Children with rheumatic disease who are at high risk for chronic uveitis, or have a history of uveitis, should continue to receive routine ophthalmologic surveillance on schedule through in-person visits, with slit lamp examination, according to COVID-19 clinical guidance from the American College of Rheumatology.
The ACR announced the “COVID-19 Clinical Guidance for Pediatric Patients with Rheumatic Disease” on Thursday, alongside another set of guidance for pediatric patients with multisystem inflammatory syndrome associated with COVID-19. Both documents are pending journal peer review.
“COVID-19 has had a profound effect on so many lives and has contributed to at least 400,000 deaths worldwide,” Jay Mehta, MD, MS, of the Children’s Hospital of Philadelphia, who oversaw the task force that drafted the guidelines, told Healio Rheumatology. “Although children have not been as affected as adults during this crisis, there is still concern from the patients, their families and their pediatric rheumatology providers about the potential impact the virus may have due to underlying rheumatic disease, and the medications they are taking.”
“Fortunately, the data suggest that children with a rheumatic disease on immunosuppressants are not getting sicker than other children without a rheumatic disease,” he added. “There are also questions about whether the children can attend summer camp and return to school in the fall. The Pediatric Rheumatic Disease Clinical Guidance document aims to help providers answer some of these questions for patients and their families.”
To provide clinical guidance to rheumatologists who treat pediatric patients against the background of the ongoing COVID-19 pandemic, Mehta and colleagues established the North American Pediatric Rheumatology Clinical Guidance Task Force in May. According to ACR, this task force included seven pediatric rheumatologists, two pediatric infectious disease physicians, one adult rheumatologist and one pediatric nurse practitioner. First, members drafted clinical questions based on a review of commonly found queries from patients, families, and rheumatology providers of children with rheumatic diseases during the COVID-19 pandemic.
The task force then developed an evidence report based on a comprehensive review of the literature. Members voted anonymously on initial questions and subsequent statements in three rounds using a modified Delphi approach. The panel gathered in three webinars to further discuss these statements and reach consensus. Final voting was completed using a 9-point numeric scoring system with predefined levels of agreement and consensus. To be approved as a guidance statement, median votes were required to fall into the highest tertile for agreement with “moderate” to “high” levels of consensus.
The clinical guidelines include 27 recommendations. They are grouped by topic, and cover ongoing treatment for patients at varying degrees of COVID-19 exposure, including asymptomatic and symptomatic infection. Among the general guidelines is a recommendation that patients at high risk for chronic uveitis, or with a history of uveitis, continue with scheduled, in-person visits with slit-lamp examination. Children with rheumatic disease should also continue to receive routine childhood vaccinations, unless contraindicated by DMARD therapy, including the annual influenza vaccine, according to the guidelines.
Regarding ongoing treatment of patients without COVID-19 exposure or infection, the guidelines state that NSAIDs, hydroxychloroquine, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, colchicine, conventional DMARDs, biologic DMARDs and targeted synthetic DMARDs may be continued or initiated to control underlying disease. Glucocorticoids may also be continued or initiated, using the lowest dose possible to control underlying disease.
Further, for pediatric patients with life- or organ-threatening conditions, high-dose oral or intravenous “pulse” glucocorticoids and cyclophosphamide may be initiated to control underlying disease.
In pediatric patients with ongoing treatment who have had close or household exposure to COVID-19, the initiation of high-dose oral or intravenous glucocorticoids should be delayed for 1 to 2 weeks, if deemed safe by the treating provider, for those with non-life- or organ-threatening conditions. However, high-dose oral or intravenous glucocorticoids should not be delayed for patients with life- or organ-threatening disease.
Regarding the ongoing treatment of pediatric patients with asymptomatic COVID-19, the ACR states that NSAIDs, hydroxychloroquine, colchicine, DMARDs, cyclophosphamide or rituximab may be continued, if necessary, to control underlying disease.
Additionally, in patients with confirmed COVID-19, DMARDs, except IL-1 and IL-6 inhibitors, should be temporarily delayed or withheld. According to the recommendations, IL-1 and IL-6 inhibitors may be continued, if necessary, to control underlying disease.
“Multiple factors must be taken into consideration when interpreting these guidance statements including individual patient characteristics, underlying rheumatic disease, current disease activity, geography and current level of SARS-CoV-2 community transmission, duration and proximity of exposure to SARS-CoV-2 and severity of COVID-19 infection,” read the draft summary of the recommendations. “This guidance is presented as a ‘living document,’ recognizing that the current literature on COVID-19 is rapidly evolving. The ACR anticipates that these guidance statements will be updated as scientific evidence accumulates.”