Jonna Lorenz

Behcet’s disease can be very difficult to treat and cause devastating effects. But emerging treatments options could offer new hope.

Alvin F. Wells, MD, a rheumatologist with Aurora Health Care in Franklin, WI, shared his perspectives on recent studies of treatments for Behcet’s disease during a webinar hosted by Christopher Parker, DO, a rheumatologist with The Austin Diagnostic Clinic in Texas.

“Expert Perspectives on Management of Rheumatic Diseases: Post ACR Convergence 2020,”

 covered highlights from the American College of Rheumatology’s virtual meeting, ACR Convergence 2020, which was held in November.

Several studies looked at apremilast for treating Behcet’s disease, showing pain improvement and healing, particularly of oral ulcers.

 presented at the event looked at systemic treatment of Behcet’s disease according to clinical phenotypes.

“It can be a very, very difficult disease to treat,” Wells said. “So, before we had drugs like apremilast, we were throwing everything we could at those patients to get them under control. One little caveat to remember is apremilast is used mainly for the oral ulcers and for the pain.”

The study included 111 patients in Northern Spain between 1980 and 2019 diagnosed with definitive or possible Behcet’s disease. All patients required systemic treatment.

“I have residents and fellows who rotate through the clinic and I say, you still need to be familiar with some of these older drugs, because indeed not everybody’s going to respond to these amazing biologic drugs we have. Not everybody’s going to respond to JAK inhibitors,” Wells said.

The study concluded that most patients required oral corticosteroids and colchincine, almost half required conventional immunosuppressants and up to a third required biologic therapy. Twenty-eight patients required biological therapy, indicated most frequently by ocular manifestations and oral ulcers, with adalimumab and infliximab being the most frequently used.

“This is not your skin, this is not your joint, we’re talking about your vision,” Wells said. “We’re going to throw the kitchen sink at it to get this under control, side effects be damned.”

 looked at autologous stem cell transplant for Behcet’s disease.

Such treatment may be considered for very severe cases. The study found that autologous hematopoietic stem cell transplantation is safe and feasible for multi-refractory patients and might stabilize patients with life-threatening disease.

“You’ve got to worry about CMV infection,” Wells said. “You’ve got to worry about other types of infections. You’ve got to worry about other malignancies. So, at the end of the day, if you pull the switch on that, I mean these are sick patients who almost have no option." 

"Cyclophosphamide failed on some of these patients. High dose steroids. TNF drugs have failed," he said. "These are patients who they needed to do something. So, it is an option, but it’s almost like a last-ditch effort to get them under control.”

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The difficult-to-treat disease has a multitude of symptoms to address with a wide spectrum of agents.

Expert Perspectives: Treatment Options for Behcet’s Disease

Treating rheumatic disease during COVID-19 has presented new challenges for rheumatologists along with opportunities for the advancement of new approaches.

Alvin F. Wells, MD, a rheumatologist with Aurora Health Care in Franklin, Wisconsin, shared his perspectives on recent research during a webinar hosted by Christopher Parker, DO, a rheumatologist with The Austin Diagnostic Clinic in Texas.

COVID-19 restrictions left rheumatologists scrambling for ways to evaluate their patients.

“In lieu of a physical exam can we look for other measures to see how patients are responding if they have psoriatic arthritis,” Wells said.

abstract presented at ACR Convergence 2020

, evaluated Routine Assessment of Patient Index Data 3 (RAPID3), which uses patients’ self-reported measures to evaluate disease activity. It included patients in the PALACE 4 study, which assessed the efficacy of apremilast in patients with psoriatic arthritis who haven’t had disease-modifying anti-rheumatic drugs (DMARDs).

The abstract examined trajectories for improving RAPID3 scores along with Clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA).

“The take home message from that abstract shows that, yes, compared to the cDAPSA the RAPID3 score works just as well,” Wells said. “So, fast forward to 2021, I’ve been using that for some of my virtual patients as we see them in the clinic because we’re still not 100% live. I’m about 60% in person, about 40% virtual with my patients in the clinic. So, it’s another tool. Like I said, whether you’re in an academic center or whether you’re in private practice, this is something you can do in lieu of the physical exam.”

RAPID3 includes Health Assessment Questionnaire Disability Index (HAQ-DI) or multidimensional HAQ, pain visual analog scale (VAS) and Patient’s Assessment of Disease Activity (PtGA) VAS.

Wells said physician assistants and nurses play an important role in the assessment, asking questions and collecting information from the patients before he picks up the virtual visit and completes the patient global assessment.

“It can be used in a busy practice and it doesn’t take much time,” he said.

The COVID-19 pandemic also has raised concerns about the risks to patients with rheumatic diseases.

 examined the outcomes of COVID-19 on patients with rheumatic diseases, finding that risk of severe COVID-19 was similar to those without rheumatic diseases in a comparative cohort.

Wells said that while the results were encouraging, the study was small and he encourages patients to submit their names to the Global Rheumatology Alliance patient registry to collect more robust data.

He also noted that prednisone has been found to increase the risk of getting COVID-19 and the risk of hospitalization with the disease, which does not occur with drugs like apremilast, interleukin-6 antagonists or tumor necrosis factor (TNF) drugs.

He encouraged rheumatologists to maintain treatment to reduce the risk of severe COVID-19.

“Because if they flair, to recapture the disease, you’re going to give them prednisone, and when they get prednisone it’s gonna have more side effects,” Wells said. “This is nothing new with the steroids, right? We’ve learned over the years that steroids increase the risk of infections, steroids increase herpes zoster, steroids do a lot of things in addition to all of the other metabolic side effects as well.”

ACR has issued COVID-19 guidance for patients with rheumatic diseases, which Wells called a living document that is likely to change as more data becomes available.

“It gives you all the different scenarios about whether you’re thinking about starting a new therapy, adding a therapy, changing a therapy or somebody who has active infection from that,” Wells said.

Expert Perspectives: COVID-19 Considerations for Rheumatologists

Chest X-Rays Show Racial Disparity in COVID-19 Severity

 are more likely to show increased disease severity and a higher risk of adverse outcomes such as admission to intensive care units and intubation.

The retrospective cohort study, 

, offered further evidence of racial disparities in COVID-19 cases.

Investigators with Harvard Medical School and Massachusetts General Hospital reviewed the electronic medical records of 326 adults hospitalized with COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, from March 27 to April 10 at Massachusetts General Hospital.

Chest X-rays on admission showed increased disease severity among non-white patients. It also found that increased disease severity was associated with delays in seeking medical attention, low English proficiency and obesity.

“Our clinical and research work has offered a sobering reality about the direct impact in health outcomes of the disparities that many vulnerable populations experience every day,” corresponding author Efren J. Flores, MD, department of radiology, Massachusetts General Hospital, told 

®. “Patients who have worse disease on chest X-rays have a higher likelihood of experiencing severe complications from COVID-19. This increased severity and higher risk of complications is in part to a complex multifactorial combination of socioeconomic and medical factors that disproportionately affect our minority communities and result in disparities every day; COVID has magnified these disparities.

“Furthermore, what we saw in clinical practice reading through the patients’ medical notes were many patients delayed their COVID-19 care to continue working at jobs deemed essential in order to provide for their families or due to lack of access to a clinic in their community, negatively affected their overall clinical course and severely impacted their livelihood. This is why it is very important to make care accessible and to share this information of early treatment for all patients and their communities.”

The average age of patients included in the study was 59 years, 57.7% were male, 43% had limited English proficiency and 64.4% were people of color.

Severity of disease was indicated by Modified Radiographic Assessment of Lung Edema (mRALE) scores, which were higher among non-White patients, at an average of 6.1 compared with 4.2 among white/non-Hispanic patients in the study. MRALE scores account for the extent and severity of lung opacities on chest radiographs.

The study found that 31% of white/non-Hispanic patients were admitted to the intensive care unit, compared with 40% of non-white patients. Intubation occurred in 23% of white patients and 34% of non-white patients. Supplemental oxygen was required for 78% of white patients and 73% of non-white patients, and death occurred among 23% of white patients and 9.1% of non-white patients.

“Health equity is everyone's duty,” Flores said. “Collaborations at the intersection of the healthcare system and public health are necessary to address social determinants of health and bridge the disparities gap affecting minority communities as we're seeing with COVID and other diseases.”

He noted that radiology provides insight into health disparities and evidence that minority communities have seen both a higher frequency of COVID-19 infections and greater severity of disease.

“Our purpose is to use this information to document the existing and emerging disparities, but also to use this information to guide health equity and public health efforts that are person-centered and collaborative with the community,” Flores said.

He pointed to a 

 created at the MGH Community Health Center in Chelsea, Mass., to increase COVID-19 testing and collaborate with the Community Health Center to provide information and guidance to better serve vulnerable patients.

“Healthcare and public health sectors need to continue close collaborations to enhance equitable access to care for vulnerable populations, particularly those who live in areas that are considered ‘hot-spots.’” Flores said. “Many of the lessons learned are applicable across the country, as we see that minority communities are disproportionately being affected by COVID.”

Future efforts could focus on providing access to vaccines and treatments for COVID-19 in high-risk areas as they become available along with addressing other health issues exacerbated by the pandemic.

“Long term, we need to focus efforts in areas that are home to people who are not only hardest hit by the pandemic and other medical conditions, but also those who traditionally lack sustainable access to health care,” Flores said. “This includes geographical communities and populations that we know are most vulnerable, including Hispanic, African-American, Native American and other communities of color, individuals with serious mental illness and individuals experiencing homelessness, among others. The pandemic has compounded the risk for these individuals many aspects of routine medical care were postponed, including preventative cancer screening. We will need to ensure robust outreach in collaboration with the public health sector, in particular to the communities previously mentioned, to avoid delays in potentially life-saving care and address some of the social determinants of health that act as barriers to care.”

The study supports other research that has highlighted the disproportionate effect the pandemic has had on racial and ethnic minorities. A study of 

COVID-19 cases and deaths in the New Orleans

 area published in June found that Black Americans are more than twice as likely to be hospitalized and more than twice as likely to die from the disease.

That study followed a survey that showed African American men were at 

. African American survey respondents were 3.2 percentage points more likely to report COVID-19 infection than white survey respondents.

An analysis of chest X-rays suggests people of color are more likely to have increased disease severity.

Racial Disparity in COVID-19 Severity

Emergency Departments See Unprecedented Drop in Visits During COVID-19

,” was originally published on ContagionLive.

 was declared a national emergency, emergency department visits for reasons unrelated to the pandemic drastically decreased.

 from the US Centers for Disease Control and Prevention (CDC), a team of investigators reviewed electronic health data from the National Syndromic Surveillance Program from March 29-April 25, compared with a similar time period a year ago.

The program includes data from all states except Hawaii, South Dakota, and Wyoming.

“The COVID-19 pandemic dramatically changed the number of Americans seeking care in emergency departments,” CDC epidemiologist Kathleen Hartnett, PhD, MPH, told 

. “While the declines were sharpest among children and in regions where the pandemic was most severe, the drop-in visits occurred in all age groups and across the country.”

In the CDC’s history of tracking these data, Hartnett said, there has never been such an observed decline on this scale.

Emergency room visits dropped 42% during the 4-week time period, falling to 1.2 million visits per week from 2.1 million visits per week in 2019. The declines were greatest among children age 14 and younger (71%), females (45%) and those living in the Northeast (49%).

“CDC’s National Syndromic Surveillance Program (NSSP) collects data from emergency departments in real-time, so that allowed state health departments and CDC a critical opportunity to monitor these declines as they happened,” Hartnett told 

. “While we were able to monitor these trends in real-time, the declines we saw remain striking and highlight why it is critical to ensure people have rapid access to medical advice to help them assess when they need to go to an emergency department.”

ED visits hit the lowest point during the week of April 12-18 before beginning to climb.

“Although the number of emergency department visits has steadily increased from the low in April, it remains to be seen how the pandemic will continue to affect people’s decisions about seeking emergency medical care,” Hartnett told 

. “There may be lasting effects in individuals who postpone care for life-threatening conditions such as heart attack and stroke that can lead to death or permanent harm if not treated in time.”

Diagnostic categories that saw noteworthy declines include abdominal pain and related symptoms (-66,456), musculoskeletal pain excluding low back pain (-52,150), essential hypertension (-45,184), nausea and vomiting (-38,536), other specified upper respiratory infections (-36,189), sprains and strains (-33,709), and superficial injuries (-30,918), nonspecific chest (-24,258) and acute myocardial infarction (-1156).

Visits for some diagnostic categories increased, including COVID-19 (17,774); pneumonia not caused by tuberculosis (3911); other lower respiratory disease (1506); respiratory failure, insufficiency, or arrest (776); cardiac arrest and ventricular fibrillation (472).

“It was concerning to see an increase in the number of visits for cardiac arrest and ventricular fibrillation when the number of visits for myocardial infarction and nonspecific chest pain decreased,” Hartnett told 

. “That suggests that some people may be delaying care for life-threatening conditions.”

The report noted that the trend may disproportionately affect people who lack access to primary care and telemedicine. Limitations of the study include changes in hospitals reporting to the NSSP, with an average of 3173 hospitals reporting in April 2019, compared with 3467 in April 2020. There were also limitations in diagnostic codes, which are missing or used inconsistently in some cases.

“Patients need rapid access to medical advice to help them assess when they need to go to an emergency department,” Hartnett told 

. “Wider access is needed to services like triage lines that can help patients identify symptoms that require immediate treatment.”

Hartnett said they hope to see continued expanded services due to the pandemic, while the recommendation remains that unnecessary in-person care continues to be conducted virtually.

“Health care systems can also address public concern about exposure to SARS-CoV-2 in the emergency department through continued adherence to CDC infection prevention and control recommendations, such as immediately screening every person for fever and symptoms of COVID-19, and maintaining separate, well-ventilated triage areas for patients with and without signs and symptoms of the virus,” Hartnett said.

Further analysis of trends in emergency department visits is ongoing.

The effects the pandemic is having on health care services unrelated to the SARS-CoV-2 virus are widespread. Another 

 showed that childhood vaccination coverage has declined sharply during the pandemic.

 on the health care system include an emphasis on telemedicine.

The pandemic dramatically changed the number of patients seeking care in emergency departments.

Jonna Lorenz

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