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Response to: ‘Treatment adherence of patients with sytemic rheumatic diseases in COVID-19 pandemic’ by Fragoulis et al
  1. Hendrik Schulze-Koops1,
  2. Klaus Krueger2,
  3. Christof Specker3
  1. 1 Division of Rheumatology and Clinical Immunology, Department of Medicine IV, Ludwig Maximilians University Munich, Munich, Germany
  2. 2 Praxiszentrum St. Bonifatius, Munich, Germany
  3. 3 Klinik für Rheumatologie und Klinische Immunologie, KEM Kliniken Essen-Mitte, Essen, Germany
  1. Correspondence to Professor Hendrik Schulze-Koops, Division of Rheumatology and Clinical Immunology, Department of Medicine IV, Ludwig Maximilians University Munich, Munich 80336, Bayern, Germany; hendrik.schulze-koops{at}

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We read with interest the study of Fragoulis et al 1 about treatment adherence and behaviour changes of patients with autoimmune inflammatory rheumatic diseases (AIRD) in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/COVID-19 pandemic. In their study, only 11 out of the 500 patients with AIRD interviewed had discontinued antirheumatic treatment solely due to fear of immunosuppression, for example, for fear of an increased risk for SARS-CoV-2 infection. This is reassuring to note as interruption of clinically efficacious therapy in AIRD is associated with an increased risk of relapse2 which might lead to the necessity of intensifying immunosuppressive therapy, possibly beyond the original level. For this very apprehension and also for the accumulating cautious impression that patients with rheumatological diseases might not have a worse prognosis during COVID-19,3 4 we highlighted the importance of the recommendation to not generally interrupt or reduce immunosuppression in the current COVID-19 pandemic by placing it as our first statement in the preliminary recommendations of the German Society of Rheumatology for the management of patients with inflammatory rheumatic diseases during the SARS-CoV-2/COVID-19 pandemic.5

Fragoulis et al report that discontinuation of medication was not associated with an exacerbation of the underlying rheumatic disease.1 However, this view has to be taken with some caution as the interviews were conducted about 2 months after the COVID-19 pandemic had started in Greece on 26 February 2020 and it is very well conceivable that not all patients who had discontinued their medication at some time after the start of the pandemic already had experienced reactivation of their AIRD when interviewed. While reactivation of inflammatory rheumatic diseases may occur within 2 weeks when treatment with JAK inhibitors is interrupted,6 it may take several weeks to months for the different biologicals.2 In light of the fact that the pandemic is ongoing and vaccination will not be available for a considerable time, patients who interrupt their antirheumatic treatment will be at risk for reactivation of their AIRD while still unprotected against SARS-CoV-2. If the patients from Fragoulis’ cohort would continue to be off antirheumatic therapy, it would be worth to follow them longitudinally. In order to gain further insight into current treatment of patients with AIRD, it would also be informative to know how many of the patients identified in the study had been advised to do so by a physician or even by their rheumatologist.

Despite the general recommendation to not stop antirheumatic medication in patients with AIRDs, several reasons and situations do exist where interruption of immunosuppressive therapies is advisable in the context of COVID-19. These situations and the preferred actions are illustrated in the current guidelines of national and international societies.5 7 8 As specific evidence for SARS-CoV-2 is currently still low, most of the guidance in these recommendations is based on analogies to other viral infections and common thoughts on providing care and caution. The association of particular social characteristics with discontinuation of medication for non-clinical reasons as found by Fragoulis is worrisome in this regard. Rheumatology societies should be encouraged to increase their efforts to educate physicians and patients with a particular focus on the risk of unjustified discontinuation of therapy solely because of fear for infection with SARS-CoV-2.



  • Handling editor Josef S Smolen

  • Contributors All authors wrote and revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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  • Correspondence
    George E Fragoulis Gerasimos Evangelatos Aikaterini Arida Vasiliki-Kalliopi Bournia Kalliopi Fragiadaki Anastasios Karamanakos Evrydiki Kravvariti Katerina Laskari Stylianos Panopoulos Maria Pappa Maria G Tektonidou Petros P Sfikakis