Article Text

Ensuring tight control in patients with rheumatoid arthritis treated with targeted therapies during the COVID-19 pandemic using a telehealth strategy
  1. Francesca Ingegnoli1,2,
  2. Gilberto Cincinelli1,2,
  3. Angela Flavia Luppino1,2,
  4. Ennio Giulio Favalli2,
  5. Annalisa Orenti1,3,
  6. Patrizia Boracchi1,3,
  7. Roberto Caporali1,2
  1. 1 Dept. of Clinical Sciences & Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milano, Italy
  2. 2 Dept of Rheumatology & Clinical Sciences, Clinical Rheumatology Unit, ASST Gaetano Pini-CTO, Milano, Italy
  3. 3 Lab of Medical Statistics, Epidemiology and Biometry GA Maccacaro, Milano, Italy
  1. Correspondence to Professor Francesca Ingegnoli, Department of Clinical & Community Science, University of Milano, UNIMI, Milano 20122, Italy; francesca.ingegnoli{at}

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COVID-19 pandemic in its early months has deeply influenced rheumatic patients’ follow-up in terms of treatment adherence, disease control achieved with treat-to-target and tight-control strategies. Nationwide mitigation strategies such as confinement, travel restrictions and inadequate access to routine visits catalysed the rapid switch to remote rheumatologic consultations as an attempt to partially compensate for the decline of in-person outpatient visits.

This observational retrospective study was conducted to establish if the hybrid of in-person and telephone tight-control approach activated by our rheumatology unit in Milan (Italy) during the first lockdown (LD) period has been effective in maintaining remission in patients with rheumatoid arthritis (RA) treated with targeted therapies and to identify potential factors associated with its maintenance.

Data were extracted from a longitudinal observational registry (Eethics Committee 138_1999) including consecutive adult patients with RA treated with biologic or targeted synthetic drugs. During the first pandemic wave, before the visit, rheumatologists provided virtual care handled by telephone to assess the clinical status and to guarantee the absence of current contraindications to therapy. After tele counselling, based on the care required, patients could choose whether to convert the next appointments to a telephone visit and receive drug home delivery or to maintain their standard in-person consultation. For each patient, Clinical Disease Activity Index (CDAI)1 was collected during face-to-face visits. Moreover, difficult-to-treat (D2T) patients with RA according to EULAR definition2 were analysed in this study.

At baseline, 502 patients with RA were eligible for this study and they were followed-up over the first wave of the pandemic. Among these, 91 patients chose drug home delivery, 52 patients failed to complete their follow-up; all the 450 patients who completed the follow-up, were included in the final analysis (online supplemental figure 1S). The median age was 59.4 years (IQR 50.7–68.4), 370 (82.22%) were women, median disease duration was 13.9 years (IQR 7.9–22.5). More details are listed in online supplemental tables 1S and 2S. The CDAI remission rate was 40.22% (n=181) and 43.78% (n=197) during pre-LD and post-LD, respectively. As for the 359 patients who choose in-person visits during LD, 43.18% (n=155) were in remission state according to CDAI (online supplemental table 3S). Although our experience cannot be generalised, these percentages are similar to those of other European cohorts.3 4

To evaluate the effect of LD on the percentage of patients in remission, logistic mixed-effects regression models were fitted, with CDAI remission as a response variable (see online supplemental file for the statistical analysis). The analysis did not show a statistically significant decrease in the percentage of patients fulfilling CDAI remission all along the three periods (online supplemental table 4S). Moreover, the final model (stepwise selection) applied to the multivariate analysis of factors that potentially could interfere with disease control in patients with CDAI remission showed that the probability to be in remission was significantly associated with the male gender, while Hispanic or Asian ethnicity and presence of fibromyalgia showed a decreased odds for remission (table 1). These results confirm characteristics known to be predictive for clinical remission.5

Table 1

Results of the final model (stepwise selection) applied to the multivariate analysis of factors that potentially could interfere with disease control in patients with CDAI remission

Finally, 52 D2T patients with RA were evaluated in a hospital setting pre-LD and post-LD. Among them, 43 choose in-person visit during LD. Median values of CDAI during pre-LD, LD and post-LD were 14.5 (IQR 12–21), 9 (IQR 5.5–16) and 11 (IQR 6–19.2), respectively (online supplemental figure 2S).

Telephone-based tight-control strategy used during the first wave of COVID-19 pandemic ensured satisfactory management of RA treated with targeted therapies, even in D2T patients. Although during normal times, the patient–physician encounter is considered fundamental for rheumatic patients,6 telemedicine was often the only way of practicing in the times of the pandemic.

In conclusion, the current pandemic has dramatically altered patterns of healthcare delivery. Although this temporary virtual approach is currently not spurred by regulatory changes, it seems to be a feasible compensation for face-to-face visits.

Ethics statements

Ethics approval

ethics Committee 138_1999


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Handling editor Josef S Smolen

  • Contributors All authors contributed to study design. FI, FL, GC contributed to data collection. All authors contributed to data analysis and interpretation. PB and AO contributed to statistical analysis. All authors contributed to drafting of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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