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With great interest, we read the recommendations from the German Society of Rheumatology regarding the management of patients with rheumatic diseases during the COVID-19 pandemic,1 in line with The American College of Rheumatology recommendations2 of continuing immunosuppressive therapy (IT) despite concerns of increased susceptibility to infections, since interruption might trigger an increase in disease activity associated with higher infection risk. Thus, one of the greatest challenges of the COVID-19 pandemic for rheumatologists concerns the patient’s adherence to treatment. Despite rheumatologists agreeing that IT should not be interrupted,1 2 patient’s own beliefs, perceptions and information about their disease influence the behaviour towards treatment adherence. Late in April, Michaud et al reported that patients with rheumatic diseases believed that IT increased their risk of contracting COVID-19 and the severity of the disease and that stopping IT might reduce that risk,3 which led to an urgent request to encourage medication adherence in patients with rheumatic diseases.4
However, a recent article in reply to Schulze-Koops et al demonstrates that despite the fear of contracting COVID-19, most patients with rheumatic diseases are not modifying their treatment. A survey of 500 patients in Greece, during the pandemic period, found that only 2.2% discontinued their disease-modifying antirheumatic drugs due to fear of immunosuppression significantly associated with chronic obstructive pulmonary disease and unemployment.5 To address this concern in our population, we conducted an anonymous electronic survey to determine treatment adherence behaviours during the COVID-19 pandemic, for consecutive patients of the outpatient rheumatology clinic in the Hospital Universitario (Monterrey, Nuevo León, Mexico), which serves a resource-limited population that lack access to health insurance, from five neighbouring states. Responses from patients without an autoimmune disease as diagnosis, of those who lacked knowledge of their medication, and duplicates were excluded.
Between the 14 and 25 May, we received 450 responses of which 105 were excluded. Thus, 345 responses were included for analysis, and the results are detailed in table 1. We found that 85% (n=293) of patients had not changed their medication schemes and that changes in medication schemes were mainly due to lack of availability (48.1%, n=25), followed by fear of contracting COVID-19 (25%, n=13). Regarding the patient’s knowledge of medication, 91.3% (n=355) knew the benefits of their medications, and only 17.7% (n=61) were unaware of the risks of stopping them.
Our results support findings by Fragoulis et al 5 and demonstrate that only a minority of patients (around 15%) are changing medication on concerns of immunosuppression, as compared with the results of Michaud et al in which up to 42% of patients had some change in their medication.3 Issues in medication supply explained changes in 48.1% (25 of 52) of our patients, a higher number than those reported by Fragoulis et al (26%, 19/73), and Michaud et al (10%, 20/197). With a shortage of antimalarials being the most frequently reported issue. Patients are not changing therapeutic regimes due to concern of COVID-19 but because of lack of availability; therefore emphasising that the new challenge for the rheumatologists is not only to encourage medication adherence but to appeal for the patients to have fair and sufficient access to medication.
Twitter @ritapineda_6, @sactMD
Contributors RAPS and DAGD provided the idea and performed the study design. RAPS, GSP and SACT performed the data analysis, interpretation and drafting of the manuscript. RAPS, GSP, DAGD, JAEV, DEFA and IDJHG helped in data acquisition and revised the manuscript for important intellectual content. All authors critically revised and approved the final version of 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.
Provenance and peer review Not commissioned; internally peer reviewed.