Autoimmune Rheumatic Disease

in the Era of Covid 19 Pandemic

dr. Dwi B. Darmawati, SpPD-KR

RST. TK II dr. Soedjono Magelang
 Table of Contents

01 02 03
Introduction ARD and Covid 19 Management ARD
patients during
COVID-19
04 05 pandemic

Covid 19 vaccination in Case

patients with ARD
 factor agents, were associated with a lower risk of
hospitalisation and death.
Conclusions Our meta-analysis demonstrated that

1. Introduction
To understand the incidence and p
patients with autoimmune diseases had an increased risk
of COVID-19 in ADs, international
of COVID-19, primarily attributed to glucocorticoid use.
of patients with inflammatory bowel
b/tsDMARDs monotherapy was associated with a lower
(SECURE-IBD registry2) or rheumatic
risk of severe COVID-19 suggesting its safety in the (C19-GRA3) diagnosed with COVID-19 h
Autoimmune Rheumatic Diseases (ARD):
COVID-19 pandemic.
Dysregulation of immune systems which would interfere developed
withandtheanalysed their COVID-19 o
whole
These data have demonstrated that simila
body’s defence mechanism which makes this group prone general to infection
population, age and underlying
bidities are poor prognostic factors of CO
Meta-analysis of INTRODUCTION seven case–controlled studies: risk in of ADs.
COVID-19
4
In terms ofin treatments, both
The outbreak of COVID-19 caused by the novel demonstrated that patients treated with gl
autoimmune
© Author(s) (or their diseases was significantly higher than in control patients (OR:
SARS-CoV-2 has spread worldwide leading to large coids (GCs) had poor clinical outcomes of
2.19) 2021. No
employer(s))
number of infections and deaths.1 Patients with 19, whereas those treated with antitumour
commercial re-use. See rights
and permissions. Published autoimmune diseases (ADs) are frequently treated factor (TNF) therapies, particularly when
by BMJ.
A study of 1641 ASD patients in Italy
with immunosuppressive : definite
or anticytokine drugs,diagnosis of Covid-19
monotherapy, wasrisk of ho
had a decreased
23
recorded
To cite: Akiyama S, which raises
in 11 (0.7%) and concern
highlyforsuspected
infectious complications,
COVID-19tion in due
14 to(0.8%)
COVID-19. These finding
Hamdeh S, Micic D, placing patients and physicians at a crossroads with that anti-TNF monotherapy may be p
autoimmune
et al. Ann Rheum Dis systemic
respectdisease (ASD)
to continuation patients
or cessation but
of these in the
disease Italian population of
against severe COVID-19. However, each
Covid- 19-infectedmodifying
2021;80:384–391. individuals only 0,3%
therapies. registry has a limited sample size. Therefo
384 Akiyama S, et al. Ann Rheum Dis 2021;80:384–391. doi:10.1136/annrheumdis-2020-218946
 of COVID-19, primarily attributed to glucocorticoid use.
of patients with inflammatory bo
b/tsDMARDs monotherapy was associated with a lower
(SECURE-IBD registry2) or rheuma
risk of severe COVID-19 suggesting its safety in the (C19-GRA3) diagnosed with COVID-1
COVID-19 pandemic. developed and analysed their COVID-1
These data have demonstrated that si
COVID-19 may have various manifestations. general population, age and underly
Populations at risk and are likely to develop severe bidities are poor prognostic factors of
clinical INTRODUCTION
outcome are older age, male sex, and those in ADs.4 In terms of treatments, bo
who have The comorbidities
outbreak of COVID-19 caused by the novel demonstrated that patients treated with
(30-50%)
r(s) (or their
SARS-CoV-2 has spread worldwide leading to large coids (GCs) had poor clinical outcomes
(s)) 2021. No
ial re-use. See rights number of infections and deaths.1 Patients with 19, whereas those treated with antitum
On theautoimmune
missions. Published diseases (ADs)risk
whole, increased are frequently
to worse treated
COVID-19
factor (TNF) therapies, particularly wh
diseasewith immunosuppressive
outcomes may beor observed
anticytokine indrugs, monotherapy, had a decreased risk of
immune-
Akiyama S, compromised which raises concern for infectious complications, tion due to COVID-19.2 3 These find
patients.
h S, Micic D, placing patients and physicians at a crossroads with that anti-TNF monotherapy may be
nn Rheum Dis respect to continuation or cessation of these disease against severe COVID-19. However, e
0:384–391. modifying therapies. registry has a limited sample size. The
Akiyama S, et al. Ann Rheum Dis 2021;80:384–391. doi:10.1136/annrheumdis-2020-218946
 02
Autoimmune Rheumatic Disease
and Covid 19
 RA
SLE SS

ARD

Scl
 RESPON IMUN PADA INFEKSI SARS-CoV-2

Respons imun pada viral load

rendah
Viral load
rendah

Respons imun bawaan Respons imun

(innate) adaptif

Viral load
RESPON tinggi atau
ada komorbid
IMUN

Respons imun bawaan Respons imun

(innate) adaptif
Gambar 1.Respons imun pada Infeksi SARS-CoV-2. 17-22
 AUTOIMMUNE DISEASES
and hypoxemia occur in severe cases. In critical Autoimmune diseases are characterized by the exis-
cases, the disease progresses rapidly and patients tence of autoantibodies and perpetuated inflamma-
can develop septic shock and multiorgan dysfunc- tory reactions due to the loss of immune tolerance

Similarities in immune responsis between COVID-19 and

tion [10]. As such, COVID-19 can be a systemic
disease affecting multiple organ systems, including
and dysregulated immune system, leading to target
organ damage and malfunction [15]. These

Autoimumune diseases
the skin, kidneys, respiratory system, cardiovascular
system, digestive system, nervous system and
immune-mediated injuries also exist in COVID-19
(Fig. 1). Infection with SARS-CoV-2 induces immune

FIGURE 1. Similar immune reactions in SARS-CoV-2 infection and autoimmune diseases. Both COVID-19 and autoimmune
COVID-19 and autoimmune diseases Liu et al. 2021
diseases present with various clinical symptoms involving different organs and systems, such as the haematological system,
Similarities in immunopathogenesis of COVID-19 and
Immunopathogenesis and treatment of autoimmune diseases
autoimmune diseases
Table 1. Similarities in immunopathogenesis of COVID-19 and autoimmune diseases

Items COVID-19 immunological features similar to Refs.

Innate immune cells
Adaptive immune cells
Cytokines and chemokines
Autoantibodies
autoimmune diseases
Overactivation of monocytes, macrophages, mast cells [12,27,2
and neutrophils. Increased proportion of mature
natural killer (NK) cells.
Decreased T-cell numbers, altered B-cell subsets, [17,30,3
dysregulation of T cells and B cells.
Increased levels of IL-1, IL-2, IL-6, IL-8, IL-10, IL-17, IL- [22–24]
18, CXCL10, CCL2.
ANA, APL, lupus anticoagulant, cold agglutinins, anti- [14,51 ,
&

Ro/SSA antibodies, anti-Caspr2 antibody, anti

Clinical conditions
Other immunopathogenesis
GD1b antibody, anti-MOG antibody
Immune-mediated haemolysis, decreased white blood [25,28,5
cell counts, cytokine storm syndrome, macrophage
activation syndrome, procoagulant condition
Increased levels of DAMPs, molecular mimicry [26,46]
 COVID-19 and autoimmune diseases Liu et a
AUTOANTIBODIES IN PATIENTS WITH COVID-19
Table 2. Autoantibodies detected in patients with COVID-19

Autoantibodies Clinical significance Refs.

ANA Poor prognosis and a significant higher respiratory rate [14]

APL Poor prognosis and a significant higher respiratory rate [14,52
Possible association with a hyperinflammatory state and thrombosis and thromboembolism
Lupus anticoagulant A higher rate of thrombosis [51 ]
&

Cold agglutinins Haemolytic anaemia. [55,58

Complicating laboratory assessment and renal replacement therapy
Anti-Ro/SSA antibodies Possible association with severe pneumonia [56]
Anti-Caspr2 antibody Unclear [54 ]
&

Anti-GD1b antibody Unclear [54 ]

&

Anti-MOG antibody Unclear [53]

Red cell bound antibodies Associated with the severity of anaemia [57]

antibodies (IgG and/or IgM) (9%). However, ANCA higher than that in non-COVID-19 controls. Th
 03
Management ARD patients during
COVID-19 pandemic
 navirus 2 (SARS-CoV-2), the virus, and the disease
caused by SARS-CoV-2, COVID-19. They address
the implications for patients with rheumatic and
musculoskeletal diseases (RMD). They have been
commissioned by EULAR, and developed under its
auspices, in order to guide both rheumatologists and
health professionals in rheumatology (HPR) who
care for patients with RMD, COVID-19-treating
EULARas wellprovisional
to provide provisional guidance for rh
HPR and patients with RMD. Althoug
was hampered by restrictions of soc
preventing them to meet in person—it
complete process successfully by video
EULAR is committed, in contrast
procedures, to consider this set of rec
Recommendation
as a ‘living document’ and a starting po
recommendations forupdated
the as soon as promising new

Ann Rheum Dis: first published as 10.1136/annrheumdis-2020-21

physicians as patients with RMD themselves be
and their family members. with potential impact on the care o
management of rheumatic
Many (inter)national professional organisations and musculoskeletal
RMD become available. These develo
diseasesandinbeyond,
in rheumatology the context as well as of SARS-
government CoV-2monitored closely, their quality judge
bodies, have issued guidance documents pertaining EULAR methodologists and, after fur
1,2 3
to the Robert BM Landewé
prevention, diagnosis, Pedro M Machado
and treatment, Félineof Kroon ,4
in the task force, included in an upda
(or their 5 6 7 8
the recommendations when appropria
) 2020. No SARS-CoV-2Hans WJ Bijlsma,
infection Gerd and
R Burmester,
COVID-19. Loreto Carmona,
Since Bernard Combe,
9 10,11 12 13
re-use. See rights generic Massimo Galli, Laure Gossec
recommendations do not ,focus Annamaria Iagnocco, John D Isaacs ,
on patients
14,15 16
sions. Published with RMD XavierandMariette, Iain McInnes, EULAR
their circumstances, Ladner,17 Peter
Ulf Mueller-consid- Openshaw,18
PROCEDURES
19 20
Josef S Smolen,
ered it essential Tanja A Stamm
to provide Dieter Wiek,21 Hendrik
a set of, recommenda- Schulze-
Focus ofKoops
22
recommendations
andewé RBM, tions that are applicable to all rheumatologists and These recommendations pertain to
Handling editor David S ABSTRACT
HPRs and their patients with RMD in ByEULAR less restrictive than EULAR recommendations.
ment of patients with RMD in
PM, Kroon F,Pisetsky
The provisional EULAR recommendations address several no means EULAR intends to overrule existing
Rheum Dis countries. Guidelines
aspects issued
of severe acute respiratory by coronavirus
syndrome national guidelines
(profes- current
at the country level ofSARS- CoV-2 epidemic an
EULAR member
51–858. For numbered affiliations see
end of article. sional) organisations
2 (SARS-CoV-2), the virus,can occasionally
and the disease caused by be states.
moreEULAR or only quent
aims toCOVID-19 disease may interf
provide a synthesis
SARS-CoV-2, COVID-19 and are meant for patients with of the best available aggregated expert opinion to
Correspondence to Landewé rheumatic
RBM,and musculoskeletal
et al. Ann Rheum diseases (RMD) and their
Dis 2020;79:851–858. inform rheumatologists and HPR and patients with
doi:10.1136/annrheumdis-2020-217877
Professor Robert BM Landewé, caregivers. A task force of 20 members was convened RMD about management decisions to be taken in
Amsterdam Rheumatology by EULAR that met several times by videoconferencing the context of the SARS-CoV-19 epidemic.
 navirus 2 (SARS-CoV-2), the virus, and the disease to provide provisional guidance for rh

j.com/ on July 24, 2021 by guest. Protected by copyright.

caused by SARS-CoV-2, COVID-19. They address HPR and patients with RMD. Althoug
t about using the term ‘immu-
was hampered by restrictions of soc
mmunomodulatory’. Thethe taskimplications for patients with rheumatic and
Box 2 Symptoms
musculoskeletal diseasesof(RMD).COVID-19 They have been preventing them to meet in person—it
e term ‘immunosuppressive’,
commissioned by EULAR, and developed under its complete process successfully by video
ion of inappropriate suppres-
auspices, *Mild symptoms of COVID-19:
in order to guide both rheumatologists and EULAR is committed, in contrast
ads to the discontinuation of
health ► These include symptoms of common cold, such as sore procedures, to consider this set of rec
. Still, some of them do not professionals in rheumatology (HPR) who
throat, running
care for patients with nose,RMD, nasal congestion,
COVID-19- anosmia or dysgeusia,
treating as a ‘living document’ and a starting po
em (eg, hydroxychloroquine
MARDs that target cytokines physicians asfatigue,
well generalised
as patients or local
with myalgia,
RMD arthralgia without be updated as soon as promising new
themselves
clinical swelling, anorexia, diarrhoea, as well as temperaturewith potential impact on the care o
f the immune system and whiletheir family members.
elevation (<38°C).professional organisations RMD become available. These develo
Many (inter)national
manipulated.
in rheumatology and beyond, as well as government monitored closely, their quality judge
9% scored 8/10 or higher.
**Worsening
bodies, have of mild COVID-19
issued guidance symptoms:
documents pertaining EULAR methodologists and, after fur
mmunosuppressive treatments,
► This applies when a patient with formerly mild symptoms ofin the task force, included in an upda
the treatment of to
Ds,(orfortheir severethe prevention, diagnosis and treatment of
COVID-19 gets fever ≥38°C or subjective shortness of breaththe recommendations when appropria
)view
2020. their expertise, SARS-
ofNo rheu- CoV-2 infection and COVID-19. Since
or tachypnoea (>20/min)
generic recommendations do notor hypoxia
focus or on
cyanosis.
patients
esre-available
use. See rights
for local-hospital,
for COVID-19.with
sions. Published
mmittees The RMD and their circumstances, EULAR consid- PROCEDURES
***Significant
ered it essential symptomsaofset
to provide COVID-19:
of recommenda- Focus of recommendations
r the treatment of COVID-19
► These include all of the above, but
tions that are applicable to all rheumatologists and accompanied by fever These recommendations pertain to
on.
andewé RBM,
PM, Kroon F, (≥38°C) or subjective shortness
HPRs and their patients with RMD in EULAR of breath or tachypnoea ment of patients with RMD in
OP3, but addresses the matter
Rheum Dis (>20/min) or hypoxia or cyanosis. current SARS-CoV-2 epidemic an
edges
51–858. the practice that countries.
some Guidelines issued by national (profes-
sional) organisations can occasionally be more or quent COVID-19 disease may interf
Landewé RBM, et al. Ann Rheum Dis 2020;79:851–858. doi:10.1136/annrheumdis-2020-217877
Landewé RBM, et al. Ann Rheum Dis 2020;79:851–858. doi:10.1136/annrheumdis-2020-217877
General measures and prevention of sARs-CoV-2 infection

Patients with RMD should be strongly advised to comply with all

RC.1 preventive and control measures prescribed by the health authorities in
their countries.

RC.2 Patients with RMD should in general be advised to comply with the same
preventive and control measures as patients without RMD.

RC.3 Patients with RMD who do not have suspected or

confirmed COVID-19 should be advised to continue their
treatment unchanged, namely NSAIDs, glucocorticoids
(GCs), sDMARDs, bDMARDs, osteoporosis medications
and analgesics, among others.
 A. Pencegahan terhadap risiko terpapar Infeksi Covid-19 pada pasien penyakit
reumatik autoimun

Gambar 2 Alur Pencegahan Terjangkit SARS-CoV-2 pada pasien Penyakit Reumatik Autoimun
Dimodifikasi dari NHS Cambridge University Hospital Coronavirus/ COVID 19 risk advice for patients on immune-suppressing
medications. 51,69

Management of CoVId-19 in the context of RMD
Patients care
RC.7
with a SARS-CoV-2-positive
themselves
RC.8
© Author(s) (or their
employer(s)) 2020. No
commercial re-use. See rights generic recommendations do not focus on patients
and permissions. Published
by BMJ.
To cite: Landewé RBM,
RC.9
Machado PM, Kroon F,
et al. Ann Rheum Dis
2020;79:851–858.
navirus 2 (SARS-CoV-2), the virus, and the disease to provide provisional gu
caused by SARS-CoV-2, COVID-19. They address HPR and patients with RM
the implications for patients with rheumatic and was hampered by restri
musculoskeletal diseases (RMD). They have been preventing them to meet
commissioned by EULAR, and developed under its complete process success
auspices, in order to guide both rheumatologists and EULAR is committed
health professionals in rheumatology (HPR) who procedures, to consider t
with for
RMD without COVID-19 symptoms treating
who haveasbeen incontact
a ‘living document’ and
patients with RMD, COVID-19-
personwith
physicians as well as patients should
RMD bethemselves
tested for be SARS-CoV-2
updated as soon as pr
and their family members. with potential impact on
Many (inter)national professional organisations RMD become available.
in rheumatology and beyond, as well as government monitored closely, their
If a patient
bodies, with RMD
have issued and documents
guidance of COVID-19EULAR
symptoms pertaining is methodologists a
to the prevention,
chronically treateddiagnosis
with GCs,and treatment
this
SARS-CoV-2 infection and COVID-19. Since
continued.
treatment in the task
of should be force, include
the recommendations wh
with RMD and PROCEDURES
If their circumstances,
patients with RMDEULAR consid-mild*
experience symptoms
ered it essential to provide a set of recommenda-
of COVID-19, potential treatment changes in
tions that are applicable to all rheumatologists and
DMARDs should be discussed on a
Focus of recommendati
These recommendation
case-by-case
HPRs and their patients with RMD in EULAR ment of patients wit
basis. issued by national (profes- current SARS-CoV-2
countries. Guidelines
sional) organisations can occasionally be more or quent COVID-19 diseas
Landewé RBM, et al. Ann Rheum Dis 2020;79:851–858. doi:10.1136/annrheumdis-2020-217877
 navirus 2 (SARS-CoV-2), the virus, and the disease to provide provisional gu
caused by SARS-CoV-2, COVID-19. They address HPR and patients with RM
the implications for patients with rheumatic and was hampered by restri
musculoskeletal diseases (RMD). They have been preventing them to meet
Patients with RMD andbyinitially
commissioned EULAR,mildandsymptoms
developed who
underexperience
its complete process success

RC.10 worsening** of COVID-19

auspices,
health
healthcare
symptoms
in order to
professionals
advice
guide bothshould
of an expert
immediately
rheumatologists
in rheumatology
in treating(HPR)
and seek
who such
COVID-19,
EULAR
further
procedures,
is committed
as a to consider t
care for as a ‘living document’ and
pulmonologist, an patients
internistwith
or aRMD, COVID-19-
specialist treatingdiseases,
in infectious
physicians as well as patients with RMD themselves be updated as soon as pr
dependent on local circumstances. with potential impact on
and their family members.
Many (inter)national professional organisations RMD become available.
in rheumatology and beyond, as well as government monitored closely, their
bodies, have issued guidance documents pertaining EULAR methodologists a
Patients with RMD who are admitted to the hospital because
RC.11
© Author(s) (or their
employer(s)) 2020. No
toof the
SARS-
prevention, diagnosis and treatment
CoV-2 infection and COVID-19. Since
recommendations for COVID-19 as applied
of
significant COVID-19 should follow local treatment
by
in the task force, include
the recommendations wh
the treating
commercial re-use. See rights generic recommendations do not focus on patients
and permissions. Published expert.
with RMD and their circumstances, EULAR consid- PROCEDURES
by BMJ. ered it essential to provide a set of recommenda- Focus of recommendati
To cite: Landewé RBM, tions that are applicable to all rheumatologists and These recommendation
Machado PM, Kroon F, HPRs and their patients with RMD in EULAR ment of patients wit
et al. Ann Rheum Dis countries. Guidelines issued by national (profes- current SARS-CoV-2
2020;79:851–858. sional) organisations can occasionally be more or quent COVID-19 diseas
Landewé RBM, et al. Ann Rheum Dis 2020;79:851–858. doi:10.1136/annrheumdis-2020-217877
Arthritis & Rheumatology
Vol. 0, No. 0, Month 2020, pp 1–12
DOI 10.1002/art.41596
© 2020, American College of Rheumatology

American College of Rheumatology Guidance for the

Management of Rheumatic Disease in Adult Patients
During the COVID-19 Pandemic: Version 3
Ted R. Mikuls,1 Sindhu R. Johnson,2 Liana Fraenkel,3 Reuben J. Arasaratnam,4 Lindsey R. Baden,5
Bonnie L. Bermas,4 Winn Chatham,6 Stanley Cohen,7 Karen Costenbader,5 Ellen M. Gravallese,5 Andre C. Kalil,8
Michael E. Weinblatt,5 Kevin Winthrop,9 Amy S. Mudano,6 Amy Turner,10 and Kenneth G. Saag6

Due to the rapidly expanding information and evolving evidence related to COVID-19, which may lead to
modification of some guidance statements over time, it is anticipated that updated versions of this article
will be published, with the version number included in the title. Readers should ensure that they are con-
sulting the most current version.

RESULTS
Of the 81 guidance statements considered in round 2 vot-
ing, 77 received median vote ratings of 7, 8, or 9 and were also
(results of re-voting shown in Supplementary Table 8, on the
Arthritis & Rheumatology website at http://onlinelibrary.wiley.com/
doi/10.1002/art.41596/abstract).
Evidence supporting the final recommendations was uni-
versally of very low quality: either indirect and/or limited to case

Table 3. Guidance for ongoing treatment of patients with stable rheumatic disease in the absence of infection or
known SARS–CoV-2 exposure and in patients with SLE*
Level of task
Guidance statement force consensus
Ongoing treatment in patients with stable rheumatic disease
HCQ/CQ, SSZ, MTX, LEF, immunosuppressants (e.g., tacrolimus, CSA, MMF, AZA), biologics, JAK Moderate to high
inhibitors, and NSAIDs may be continued. (This includes patients with GCA with an indication,
in whom IL-6 receptor inhibitors should be continued, if available.)
Denosumab may still be given, extending dosing intervals to no longer than every 8 months, if Moderate
necessary to minimize health care encounters.
For patients with a history of vital organ–threatening rheumatic disease, immunosuppressants Moderate
should not be dose-reduced.
Treatment of SLE
For patients with newly diagnosed disease, HCQ/CQ should be started at full dose, when High
available.
For pregnant women with SLE, HCQ/CQ should be continued at the same dose, when available. High
If indicated, belimumab may be initiated. Moderate
* SARS–CoV-2 = severe acute respiratory syndrome coronavirus 2; SLE = systemic lupus erythematosus; HCQ =
hydroxychloroquine; CQ = chloroquine; SSZ = sulfasalazine; MTX = methotrexate; LEF = leflunomide; CSA = cyclosporin
A; MMF = mycophenolate mofetil; AZA = azathioprine; NSAIDs = nonsteroidal antiinflammatory drugs; GCA = giant cell
arteritis; IL-6 = interleukin-6.
status. Available evidence is summarized below, organized by with COVID-19 that are specific to rheumatic disease. Bas
risk assessment, infection prevention, and rheumatic disease preliminary retrospective cohort studies (11–14), risk facto
treatments. poor outcome with COVID-19 include older age (e.g., >65

Table 5. Guidance for the treatment of rheumatic disease following known SARS–CoV-2 exposure and in the context of active or presum
COVID-19*
Level of task fo
Guidance statement consensus
Following SARS–CoV-2 exposure
SSZ and NSAIDs may be continued. Moderate to hi
HCQ/CQ, immunosuppressants (e.g., tacrolimus, CSA, MMF, AZA), non–IL-6 biologics, and JAK inhibitors should be Moderate to hi
stopped temporarily, pending 2 weeks of symptom-free observation.†
In select circumstances, as part of a shared decision-making process, IL-6 receptor inhibitors may be continued. Moderate
Documented or presumptive COVID-19
Regardless of COVID-19 severity, HCQ/CQ, SSZ, MTX, LEF, immunosuppressants, non–IL-6 biologics, and JAK inhibitors Moderate to hi
should be stopped or withheld.
For patients with severe respiratory symptoms, NSAIDs should be stopped.‡ Moderate
In select circumstances, as part of a shared decision-making process, IL-6 receptor inhibitors may be continued. Moderate
Reiniating treatment following COVID-19
For patients with uncomplicated COVID-19 infections (characterized by mild or no pneumonia and treated in the High
ambulatory setting or via self-quarantine), consideration may be given to restarting rheumatic disease treatments
(e.g., DMARDs, immunosuppressants, biologics, and JAK inhibitors) within 7–14 days of symptom resolution. For
patients who have a positive PCR test result for SARS–CoV-2 but are (and remain) asymptomatic, consideration
may be given to restarting rheumatic disease treatments (e.g., DMARDs, immunosuppressants, biologics, and JAK
inhibitors) 10–17 days after the PCR result is reported as positive.
Decisions regarding the timing of reinitiating rheumatic disease therapies in patients recovering from more severe High
COVID-19–related illness should be made on a case-by-case basis.
* SARS–CoV-2 = severe acute respiratory syndrome coronavirus 2; COVID-19 = coronavirus disease 2019; HCQ = hydroxychloroquine
chloroquine; SSZ = sulfasalazine; NSAIDs = nonsteroidal antiinflammatory drugs; CSA = cyclosporin A; MMF = mycophenolate mofetil;
azathioprine; IL-6 = interleukin-6; MTX = methotrexate; LEF = leflunomide; DMARDs = disease-modifying antirheumatic drugs; PCR = polym
 Tabel 5. Rekomendasi tatalaksana farmakologi penyakit reumatik autoimun pada masa pandemi COVID-19

No Nama obat Pasien tanpa gejala infeksi Pasien tanpa gejala infeksi Pasien dengan gejala infeksi Pasien terkonfirmasi COVID-19
COVID-19 dan tanpa kontak dengan kontak erat positif COVID-19 namun status infeksi
erat kasus COVID-19 COVID-19 belum terkonfirmasi
Aktivitas penyakit Pasien Remisi Moderate Pasien Remisi Moderate Pasien Remisi Moderate Pasien Remisi Moderate
reumatik-autoimun baru /low -high baru /low -high baru /low -high baru /low -high
disease disease disease disease disease disease disease disease
activity activity activity activity activity activity activity activity
1. NSAID @
2. Kortikosteroid ^ ^ $ ^ # $ ^ # $ ^ #
3. HCQ/CQ
4. Methotrexate
5. Sulfasalazine
6. Leflunomide
7. MMF
8. MPA
9. Azathioprin
10. Siklosporin
11. Siklofosfamid
12. Anti TNF-α
13. Anti IL-6 + + + + + +
14. Anti IL-17
15. Anti IL-12/23
16. Rituximab
17. IVIG
18. Takrolimus
19. Mesalazin
20. ACEI/ARB
Warna hijau: obat-obatan dapat diberikan/dilanjutkan
Warna kuning: pemberian obat-obatan mempertimbangkan rasio manfaat-risiko kasus per kasus
 04
Covid 19 vaccine in ARD patients
Arthritis & Rheumatology
Vol. 0, No. 0, Month 2021, pp 1–16
DOI 10.1002/art.41877
© 2021, American College of Rheumatology

American College of Rheumatology Guidance for

COVID-19 Vaccination in Patients With Rheumatic and
Musculoskeletal Diseases: Version 2
Jeffrey R. Curtis,1 Sindhu R. Johnson,2 Donald D. Anthony,3 Reuben J. Arasaratnam,4 Lindsey R. Baden,5
Anne R. Bass,6 Cassandra Calabrese,7 Ellen M. Gravallese,5 Rafael Harpaz,8 Andrew Kroger,9
Rebecca E. Sadun,10 Amy S. Turner,11 Eleanor Anderson Williams,12 and Ted R. Mikuls13

Due to the rapidly expanding information and evolving evidence related to COVID-19, which may lead to
General considerations related to COVID-19 vaccination in patients with
RMD*
v 3. AIIRD patients are at higher risk for incident viral infections compared to the general
population.

v 5. Acknowledging heterogeneity due to disease- and treatment-related factors, AIIRD patients

have worse outcomes associated with COVID-19 compared to the general population of similar
age and sex.

v 7. Based on increased risk for COVID-19, AIIRD patients should be prioritized for
vaccination before the nonprioritized general population of similar age and sex.

v 8. Beyond known allergies to vaccine components, there are no known additional

contraindications to COVID-19 vaccination for AIIRD patients.

v 9.The expected response to COVID-19 vaccination for many AIIRD patients receiving
systemic immunomodulatory therapies is likely to be blunted in its magnitude and
duration compared to the general population.
Recommendations for use of the COVID-19 vaccine in RMD
patients*

Vaccine effectiveness/safety

Ø Based on the data for the mRNA COVID-19 vaccines available in the US,
there is no preference for one COVID-19 vaccine over another.‡ Therefore,
AIIRD patients should receive either vaccine available to them.

Ø For a multidose vaccine, AIIRD patients should receive the second

dose of the same vaccine, even if there are nonserious adverse
events associated with receipt of the first dose, consistent with timing
described in CDC guidelines (30).
Table 4. Guidance related to the timing of COVID-19 vaccination in relation to use of immunomodulatory therapies in RMD
patients*
COVID-19 vaccine administration Level of task force
Medication(s) timing considerations consensus
Hydroxychloroquine; sulfasalazine; leflunomide; Do not delay or adjust vaccine administration Strong
apremilast; IVIG timing.
Methotrexate; mycophenolate mofetil; Do not delay or adjust vaccine administration Moderate
azathioprine; cyclophosphamide (IV or oral); timing.
TNFi; IL-6R; IL-1R; IL-17; IL-12/23; IL-23;
belimumab; JAK inhibitors; abatacept (IV or SC);
oral calcineurin inhibitors; GCs (prednisone-
equivalent dose <20 mg/day)†
Rituximab Assuming that a patient’s COVID-19 risk is low Moderate
or able to be mitigated by preventive health
measures (e.g., self-isolation), schedule
vaccination so that the vaccine series is
initiated ~4 weeks prior to next scheduled
rituximab cycle.
10       | CURTIS ET A

Table 5. Guidance related to the use and timing of immunomodulatory therapies in relation to COVID-19 vaccination administration
in RMD patients*
Immunomodulatory therapy Level of task force
Medication(s) timing considerations consensus
Hydroxychloroquine; apremilast; IVIG; GCs (prednisone- No modifications. Strong
equivalent dose <20 mg/day)
Sulfasalazine; leflunomide; azathioprine; No modifications. Moderate
cyclophosphamide (oral); TNFi; IL-6R; IL-1R; IL-17;
IL-12/23; IL-23; belimumab; oral calcineurin inhibitors;
GCs (prednisone-equivalent dose ≥20 mg/day)†
Mycophenolate Assuming that disease is stable, withhold for Moderate
1 week following each vaccine dose.
Methotrexate Hold methotrexate for 1 week after each of the Moderate
2 mRNA vaccine doses, for those with
well-controlled disease; no modifications to
vaccination timing.
Methotrexate Withhold methotrexate 2 weeks after single- Moderate
dose COVID-19 vaccination, for those with
well-controlled disease.
JAK inhibitors† Withhold JAK inhibitors for 1 week after each Moderate
vaccine dose.
Abatacept (SC) Withhold abatacept both 1 week prior to and Moderate
 Methotrexate Withhold methotrexate 2 weeks after single- Moderate
dose COVID-19 vaccination, for those with
well-controlled disease.
JAK inhibitors† Withhold JAK inhibitors for 1 week after each Moderate
vaccine dose.
Abatacept (SC) Withhold abatacept both 1 week prior to and Moderate
1 week after the first COVID-19 vaccine dose
only; no interruption around the second
vaccine dose.
Abatacept (IV) Time administration so that the first vaccination Moderate
will occur 4 weeks after abatacept infusion
(i.e., the entire dosing interval), and postpone
the subsequent abatacept infusion by 1 week
(i.e., a 5-week gap in total); no medication
adjustments for the second vaccine dose.
Cyclophosphamide (IV) Time cyclophosphamide administration so that Moderate
it will occur ~1 week after each vaccine dose,
when feasible.
Acetaminophen, NSAIDs Assuming that disease is stable, withhold for Moderate
24 hours prior to vaccination (no restrictions
on postvaccination use to treat symptoms).
Rituximab Assuming that patient’s COVID-19 risk is low or is Moderate
able to be mitigated by preventive health
measures (e.g., self-isolation), schedule
vaccination so that the vaccine series is
initiated ~4 weeks prior to next scheduled
rituximab cycle; after vaccination, delay
rituximab 2–4 weeks after final vaccine dose if
disease activity allows.
* Guidance to withhold a therapy was made based on the assumption that the patient had well-enough controlled disease to allow for
a temporary interruption; if not, decisions should be made on a case-by-case basis considering the circumstances involved. For details
05. CASE
Riwayat medis pasien
❏ Nama: Ny. HS
❏ Usia; 48 th

❏ MRS; 20 jan 2021

RPD :
Sejak juni 2020 OS terdx : Rheumatoid arthritis
sero negatif
Tx terakhir: Methotrexate 10 mg / mgg
Asam folat 5 mg/ mgg
Metilprednisolon 4 mg 1-0-0
20 Jan-26 Jan 2021:

RPS : 3 hari lemas PF:

WBC: 114.400–
,tidak ada nafsu makan 4500-1600
MRS: KU lemah , CM
, demam mriang , HGB: 10.3-7,2-7,2
T ; 60/40, N ; 68, Sat :
PLT: 546-182-107
batuk -, sesak –, diare 93%
Ureum : 130.
-, BAK << , kulit Hr 2; KU lemah , GCS;
Cr; 3,1, K ; 6,85
muncul lesi kehitaman 2/2/3, GPT:35, GOT: 76
T; 107/70 on Vascon ,
dilengan dan kaki Rapid antigen : neg
Sat : 90%
Hari 2 perawatan OS Hr 6: KU lemah, CM
PCR: positive
kejang , kesadaran CRP; 29.7
T: 133/73, N ; 100, sat;
menurun Ddimer; > 10000
95 % ANA test : 1/320
Hari 6; sesak nafas,
batuk –sulit menelan ,
Urin keluar
DX:
COVID 19, Pneumonia, Sepsis , Acute renal Failure, susp
CVA, SLE flare?
 31 Jan 2021

Lab:
KU : membaik,
Hb : 7,2
komunikasi baik
AL : 1600
T;:117/77, N ; 102
AT : 88000
Sat : 99% dg nasal
Ureum : 39
kanul
Cr; 0,8

2 Feb 2021
Swab PCR Sars Cov: negatif
21 juli 2021

Keluhan : sesek -, cepet capai <<, demam

-, batuk <<
PF: T 110/70, N; 100, Sat: 99%
Lab :
Ddimer: 2047
LED: 67
Ureum : 24 TX:
Cr; 0,8
AZATHIOPRIN 50 MG 1-0-0
GOT: 40
METHYLPREDNISOLON 4 MG 1-0-0
GPT; 25
Anti SARS Cov 2: 81,82 HIDROKSIKLOROKUIN 200 MG 1x1
Conclusions
Terimakasih

CREDITS: This presentation template was created by

Slidesgo, including icons by Flaticon, and infographics
& images by Freepik.

Please keep this slide for attribution.

My team