It has now been several months since the novel coronavirus (COVID-19) pandemic first emerged, and sarcoidosis patients and providers are seeking guidance on how best to manage immunosuppressive treatments. With our knowledge of COVID-19 constantly evolving, this review is up to date as of July 2020, and may need to be updated periodically as our knowledge of COVID-19 unfolds. We will discuss treatment principles to guide rheumatologists and other sarcoidosis providers as we navigate this unprecedented viral epidemic.
Patients with sarcoidosis are a unique population, and several factors specific to sarcoidosis must be considered in the context of a novel, contagious respiratory virus. First, 90-95% of people with sarcoidosis have pulmonary involvement, leading to underlying lung disease and damage. This may put them at a higher risk than the general population, or even other patients with rheumatic diseases being prescribed immunosuppressive medications. Sarcoidosis patients may have baseline decreased lung capacity and fibrosis related to granulomas. Likewise, treatment for sarcoidosis generally involves immunosuppression, which potentially results in increased susceptibility to infectious diseases. Side effects of immunosuppression—in particular glucocorticoids such as prednisone—are linked to diabetes and hypertension. These comorbidities are frequently cited as factors that appear to put patients at an increased risk for complications related to COVID-19. The mechanism for this association remains unclear. Given the complex interplay between sarcoidosis/granuloma formation, the immune system, and new antigens like COVID-19, patients and providers need to weigh the evidence for continuing, modifying, or ceasing therapy for sarcoidosis. They need to balance the risk of recurrent sarcoidosis if treatment is tapered with the theoretical risks of COVID-19 infection if therapy remains unchanged.
A consensus statement from the American College of Chest Physicians recommends that physicians stratify patients based on the risk of organ damage . Patients with active disease, especially those with a risk of organ damage (uveitis, neurosarcoidosis, cardiac sarcoidosis, progressive pulmonary sarcoidosis) should likely continue their treatments without change. They note that patients with life threatening manifestations of sarcoidosis like cardiac and neuro-sarcoidosis should continue therapy regardless of whether they have quiescent disease. These patients are at risk for organ damage and poor outcomes should they stop therapy, even during a viral pandemic. Patients with stable disease, without risk of organ damage, are further stratified by the type of therapy they are on. It is reasonable to consider reducing TNF inhibitors (either the dose or frequency), reducing steroids to the lowest possible dose, and reducing the dose of disease modifying antirheumatic drugs (DMARDs) such as methotrexate if possible. Patients should be able to readily access their care team should they experience a flare. It is important for sarcoidosis patients to remain in close communication with their providers while reducing therapy, so that if a flare occurs, therapy can be re-intensified.
In addition to identifying patients who may be eligible for treatment tapering, providers should also stratify by risk of complications related to COVID-19. Current knowledge in the general population suggests advanced age, comorbid medical conditions (such as diabetes and hypertension) and smoking status influence COVID-19 related outcomes. In addition, studies that focus on patients with rheumatologic disease probably best reflect the risks for patients with sarcoidosis, as sarcoidosis is treated with many of the same therapies as other rheumatic conditions. A large global registry of patients with rheumatic diseases that have contracted COVID-19 (the COVID-19 Global Rheumatology Alliance) was recently utilized to conduct a case study of 600 patients . This study demonstrated an increased risk of hospitalization for COVID-19 associated with glucocorticoid use (prednisone ³10mg daily). As in the general population, comorbid medical conditions like diabetes and cardiovascular disease also increased the risk of COVID-19 related hospitalizations. Notably, non-glucocorticoid therapies including DMARDS (such as methotrexate), antimalarial drugs (such as hydroxychloroquine and chloroquine), and TNF inhibitors (such as adalimumab and etanercept) did not increase the risk of COVID-19 related hospitalizations.
This review highlights the challenges sarcoidosis patients and providers face in navigating this novel, global pandemic in conjunction with a disease that requires long term immunosuppressive treatment. Patients and providers should consider the risk of disease flares and the specific risks of organ damage in deciding whether to taper or adjust therapy. They should focus on reducing glucocorticoids whenever possible, and continue other therapies as appropriate. Finally, patients and providers should remain engaged and up to date as new data emerges from COVID-19 studies, and as our guidance continues to change based on new information.
1. Sweiss, N.J., et al., When the Game Changes: Guidance to Adjust Sarcoidosis Management During the COVID-19 Pandemic. Chest, 2020.
2. Gianfrancesco, M., et al., Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis, 2020. 79(7): p. 859-866.
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