Table 1

EULAR provisional recommendations for the management of rheumatic musculoskeletal diseases in the context of SARS-CoV-2—April 2020 version

Overarching principlesLoA
Mean±SD≥8/10 (%)
1.To date, there is no evidence that patients with RMD face more risk of contracting SARS-CoV-2 than individuals without RMD, nor that they have a worse prognosis when they contract it.9.1±1.284
2.The diagnosis and treatment of COVID-19 in patients with RMD is the primary responsibility of an expert in treating COVID-19, such as a pulmonologist, an internist or a specialist in infectious diseases, dependent on local circumstances.9.3±1.384
3.Rheumatologists are the leading experts for the immunosuppressive treatments of their patients and should be involved in the decision to maintain or discontinue them.9.2±2.489
4.The knowledge about immunosuppressive treatments, including sDMARDs and bDMARDs, for the treatment of severe COVID-19 is rapidly evolving. In view of their expertise, rheumatologists should make themselves available for local-hospital, regional or national guideline committees for COVID-19. The use of immunosuppressive drugs for the treatment of COVID-19 should be a multidisciplinary decision.9.3±1.484
5.Availability and distribution of, and access to, sDMARDs and bDMARDs for the treatment of patients with RMD as well as for patients with COVID-19 (but without RMD) is a delicate societal responsibility. Therefore, the off-label use of DMARDs in COVID-19 outside the context of clinical trials should be discouraged.8.9±1.289
1.Patients with RMD should be strongly advised to comply with all preventive and control measures prescribed by the health authorities in their countries.9.9±0.595
2.Patients with RMD should in general be advised to comply with the same preventive and control measures as patients without RMD.9.3±1.089
3.Patients with RMD who do not have suspected or confirmed COVID-19 should be advised to continue their treatment unchanged, namely NSAIDs, glucocorticoids, sDMARDs, bDMARDs, osteoporosis medications and analgesics, among others.9.6±0.694
4.If the RMD and its drug treatment are stable, and signs or symptoms of drug toxicity are absent, regular blood monitoring and face-to-face rheumatology consultations can be postponed temporarily. If necessary, consultation can take place remotely.9.6±0.994
5.If the RMD is active, if drug therapy has recently been started or needs adjustment, or if signs or symptoms of drug toxicity emerge, patient and rheumatologist should liaise, weigh the risks of a visit to the clinic against the limitations of remote advice and decide together.9.7±1.089
6.If a patient with RMD is offered an outpatient, day care or other type of hospital appointment, patients and members of the rheumatology team should follow local guidance for infection prevention and control, including the use of personal protection equipment if indicated.9.9±0.294
7.Patients with RMD without COVID-19 symptoms who have been in contact with a SARS-CoV-2-positive person should be tested for SARS-CoV-2 themselves.8.0±2.563
8.If a patient with RMD and symptoms of COVID-19 is chronically treated with glucocorticoids, this treatment should be continued.8.8±1.679
9.If patients with RMD experience mild* symptoms of COVID-19, potential treatment changes in DMARDs should be discussed on a case-by-case basis.8.9±1.484
10.Patients with RMD and initially mild symptoms who experience worsening† of COVID-19 symptoms should immediately seek further healthcare advice of an expert in treating COVID-19, such as a pulmonologist, an internist or a specialist in infectious diseases, dependent on local circumstances.9.8±0.594
11.Patients with RMD who are admitted to the hospital because of significant†, ‡ COVID-19 should follow local treatment recommendations for COVID-19 as applied by the treating expert.9.7±0.889
12.Patients with RMD without symptoms of COVID-19 should be advised to update their vaccination status in accordance with the EULAR recommendations for the vaccination of patients with RMD, with a particular focus on pneumococci and influenza.9.4±1.089
13In patients with RMD treated with cyclophosphamide or glucocorticoids, Pneumocystis Jiroveci pneumonia prophylaxis should be considered.9.3±0.989
  • *See definition of mild symptoms in box 2.

  • †See definition of worsening in box 2.

  • ‡See definition of significant COVID-19 in box 2.

  • bDMARD, biologic disease modifying antirheumatic drug; EULAR, European League Against Rheumatism; LoA, level of agreement; NSAID, non-steroidal anti-inflammatory drug; RMD, rheumatic and musculoskeletal diseases; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; sDMARD, synthetic disease modifying antirheumatic drug.