A Rheumatology View of Covid

For the last 6 months, it has been difficult for all of us to think of anything else other than Covid as our world has been turned upside down to borrow a phrase from Hamilton. As rheumatologists, we have our own particular view of Covid. Other than the unfortunate politicizing of social distancing, most of the world understands that this is vital if we are to survive this pandemic. Wearing masks, frequent hand washing, staying an appropriate distance from others and quarantining when necessary is vitally important. Avoiding prolonged exposure to others in non-ventilated rooms is obviously worthwhile. We have learned much in the last 6 months and the turnaround in former hot areas like New York City teaches us that we can do it but unfortunately at huge economic sacrifice for many. As we often say, “Listen to Fauci”.

In our office, we are using HEPA filtering which significantly reduces the amount of virus particles in the air. Questioning patients as to travel and having temperatures taken makes it a considerably safer place then many (i.e. supermarkets). We also continue to offer TeleMed visits which provides sufficient information in many cases but obviously does not work when infusions of medications, joint aspiration and injections are necessary. We now know that neither the diseases we typically treat nor the medications we use are risk factors for Covid. Identified risks are obesity, lung disease, vaping, smoking, and diabetes.

We have learned that many of the deaths cause by Covid have less to do with overwhelming infection and more to do with our bodies ‘accelerated inflammatory response to the infection. This is commonly referred to as cytokine storm where the immune system essentially goes haywire trying to eliminate Covid but unfortunately ends of damaging the endothelial cells which line the insides of blood vessels. Damaged blood vessels are more prone to promote clots throughout the body as well as limiting the ability of the lung to oxygenate blood.

Numerous drugs are being studied to better control cytokine storm. Thus far there are no definite winners. The public gets their hopes up when drugs like hydroxychloroquine (Plaquenil) get endorsed by non-medical politicians but there are some other medications that are intriguing. As rheumatologists, we have used virtually all of them for the inflammatory diseases that we treat. Corticosteroids are being carefully examined as they are inexpensive and suppress inflammation. Of course the timing is critical. Using drugs that suppress inflammation can allow infection to go unchecked. Thus, drugs that may work on Covid infection such as remdesavir would be more useful in the beginning of a Covid infection and less useful later whereas the cytokine storm inhibitors need to be given at a later time. Currently the 2 drug classes being most intensively studied are interleukin-1 and interleukin-6 inhibitors. Examples of these drugs include Kineret, Ilaris, Actemra and Kevzara. They are approved for use in rheumatoid arthritis. As of this writing, all these medications are considered off label and not covered by insurance for Covid. Double-blind studies suggest that they may work but are certainly not conclusive. Numerous studies are underway in the United States and around the world and we anxiously await the results.

Work on vaccines is moving along rapidly. Historically we have never been able to develop a vaccine as fast as current work is proceeding in this area. Efficacy and safety still need to be established and hopefully this will not be another politicized issue. This is reminiscent of the speed with which ships and fighter airplanes were built in a few days during World War II. (I think of this often when I see the bridges being repaired in Ardmore which take at least 2 years each).

We will get past this. The economic and social impact is already devastating. People are out of work or unable to go to work if they have children unable to go to school. Nothing will be the same, but Main Line Rheumatology and Osteoporosis along with the dedicated health care providers in the Philadelphia area plan to provide the best health care we can offer.

Main Line Rheumatology & Osteoporosis Continues to Function

As we remain under what looks to be a long siege, Main Line Rheumatology & Osteoporosis continues to function. We are still seeing patients with rheumatologic emergencies, patients needing infusions and are ramped up to do TeleMed via the Internet and telephone. We are using Zoom, Doxy.me, as well as FaceTime. We are also “seeing” new patients until we are able to follow up with them in the office. If you have a fever, cough or have been exposed to somebody in the last 2 weeks whom you suspect to have Covid 19, out of respect to other patients and our hard-working staff, we ask that you do not come to the office.

If you are over 60 and need to do grocery shopping, you may already know that Whole Food and Acme open an hour earlier at 7 AM and Giant opens at 6 am. Whole Food is now only limiting 100 people into the store at a time which translates into about 3 customers every 10 minutes depending on the time you get there. We would recommend trying to go early or late to avoid this bottleneck. Trader Joe is not opening earlier for seniors.

When you shop, remember to wear latex gloves if you have them and wipe down the handle of the grocery cart, your car door handle and steering wheel. If you pull your credit card out of your pocket, take off your glove and remember to wash your hands again as well as wiping down the credit card and your cellphone. I never realized how much I touch my face but we should all try to make every effort to avoid that.

The newspapers are full of websites to try to entertain yourself at home including all kinds of music, museums and activities. One of my favorite pastimes is listening to Dr. Harder’s wife, Debra Lew Harder, M.D., on WRTI 90.1 on Saturdays from 6 AM to noon and some weekdays from 10 AM to 2 PM. I cannot imagine anyone who knows more about music, has such a soothing voice and in her own right is a much recorded concert pianist.

Lastly, try to reach out to your neighbors who are living alone. We can get through these unprecedented difficult times.

Covid-19 & Your Medications

As we have written previously, it is not clear whether Covid 19 creates additional risk for the biologic medications our patients take for inflammatory diseases.  Most rheumatologists are not telling their patients to stop their medicines unless they have an infection.   This advice has been given for many years.  One unexpected medicine we especially want patients to continue if they are already on it is Plaquenil, (hydroxychloroquine). This drug, used for lupus, Sjogrens and rheumatoid arthritis, is  a cousin of chloroquine. Chloroquine in studies done in China ( for whatever that may be worth) may be beneficial in treating Covid 19. There is not enough data to tell people to take Plaquenil for Covid 19, but if you are on it, talk to us before considering stopping it.