Recommendations for patients taking immunosuppressive drugs during the COVID-19 pandemic

Dear patient:

The COVID-19 pandemic has forced many western countries, including Switzerland to impose exceptional measures. These are meant to reduce the rate of spread of the virus within the population thereby reducing the pressure on limited hospital resources, keeping them for people hit by COIVD-19 and people at risk. Part or all of these measures will probably be needed for several months, and possibly up to 2 years.

The fact you are taking immunosuppressive drugs places you in one of the risk groups for the COVID virus.

You are already taking precautionary measures and this decreases your risk of catching this virus. However, you should be even more vigilant than usual. The measures proposed by the Swiss government are certainly effective:

- staying home as much as possible

- practicing social isolation (keeping at 1.5 to 2m from other individuals)

- wearing a mask when close to people coughing or in risky locations (such as hospitals) - washing your hands frequently with soap for 2 minutes

- not touching your face if you have not been able to wash your hands

I would add to this :

- wearing gloves when you go shopping (grocery shopping for example). Leather gloves, even ski gloves will do. The virus can survive on plastic and stainless steel surfaces for up to 5 days if not sanitized.

These same precautions apply to all your immediate family members.

If you develop symptoms: fever or a dry cough, contact your GP, go the hospital or contact us. Indicate to hospital personnel that you are on immunosuppressives and tell them which one. Give them our telephone number and our coordinates.

For fever, paracetamol (acetaminophen) is a good treatment. Avoid aspirin and non steroidals such as ibuprofen.

I would also like to make you aware of specific recommendations regarding your immunosuppression.

There are 3 possible scenarios:

A- You are healthy and have not been exposed to COIVD-19:

Your immunosuppression is important to maintain your vision. I will attempt to contact all of you personally to review your need for treatment and the need to maintain the current dose.

To date, neither rheumatologists or ophthalmologists specialized in uveitis have recommended to stop treatment as it could lead to a recurrence of uveitis and a loss of vision. There is also some evidence that a level of immunosuppression may be beneficial in reducing the severity of the most severe form of the infection: respiratory distress syndrome.

Keep your appointment at the clinic, an adequate follow-up remains important. We remain open during this crisis, but consultations are spread throughout the day to avoid crowds in the waiting room. Patients in risk groups are seen in the morning rather than later in the day. People accom- panying you will be asked to wait outside until the consultation is completed.

B- You have been close to a person who was diagnosed with COVID-19:

First of all, this does not mean that you are sick. A close contact does not mean that you have contracted the virus, and is not likely with a contact of less than 15 minutes. However, you should stay home and isolate yourself for 14 days, except for a visit to the doctor. Wear a mask when you leave your home.

Continue your immunosuppresive medications, but contact us. A change in your treatment might be useful in some cases and a closer follow-up will likely be needed. Follow-up will mainly be provided by phone. I would also like to contact your GP at this time to coordinate treatment as needed, should your condition necessitate it.

It may also be necessary to see you in the office to evaluate the state of your eyes. A case by case deicision is required.

C- You have symptoms or contracted COVID-19:

For fever, paracetamol (Dafalgan, Tylenol) is a good drug. Avoid aspirin and non steroidals.

Contact your generalist, and our office. Get confirmation of the diagnosis in a designated center. While COVID-19 may be the likely diagnosis, there are other causes with these symptoms includ- ing the common cold, the flu and influenza.

Since you are in a risk group, indicate this to the screening personnel - tell them you are taking immunosuppression and which one. For patients at risk, the diagnostic test will be carried out earlier, giving us more time to adapt the therapy if needed. Give them also our coordinates.

In case of oral immunosuppressive agents, you recommend that you continue the treatment as is. If you are on corticosteroids (prednisone), we will likely recommend lowering the dose and giving you local treatment in or around the eye. In case of biologics, anti-TNF or others, we need to decide if it is appropriate to switch to an alternative or to continue the treatment as is.

In most cases, the infection is self limiting, and you will be over it in 10 to 14 days. Some will have no symptoms, others will remember it as the worst flu they ever had. Once the episode is past and you are cured of COVID-19, you can go back to your original immunosuppressive dose, if we reduced it.

Patients that ended up requiring respiratory support had often other medical problems: age over 60, cardiovascular or pre-existing pulmonary disease, hypertension requiring treatment, or diabetes.

The situation is constantly evolving. I am in contact with colleagues around the world who also treat patients with uveitis. The recommendations above are based on discussions within the IUSG (International uveitis study group) where I am part of a task force monitoring response to the epidemic. If the measures proposed were to change, you will be promptly informed.

Remain vigilant, stay safe, and it will be with pleasure that we see you again in our clinic. In case of doubt, call us and leave a message. We will be here for you throughout this period, and be- yond.


Marc D. de Smet, MDCM, FMH and his devoted team