxychlorquine (HCQ) and sulphasalazine [SLZ] should be continued and should not increase the risk of infection
• Use of other conventional synthetic disease modifying drugs (csDMARDs e.g. methotrexate, leflunomide) and immunosuppressants (e.g. cyclophosphamide, azathioprine, mycophenolate mofetil, tacrolimus) should be continued
• Corticosteroid use can be continued
• A new prescription of immunosuppressant or increase in dose of an ongoing immunosuppressant would need to be carefully discussed in epidemic areas.
• Use of all biologic DMARDs should be continued if possible
• If infliximab infusion is not accessible, switching to other anti-TNF injection at home is encouraged
• Targeted synthetic DMARDs (JAK inhibitors) including Tofacitinib/ Baricitinib/ Upadacitinib can be continued

Surgery

• Postpone elective surgery e.g. joint replacement surgery
• Screening for COVID-19 (symptoms suggestive of COVID-19, complete blood count, nasopharyngeal swab and chest x-ray or chest CT according to local recommendation) before emergency surgery

Patients with RD and fever*

• Contact your rheumatologist about potential option to visit fever outpatient clinic with

personal protection provisions if temperature continues over 38°C

• Patients must not suddenly stop prednisolone
• Suspend the use of immunosuppressants and biological agents after consultation with your rheumatologist, and follow appropriate local guidance for suspected COVID-19 if COVID-19 cannot be ruled out

• Patients can continue HCQ and SLZ if they are infected with COVID-19.

# Concerning glucocorticoids, immunosuppressants, csDAMRDs, bDMARDs and JAK inhibitors, the balance of safety and efficacy in viral infection as well as pulmonary inflammation remains unclear.