Rheumatologists as Patient Advocates in the COVID-19 Era

As of early May 2020, the United States had 1.19 million confirmed coronavirus cases and nearly 70,000 deaths due to COVID-19. In the urgent quest for therapeutic solutions, some have looked to antimalarial medications such as hydroxychloroquine (HCQ).

A recent paper in Annals of the Rheumatic Diseases argues that rheumatologists as well as “researchers and patient partners must advocate for the appropriate distribution and use of HCQ, as millions of people with rheumatic diseases worldwide depend on HCQ to control disease activity and maintain quality of life.”

Jeffrey A. Sparks, MD, MMSc, a rheumatologist and population scientist in the Brigham and Women’s Hospital Division of Rheumatology, Inflammation and Immunity, is the corresponding author of “Festina lente: hydroxychloroquine, covid-19 and the role of the rheumatologist.”

“We’re not necessarily recommending that HCQ not be used for COVID-19,” Dr. Sparks said. “But this isn’t an infinite resource, so I would like to see more thoughtful consideration go into using it for COVID-19. As rheumatologists, we have to advocate for our patients so they continue to have access to HCQ and other medications, such as interleukin-1 and interleukin-6 inhibitors, that we know are safe and effective for rheumatic disease.”

Focusing on Rheumatic Disease Patients With COVID-19

Dr. Sparks is a leader for the COVID-19 Global Rheumatology Alliance (GRA), the international group behind the “Festina lente” (which means “make haste slowly” in Latin) paper. The GRA is perhaps best known for its creation of a worldwide clinician case-reporting registry to collect information on outcomes of patients with rheumatic disease who test positive for COVID-19 infection.

The alliance is also compiling patient surveys to ascertain how COVID-19 is affecting care and treatment for rheumatic disease patients. Other components of their mission include systematic reviews and opinion pieces, such as the one in Annals of the Rheumatic Diseases.

“This article is talking about ethics and resource allocation, and how rheumatologists are at the crosshairs of those issues, with respect to HCQ and other rheumatic disease medications that are being considered for COVID-19 treatment and prophylaxis,” Dr. Sparks said.

Protecting the Vulnerable and Maximizing Utility

The paper aims to offer health systems “a structure for approaching the use and distribution of HCQ during the covid-19 pandemic to minimise potential impact on patients with rheumatic disease.”

For Dr. Sparks, one of the foremost priorities must be to protect vulnerable patients—i.e. those at increased risk for poor outcomes. This patient population includes not only those living in underserved communities with disparities, but also those who lack the time, resources and access to secure HCQ.

“Simply increasing the supply of HCQ by itself is not necessarily a solution. It still requires some participation and advocacy on the part of rheumatologists so that the interests of their patients are served,” he said. “The American College of Rheumatology under the direction of president Ellen M. Gravallese, MD [who is also chief of the Brigham’s Division of Rheumatology, Inflammation and Immunity], is a great example of performing that kind of advocacy on the national stage.”

Dr. Sparks also discussed the notion of maximizing utility. While extensive research supports the use of HCQ in rheumatic diseases such as systemic lupus erythematosus and rheumatoid arthritis, the same cannot be said about COVID-19. “If you are going to prioritize a certain patient population, you should probably prioritize one where the safety and efficacy are well-established,” he said.

He added that using HCQ empirically to treat COVID-19 patients under close supervision in the hospital setting could possibly have merit. What is more concerning, he said, is the prospect of its widespread use as a prophylactic measure.

“Everyone is potentially at risk for COVID-19,” Dr. Sparks concluded. “If you are going to start taking HCQ prophylactically, you could be taking it for weeks or months without an obvious end. A two-week course is a lot different than, say, a four-month course. I think safety considerations have to come into play, and certainly the supply issue would be much worse if nearly everyone were taking this medication.”