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With great interest but also some concerns we read the study of Dr Pineda-Sic et al 1 on treatment adherence of patients with inflammatory rheumatic diseases (IRD) during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/COVID-19 pandemic in Latin America. In an anonymous electronic survey of consecutive patients at the rheumatology outpatient clinic of the university hospital in Monterrey, Mexico, the authors requested information about treatment adherence from patients with IRD. From the 345 patients who responded between 14 and 25 May 2020, 293 (85%) had not changed their medication. Importantly, 91.3% of all patients indicated that they knew about the benefits of their treatment.
These data are reassuring, as current guidelines, for example by the German Society of Rheumatology (DGRh eV),2 the European League Against Rheumatism3 or the American College of Rheumatology,4 for the management of patients with IRD during the SARS-CoV-2/COVID-19 pandemic all recommend maintaining antirheumatic therapy in patients with IRD as long as the patients do not show signs of COVID-19. However, adherence to therapy depends on the patients and their individual balance of presumed advantage and feared risk. The study by Pineda-Sic et al 1 nicely demonstrates that patients with IRD regard the benefits of their treatment very high. It is, thus, satisfying to note that the patients’ perspective of continuous treatment matches well with the contention of rheumatology experts that interruption of a clinically efficacious therapy in IRD may be associated with an increased risk of relapse,5 which could lead to the necessity of intensifying immunosuppressive therapy, possibly beyond the original level.
The concern that Dr Pineda-Sic et al’s1 study raises relates to 15% of patients who did modify their antirheumatic medication and the reasons why they did so. While 25% of the patients who changed their medication did so for fear of getting sick from COVID-19, 48.1% had to change treatment for lack of availability of medication. These observations are calling for two reactions. (1) In light of the increasingly apparent fact that patients with IRD are not at an increased risk for infection with SARS-CoV-25 or severe COVID-196 7 even when treated with biologic or targeted synthetic disease-modifying antirheumatic drugs, rheumatologists should be encouraged to increase their efforts to educate patients with a particular focus on the risk of unjustified discontinuation of therapy solely because of fear of infection with SARS-CoV-2. (2) National and international rheumatology societies must make every effort to ensure continuous supply of medication to their patients. In addition to the need to improve the infrastructure of the basic supply of drugs in the future, there should also be ethical discussion on providing patients with chronic diseases with drugs that might prevent infection with SARS-CoV-2 or avoid a severe course of COVID-19 in the general public. To prevent patients with IRD from suffering from harm due to lack of medical care, the use of drugs necessary for patients with IRD in the context of the SARS-CoV-2/COVID-19 pandemic should be the exclusive subject of clinical trials. The use of these drugs outside of controlled clinical trials does not provide reliable data on their relevance in the pandemic and also risks the health of patients, for example those with IRD, who depend on the continued use of these drugs.
Handling editor Josef S Smolen
Contributors HS-K, KK and CS 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.
Provenance and peer review Commissioned; internally peer reviewed.
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