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.

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.

New Hours!

To accommodate our patients, Main Line Rheumatology has increased its hours to better serve you!

Monday 9am – 5:30pm
Tuesday and Wednesday 8am- 4pm
Thursday 9am – 4pm
Friday 8am- 4pm

Tuesday, Wednesday and Friday  9am – 4pm

Lupus and Pregnancy, by Amy Lundholm, DO

Systemic Lupus Erythematosus (SLE)
or Lupus can be associated with gestational hypertension (maternal high blood pressure), preterm birth, intrauterine growth restriction and fetal death. Lupus patients may have abnormal placentation (attachment), which is a major contributor of many pregnancy complications due to reduction in maternal blood flow to the fetus. Despite potential risks, women with SLE can have healthy pregnancies. Women with SLE should have low disease activity for the 6 months prior to conception for the best chance of a successful, healthy pregnancy. The PROMISSE Study was a large multicenter prospective study of pregnant and postpartum SLE patients. The study showed that 26 % of patients had a flare (worsening) during pregnancy, and 24.4% had a flare in the postpartum period. Most of the flares were mild and infrequently required therapy.  Only 6.3% of the patients had severe flares during pregnancy and 1.7% had severe postpartum flares.

Data suggests that the drug, Plaquenil, used during pregnancy was associated with fewer preterm births and less intrauterine growth restriction. Findings also suggest that discontinuation of Plaquenil is associated with higher lupus disease activity during pregnancy.

For SLE patients not looking to conceive, IUDs are considered safe and effective. Other acceptable contraceptive options, when used appropriately, include condoms, progestin (only oral contraceptives) or depo-provera injections. Estrogen-containing contraceptives are contraindicated in the setting of active lupus, as they may flare the disease.

Main Line Rheumatology’s Amy L. Lundholm, DO, is board certified in both rheumatology and internal medicine. Dr. Lundholm holds current membership in the Pennsylvania Osteopathic Medical Association and the American College of Rheumatology. She was chosen as a rheumatology Top Doctor 2018 Main Line Today magazine. To read more about Dr. Lundholm, go to Our Staff.

Main Line Rheumatology Doctors are Coming to the Aid of Workers During the Government Shutdown

The doctors and staff at Main Line Rheumatology (MLR) are coming to the aid of government and furloughed workers who are practice patients currently experiencing a financial strain during the government shutdown. MLR will offer relief from current office co-payments, which can be received from patients at a later date after the government reopens. MLR has office locations at Lankenau Medical Center in Wynnewood, and Main Line Health Center in Broomall. CALL NOW 610-896-8400 for an appointment, and visit mainlinerheumatology.com

Did You Know That Certain Medications You Take Can Cause Osteoporosis, Fractures or Bone Loss?

This could be a wake-up call to action!

Glucocorticoids  or steroid medications taken for many medical conditions to help you feel better, can end up creating a serious bone fracture and disease problem for many adults. The question to ask yourself, and your family doctor or rheumatologist is, “Am I exchanging one problem for another?”

What are glucocorticoids, and why does my doctor prescribe them, if they lead to bone fractures and osteoporosis?  Your body has naturally-occurring glucocorticoids, or steroid hormones, that have many important functions. They help to interrupt or suppress inflammation, help your body respond to stress, and regulate how your body uses fat and sugar.

Many health problems involve inflammation, and if your body’s natural glucocorticoids are not performing well, drug assistance may be indicated. Glucocorticoid drugs are man-made, or synthetic versions of natural glucocorticoids, and can help suppress inflammation from autoimmune reactions, reducing pain, swelling, cramping, and itching. They are prescribed to treat autoimmune diseases like arthritis, rheumatoid arthritis or lupus; skin conditions like psoriasis or eczema; allergic reactions; breathing disorders like COPD and asthma; inflammatory bowel disease like Crohn’s or ulcerative colitis; various cancers, multiple sclerosis; surgery recovery, or sepsis. These drugs are effective in stopping damaging inflammation, but are more potent than the naturally occurring steroids and can cause serious damage.

According to the January 2, 2019 New England Journal of Medicine (NEJM), approximately 1% of all adults and 3% of adults older than 50 years of age receive glucocorticoids for allergies, inflammatory conditions, or cancer. Long-term use of glucocorticoids is associated with clinically significant toxic effects. Fracture, followed by diabetes, is the most common serious and preventable adverse event associated with these agents. The risk of fracture increases with age and with the dose and duration of glucocorticoid use. Here are the facts.

Vertebral fractures are the most common fractures associated with glucocorticoids; the risk of vertebral fracture increases within 3 months after initiation of treatment and peaks at 12 months. The relative risk of clinically diagnosed vertebral fracture doubles and the risk of hip fracture increases by approximately 50% among patients who receive 2.5 to 7.5 mg of prednisolone daily. In a study with a follow-up of 6 months to 10 years, glucocorticoids taken at very high doses significantly increased the risk of vertebral fractures.

Glucocorticoids have direct and indirect effects on bone remodeling. Bone loss can lead to an early increased risk of fracture and osteoporosis. Bone formation also decreases early in glucocorticoid treatment. Indirect glucocorticoid effects predispose patients to reduced muscle mass leading to an increased risk of falls, decreases in renal calcium resorption and levels of sex hormones, and alterations in parathyroid hormone functioning.

The risk of fracture rapidly decreases when glucocorticoids are discontinued. A prospective study showed clinically significant improvement in bone mineral density at the lumbar spine within 6 months after discontinuation of glucocorticoids. A large retrospective study showed an increased risk of a major osteoporotic fracture among patients with recent prolonged glucocorticoid use but not among those with intermittent or past use of these drugs.

What you need to know from this NEJM Report

  • Risk factors for glucocorticoid-induced fractures include age (>55 years), female sex, white race, and long-term use of prednisone at a dose of more than 7.5 mg per day.
  • Screening for fracture risk should be performed soon after the initiation of glucocorticoid treatment. The risk of fracture among patients who are 40 years of age or older can be estimated with the use of bone mineral density testing and the fracture risk assessment tool (FRAX).
  • Patients who receive glucocorticoids should be counseled about adequate intake of calcium and vitamin D, weight-bearing exercise, and avoidance of smoking and excessive alcohol intake.
  • Pharmacologic treatment is strongly recommended for anyone who has had a fracture and for patients who are at least 40 years of age if, according to the FRAX tool, the risk of major osteoporotic fracture is 20% or higher or the risk of hip fracture is at least 3%. Among patients who are receiving glucocorticoids and have a bone mineral density T score of −2.5 or less (indicating osteoporosis) at either the spine or the femoral neck, pharmacologic treatment is also recommended for men who are 50 years of age or older and for postmenopausal women.
  • Bisphosphonates (i.e. Fosamax, Actonel) are recommended as first-line treatment of osteoporosis because of their low cost and safety.
  • The risk of fracture decreases rapidly when glucocorticoids are discontinued. Exposure to glucocorticoids should be minimized as much as possible.

Non-drug options that can help (with or without taking glucocorticoids) bone loss, osteoporosis and fractures

  • Weight-bearing exercise, maintenance of normal weight, smoking cessation, limitation of alcohol consumption, and the assessment and management of fall risks.
  • Calcium and Vitamin D: Adequate dietary intake of 1,000 mg calcium per day and 600-800 IU of vitamin D (600 to 800 IU) is routinely encouraged in patients who receive glucocorticoids.
  • Bisphosphonates increase bone mineral density, help strengthen bone preventing further weakness, and slow down further bone loss.

Be an informed consumer! Talk to your doctor about glucocorticoid drugs that include beclomethasone, betamethasone, budesonide, cortisone, dexamethasone, hydrocortisone, methylprednisolone, prednisolone, prednisone and triamcinolone.

Make every effort to reduce your chance of disabling osteoporosis, fractures and bone loss. Discuss all medication and potential side effects with your primary care doctor, rheumatologist, and/or endocrinologist and together, make the best choices for your overall health and well-being.