American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID‐19 Pandemic: Version 2

Abstract

Objective. To provide clinical guidance to rheumatology providers who treat children with pediatric rheumatic disease (PRD) in the context of the coronavirus disease 2019 (COVID-19) pandemic.Methods. The task force, consisting of 7 pediatric rheumatologists, 2 pediatric infectious disease physicians, 1 adult rheumatologist, and 1 pediatric nurse practitioner, was convened on May 21, 2020. Clinical questions and subsequent guidance statements were drafted based on a review of the queries posed by the patients as well as the families and healthcare providers of children with PRD. An evidence report was generated and disseminated to task force members to assist with 3 rounds of asynchronous, anonymous voting by email using a modified Delphi approach. Voting was completed using a 9-point numeric scoring system with predefined levels of agreement (categorized as disagreement, uncertainty, or agreement, with median scores of 1-3, 4-6, and 7-9, respectively) and consensus (categorized as low, moderate, or high). To be approved as a guidance statement, median vote ratings were required to fall into the highest tertile for agreement, with either moderate or high levels of consensus.Results. To date, 39 guidance statements have been approved by the task force. Those with similar recommendations were combined to form a total of 33 final guidance statements, all of which received median vote ratings within the highest tertile of agreement and were associated with either moderate consensus (n = 5) or high consensus (n = 28).Conclusion. These guidance statements have been generated based on review of the available literature, indicating that children with PRD do not appear to be at increased risk for susceptibility to SARS-CoV-2 infection. This guidance is presented as a "living document," recognizing that the literature on COVID-19 is rapidly evolving, with future updates anticipated.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 consulting the most current version.Guidance developed and/or endorsed by the American College of Rheumatology (ACR) is intended to inform particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to this guidance to be voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. Guidance statements are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidance developed or endorsed by the ACR is subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.

The impact of the COVID-19 pandemic on patients with juvenile idiopathic inflammatory myopathies

“…Despite reassuring data suggesting that children and adolescents with rheumatic disease are not at increased risk of severe outcomes from COVID-19, conventional clinical practice has been for providers to withhold immunosuppressive medications in the context of active infection. Given that symptoms from active COVID-19 can vary widely and there is limited data regarding the impact of immunosuppressive medications on those symptoms, clinical guidance provided by the American College of Rheumatology (ACR) recommends that disease-modifying antirheumatic drugs be held in cases of con rmed symptomatic COVID-19 (14). It is suggested that medications may be restarted 7-14 days after resolution of fever and respiratory symptoms.…”

Impact of COVID-19 on children with rheumatic diseases: a retrospective cohort analysis

“…15 According to the American College of Rheumatology Guidance, the task force unanimously agreed that primary control of underlying rheumatic disease with judicious use of immunosuppressive treatment is of utmost importance, to minimize diseases flares and immune dysregulation. 16 In a cohort of children with rheumatic diseases, biological treatments did not have a negative impact on COVID-19 outcome and the authors recommended that caution should be taken during the infection period because interruption of treatment might exacerbate the rheumatic disease activity. The decision should be taken on individual basis considering the current biological agent, primary disease status, COVID-19 severity, and the available guidelines.…”

The Impact of COVID‐19 on Education and Training in Rheumatology: A Narrative Review

“…The ACR created a COVID-19 Clinical Guidance Task Force to develop and disseminate recommendations on vaccination, treatment for acute infection, and guidance on management of immunosuppressive medications in patients infected with COVID-19. [26][27][28] High-quality data regarding the impact of COVID-19 in rheumatic disease populations were lacking early in the pandemic, creating a vacuum that was often filled with poorly designed studies and resulting misinformation, such as the proposed utility of hydroxychloroquine in the treatment of acute viral infection. Colleagues in the rheumatology community, such as the GRA, offered a helpful counter to claims made in the media and represented a rational voice calling for a cautious, and scientific, approach to investigations regarding COVIDrelated therapies.…”