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Ensuring tight control in patients with rheumatoid arthritis treated with targeted therapies during the COVID-19 pandemic using a telehealth strategy

COVID-19 pandemic in its early months has deeply influenced rheumatic patients’ followup in terms of treatment adherence, disease control achieved with treattotarget and tightcontrol strategies. Nationwide mitigation strategies such as confinement, travel restrictions and inadequate access to routine visits catalysed the rapid switch to remote rheumatologic consultations as an attempt to partially compensate for the decline of inperson outpatient visits. This observational retrospective study was conducted to establish if the hybrid of inperson and telephone tightcontrol approach activated by our rheumatology unit in Milan (Italy) during the first lockdown (LD) period has been effective in maintaining remission in patients with rheumatoid arthritis (RA) treated with targeted therapies and to identify potential factors associated with its maintenance. Data were extracted from a longitudinal observational registry (Eethics Committee 138_1999) including consecutive adult patients with RA treated with biologic or targeted synthetic drugs. During the first pandemic wave, before the visit, rheumatologists provided virtual care handled by telephone to assess the clinical status and to guarantee the absence of current contraindications to therapy. After tele counselling, based on the care required, patients could choose whether to convert the next appointments to a telephone visit and receive drug home delivery or to maintain their standard inperson consultation. For each patient, Clinical Disease Activity Index (CDAI) was collected during facetoface visits. Moreover, difficulttotreat (D2T) patients with RA according to EULAR definition were analysed in this study. At baseline, 502 patients with RA were eligible for this study and they were followedup over the first wave of the pandemic. Among these, 91 patients chose drug home delivery, 52 patients failed to complete their followup; all the 450 patients who completed the followup, were included in the final analysis (online supplemental figure 1S). The median age was 59.4 years (IQR 50.7–68.4), 370 (82.22%) were women, median disease duration was 13.9 years (IQR 7.9–22.5). More details are listed in online supplemental tables 1S and 2S. The CDAI remission rate was 40.22% (n=181) and 43.78% (n=197) during preLD and postLD, respectively. As for the 359 patients who choose inperson visits during LD, 43.18% (n=155) were in remission state according to CDAI (online supplemental table 3S). Although our experience cannot be generalised, these percentages are similar to those of other European cohorts. 4 To evaluate the effect of LD on the percentage of patients in remission, logistic mixedeffects regression models were fitted, with CDAI remission as a response variable (see online supplemental file for the statistical analysis). The analysis did not show a statistically significant decrease in the percentage of patients fulfilling CDAI remission all along the three periods (online supplemental table 4S). Moreover, the final model (stepwise selection) applied to the multivariate analysis of factors that potentially could interfere with disease control in patients with CDAI remission showed that the probability to be in remission was significantly associated with the male gender, while Hispanic or Asian ethnicity and presence of fibromyalgia showed a decreased odds for remission (table 1). These results confirm characteristics known to be predictive for clinical remission. Finally, 52 D2T patients with RA were evaluated in a hospital setting preLD and postLD. Among them, 43 choose inperson visit during LD. Median values of CDAI during preLD, LD and postLD were 14.5 (IQR 12–21), 9 (IQR 5.5–16) and 11 (IQR 6–19.2), respectively (online supplemental figure 2S). Telephonebased tightcontrol strategy used during the first wave of COVID-19 pandemic ensured satisfactory management of RA treated with targeted therapies, even in D2T patients. Although during normal times, the patient– physician encounter is considered fundamental for rheumatic patients, telemedicine was often the only way of practicing in the times of the pandemic. In conclusion, the current pandemic has dramatically altered patterns of healthcare delivery. Although this temporary virtual approach is currently not spurred by regulatory changes, it seems to be a feasible compensation for facetoface visits.