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Caring for Patients with Rheumatologic Disease During Influenza Season

Cassandra Calabrese, DO

Assistant Professor of Medicine
Department of Rheumatologic and Immunologic Disease
Cleveland Clinic
Cleveland, Ohio

Cassandra Calabrese, DO: consultant/advisor/speaker: AstraZeneca, Lilly, Sanofi.

View ClinicalThoughts from this Author

Released: December 2, 2022

Key Takeaways

  • Patients with rheumatologic disease have a significantly increased risk of morbidity and mortality with influenza.
  • Current guidelines recommend treatment with antivirals in cases of suspected or confirmed influenza in outpatients who are at high risk of complications, such as immunocompromised patients with rheumatologic disease.

As rheumatologists, we take care of immunocompromised patients who may be at higher risk for complicated influenza and have a greater risk for more severe outcomes, pneumonia, hospitalization, and prolonged viral shedding. Getting a yearly flu shot and use of nonpharmacologic interventions such as hand washing, masking, and staying home when sick are important, but with the resurgence of influenza activity this year what else do rheumatologists have in our toolbox to protect and treat our patients if they get the flu?

Challenges in the Rheumatology Practice: Lack of Awareness and Misconceptions
With COVID-19 still an ongoing concern, I think it is important to know when to test, when to treat, and what to treat with. I think rheumatologists are also not aware of post-exposure chemoprophylaxis for influenza and available antiviral treatment options.

Several challenges exist; the first is that we need to know when our patients have influenza. Patient communication is the limitation and, as with COVID-19, we cannot test or treat the patient if we do not know that they have COVID or influenza symptoms.

A second challenge is to make patients with rheumatologic disease aware that they are at risk and that they need to be aware of respiratory tract symptoms and to test for COVID-19 and the flu. Lack of access to in-office testing or an easy way to get our patients tested for flu when we have suspicion is another challenge. Therefore, we often end up referring patients to urgent care if think they need to be treated for flu. This season will be even more challenging as we have COVID-19, RSV, and influenza all circulating. While lack of easy access to testing is a great challenge for our patients, having them do a home COVID-19 test is a good first step in the right direction.

Although misconceptions around treatment indications and treating influenza in general are prevalent, information is readily available. On their website, the Centers for Disease Control and Prevention (CDC) provides an algorithm to assist in the interpretation of influenza testing results and clinical decision-making during periods when influenza viruses are circulating in the community and the Infectious Disease Society of America (IDSA) also provides guidelines on diagnosis, treatment, and chemoprophylaxis for seasonal influenza.

It is recommended to treat with antivirals in cases of suspected or confirmed flu in outpatients who are at high risk of complications, and that includes our immunocompromised rheumatology patients. Ideally, antivirals should be started within 48 hours of symptom onset but immunocompromised patients who fall outside of that window should still receive antivirals.

It is also recommended that influenza treatment be started empirically if there is a high index of suspicion. For example, if the patient is sick with upper respiratory tract symptoms, and someone in their house has influenza, or a child is home from daycare where everyone has influenza, this patient can be treated for presumed flu.

Treatments for Patients With Rheumatologic Disease
Several oral antivirals are available to treat outpatients, and they can also be used for post-exposure prophylaxis. If you have a high-risk patient who was exposed to someone with the flu, such as a grandchild, you can give them certain antivirals to prevent them from getting flu.

We can readily prescribe these antivirals for our patients, but I think there are knowledge gaps that prevent rheumatologists from doing this and so we often refer patients to primary care, which causes further delays in treatment.

The challenges rheumatologists encounter are demonstrated in this case: A 56-year-old woman with rheumatoid arthritis (RA) presents to clinic with influenza-like symptoms, a fever of 101° F, body aches, and a cough. For her RA, she is receiving the biologic abatacept, a T-cell inhibitor, and methotrexate. She works in an office—in a cubicle setting—where masks are no longer worn in the workplace. She is fully vaccinated against COVID-19 and the flu. She calls her rheumatologist as she has done a home test for COVID-19 and it is negative. She shares that her granddaughter had influenza last week, and she spent time with her over the weekend. Would you prescribe an antiviral such as oseltamivir or baloxavir?

This is a high-risk patient with a high index of suspicion for influenza, especially because her home COVID-19 test was negative. Therefore, she should be treated with antivirals. And had she come to her rheumatologist's office after this high-risk contact with her granddaughter and had no symptoms, it would have been possible to give her post-exposure chemoprophylaxis.

The Importance of Risk Counseling
It is important for patients to be up to date with their vaccines as vaccination is the best prevention. One reason vaccines are often not up to date is that patients think the primary care doctor should do it, whereas the primary care doctors think the rheumatologist should do it: vaccination can get lost in the shuffle. I think this scenario is the same for influenza and influenza treatments. To counter this, I would argue that if we are providing the immunosuppression and creating the risk, then it is our job to provide risk counseling to our patients.

There are several survey-based studies of patients sharing what is most impactful in convincing them to get a vaccine. Across the board, rheumatologist recommendations carried a lot of weight with patients. Visits are so harried these days and sometimes vaccines are not discussed. For people who are on the fence and are not going to go to the drugstore and get their flu shot otherwise, if you pause and tell them that is what they should do, they will listen.

Of course, there are always patients who are on a different wavelength but hearing from their provider what is recommended and why it is important to be vaccinated carries a lot of weight with patients.

Final Thoughts
During flu season, I tell my patients who are immunocompromised,  "If you're sick, I want to hear about it. Call me if you think you have the flu or if you think you have COVID-19. There are things we can do." It only takes a minute, and it is important to tell patients that you are their contact.

Your Thoughts?
How do you manage flu in your rheumatology practice? Join the discussion by posting a comment.

Provided by Partners for Advancing Clinical Education, in partnership with Practicing Clinicians Exchange

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