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*For medical professionals only
After the opening of the new crown epidemic, the situation of rheumatism patients infected with the new crown is worth paying attention to
.
Written by Jeni
, 2023.
The latest version has adjusted the name of the disease, and renamed "new coronavirus pneumonia" to "new coronavirus infection"
.
For the infection with the new coronavirus, our rheumatism patients should be treated as a top priority, raise their spirits, be prepared, and never take it lightly
.
This article answers the four aspects that patients with rheumatic immunological diseases need to focus on
.
1.
Are rheumatology patients a severe/critical high-risk group of new coronavirus infection?
Be!
Common "rheumatic immune diseases" include rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis/polymyositis, Sjogren's syndrome, ANCA-associated vasculitis, and more
.
Due to the need for disease treatment, rheumatism patients often need to receive hormones, immunosuppressants or biological agents for treatment for a long time, on the one hand, these drugs control the disease to a certain extent, prevent the "self-attack damage" of their own organs, and on the other hand, it is convenient to inhibit the body's immune function to a certain extent, so rheumatism patients are usually considered to belong to immunosuppressed people, Daily life is more susceptible to pathogens
such as bacteria and viruses than the general population.
For the new coronavirus, rheumatism patients are also generally susceptible, and due to suppressed immune function, once infected, the condition may be more difficult to control, and it is more likely to have critical manifestations, so the domestic "Tenth Edition of the Diagnosis and Treatment Plan for Novel Coronavirus Infection" lists immune dysfunction (such as AIDS patients, long-term use of corticosteroids or other immunosuppressive drugs leading to immunodeficiency) as severe / Critically ill and high-risk groups, in addition to five other groups are also classified as high-risk groups, as shown in Table 1
below.
Table 1: Severe/critical high-risk groups of class 6 new coronavirus infection
Second, when the body of rheumatology patients releases what signals, they should be especially vigilant about the coming danger?
For adults, early warning of severe/critical disease should be alerted when the following indicators change:
1.
Progressive exacerbation of hypoxemia or respiratory distress;
2.
Deterioration of tissue oxygenation index (such as oxygen saturation, oxygenation index) or progressive increase of lactic acid;
3.
Progressive decrease in peripheral blood lymphocyte count or progressive rise in inflammatory factors such as interleukin 6 (IL-6), CRP, ferritin, etc.
;
4.
D-dimer and other coagulation function related indicators are significantly increased;
5
.
Chest imaging shows significant progression of lung lesions.
Third, rheumatism patients are positive, how to preliminarily judge whether it is heavy or not? How is it clinically classified?
With the continuous mutation of the virus, combined with the characteristics of the disease after the new coronavirus infection, the 10th version of the scheme further optimizes the clinical classification basis in the 9th version, mainly according to the severity of the infected person's condition, divided into "light, medium, heavy, critical", which is more in line with clinical reality
.
Table 2 shows the changes in clinical classification adjustment of the 10th edition VS the 9th edition (focusing on the definition of light and medium)
Table 2: 10th Edition VS 9th Edition Clinical Classification Changes
However, in clinical practice, the most common symptoms of new crown patients are the following manifestations, in no particular order
.
Cold intolerance (fear of cold) fever;
cough, sputum (dry cough in the early stage, blood-streaked sputum in the later stage);
poor breathing or difficulty breathing (feeling that you need to work harder than usual to bring in air);
fatigue (feeling that there is no strength in the whole body, very tired and does not like to move, obviously sleeping enough as if not sleeping enough);
Headache;
Muscle pain throughout the body;
Nasal blockage or runny nose;
Sore throat;
nausea, nausea, vomiting, or indigestion;
Bellyache;
Lumbago;
eye pain;
Diarrhoea;
Sudden loss of smell or taste
.
4.
How to use hormone/IL-6 inhibitors in severe new crown patients?
(1) What are the treatments for new coronavirus infection?
According to the recommendations of the latest domestic version of the "Tenth Edition of the Diagnosis and Treatment Plan for Novel Coronavirus Infection", the current treatment of new coronavirus infection includes the following aspects:
General treatment, antiviral therapy (nematevir/ritonavir combination package, azvudine tablets, monogravir capsules, monoclonal antibodies: ambavirumab/romisivimab injection, intravenous COVID-19 human immunoglobulin, convalescent plasma in convalescent patients), immunotherapy, anticoagulation, prone therapy, psychological interventions, heavy/critical support
.
(2) Why can hormone/IL-6 inhibitors be used to treat patients with severe new crown disease?
Pharmacological doses of glucocorticoids have a variety of anti-inflammatory, immunosuppressive, antiviral and anti-shock effects
.
Glucocorticoids have a wide range of applications and can be used for the treatment
of rheumatic diseases and autoimmune diseases, endocrine system diseases, respiratory diseases, blood system diseases, etc.
Severe pneumonia is a progressive lung inflammation, the spread of local inflammation of severe pneumonia and waterfall-like inflammatory response in the body are related to anti-inflammatory decompensation, rapid outbreak of "inflammatory factor storm" may be the main cause of progression to organ failure and death in pneumonia patients, so inhibition of inflammation in the body is another strategy
for the treatment of severe pneumonia.
Glucocorticoids are used in the treatment of severe pneumonia, the main mechanism of action is to inhibit the inflammatory response, reduce or avoid the production and degree of cytokine storm, reduce the exudation of pulmonary capillaries, but also have immunosuppressive effect, manifested as reducing the production of inflammatory cytokines by monocytes and inhibiting the phagocytosis and migration of phagocytes; Rapidly reduce lymphocytes, inhibit the production of cytokines by activated T cells, and so on
.
Although hormone use may affect viral clearance, it may also be associated with
secondary infection.
There is growing evidence that virus-induced cytokine storms may be associated with poor prognosis in patients with
high levels of inflammatory factors.
After the new coronavirus invades the human body, it can induce excessive inflammatory reactions through immune cells, epithelial cells and endothelial cells, trigger cytokine storms, and promote the release of a large number of inflammatory factors, including tumor necrosis factor ɑ (TNF-ɑ), IL-6, etc
.
A large number of inflammatory factors in the lungs can not only cause tissue damage, but also cause the failure
of multiple organs.
Studies have found that IL-6 may be a key factor in triggering cytokine storms, so many researchers treat severely ill new coronavirus patients
by inhibiting the release of IL-6, thereby reducing or preventing the occurrence of cytokine storms.
(3) When are hormone/IL-6 inhibitors used? How to use it? How much to use?
In clinical practice, for patients with many diseased lung segments and rapid progression, inflammatory indicators are significantly increased, patients with underlying diseases have a high risk of developing SIRS, ARDS, progression to severe, critical may be large, if not early use of hormone intervention, it is easy to develop into severe disease, even critical, may lead to the failure of the entire treatment
.
On the one hand, identify people with severe and critical disease as soon as possible, and pay attention to the early warning manifestations
of severe and critical diseases.
On the other hand, it is very important to grasp the timing of hormone application and precautions for use, and the following is the latest domestic version of the "Tenth Edition of the Diagnosis and Treatment Plan for Novel Coronavirus Infection" for the clinical application timing, specific usage and dosage of hormones and IL-6 inhibitors:
Table 3: Clinical application time, specific usage and dosage recommendations of IL-6 inhibitors
References:
[1] National Health Commission's Diagnosis and Treatment Plan for Novel Coronavirus Infection (Trial Version 10)
[2] COVID -19: consider cytokine storm syndromes and immunosuppression ［J］．Lancet.
[3] Corticosteroids in Community -Acquired Pneumonia [J]． JAMA．
