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the management is challenging&#46; When a patient with RA without prior interstitial lung disease &#40;ILD&#41; is hospitalized with severe SARS-CoV-2 pneumonia passes the acute phase&#44; and suffers a flare of RA&#44; there is an understandable concern to reintroduce immunosuppression&#46; In this phase&#44; the patient is normally still on low-dose steroid treatment&#44; but the bDMARDs that can be used for SARS-CoV-2 infection have been stopped &#40;such as tocilizumab or bariticinib&#44; also useful for RA&#41;&#46; Therefore&#44; the rheumatologist must decide to reintroduce the RA baseline treatment or to change it due to the new ILD secondary to the virus&#46; We would like to share our experience&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 72-year-old woman with RA since 1997 treated with 25<span class="elsevierStyleHsp" style=""></span>mg of methotrexate &#40;MTX&#41; weekly and 125<span class="elsevierStyleHsp" style=""></span>mg of abatacept weekly&#44; in remission&#46; In 2018 she complained of a dry cough and was studied with CT scan &#40;normal&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; and finally diagnosed with gastric reflux&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In March 2020&#44; she was admitted to the intensive care unit for severe global bilateral SARS-CoV-2 pneumonia&#46; MTX and abatacept were suspended&#44; she was intubated and treated with corticosteroids&#44; antivirals&#44; and later tocilizumab&#46; Her evolution was favorable&#44; but on the 40th day of hospitalization&#44; despite maintaining 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg of prednisone&#44; she presented a severe polyarticular RA flare&#46; At that time&#44; MTX and abatacept were reintroduced&#46; She has been in remission to date&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In September 2020&#44; one month after hospital discharge&#44; she was still reporting stable dyspnea on moderate efforts&#44; the CT scan was as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B &#40;ground glass areas and thickening of interlobular septa in both lower lobes&#44; patchy ground consolidation in all lobes&#44; and honeycomb changes in the left upper lobe&#41;&#44; and the functional tests were as follows&#58; FEV1 2140<span class="elsevierStyleHsp" style=""></span>ml &#40;104&#37; of predicted value&#41;&#44; FVC 2620<span class="elsevierStyleHsp" style=""></span>ml &#40;99&#37;&#41;&#44; DLco &#40;corrected for hemoglobin&#41; 3030<span class="elsevierStyleHsp" style=""></span>mmol&#47;kPa&#47;min &#40;49&#37;&#41;&#46; She was treated by pneumologists with a descending dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg of prednisone for a month&#46; Six months later functional tests improved &#8211; FEV1 2240<span class="elsevierStyleHsp" style=""></span>ml &#40;111&#37;&#41;&#44; FVC 2740<span class="elsevierStyleHsp" style=""></span>ml &#40;105&#37;&#41;&#44; DLco 3950<span class="elsevierStyleHsp" style=""></span>mmol&#47;kPa&#47;min &#40;64&#37;&#41; &#8211; as well as the CT scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; To date&#44; she has not reported dyspnea and her baseline saturation is 99&#37;&#46; She has maintained MTX and abatacept without any adverse event or RA flare&#46; NSAIDs or other corticosteroids have not been needed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is another report of a RA patient maintaining 10<span class="elsevierStyleHsp" style=""></span>mg of MTX during the hospitalization period&#44; and her condition remained stable&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> MTX does not have an increased risk of infections <a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a>and is not associated with an increased risk of RA-ILD in RA&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> We suggest&#44; sustained on current published data&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#8211;9</span></a> that reintroducing baseline treatment when RA patients surpass the critic phase of COVID-19 disease does not worsen the evolution of ILD secondary to SARS-CoV-2&#44; as it appears to be independent&#46; However&#44; given that the bDMARD in our case is abatacept&#44; which has a good ILD profile in patients with RA&#44; it would be of great interest to collect more data with all DMARDs and bDMARDs in these patients&#46;</p></span>"
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Letter to the Editor
Post-COVID-19 interstitial lung disease: A new treatment challenge in rheumatoid arthritis patients
Enfermedad pulmonar intersticial post-COVID 19: Un nuevo reto de tratamiento en pacientes con artritis reumatoide
Jose Luis Morell-Hitaa, Juan A. Rigual-Bobillob, Cristina C. Macía-Villaa,
Corresponding author
ccmacia@gmail.com

Corresponding author.
a Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain
b Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The coronavirus disease 2019 &#40;COVID-19&#41; is the result of infection with the SARS-CoV-2 virus that is making us live one of the worst pandemics of the 21st century&#46; It has affected the management of rheumatoid arthritis &#40;RA&#41;&#44; since these patients are treated with immunosuppressants such as disease-modifying drugs and biologics &#40;bDMARDs&#41;&#46; At the beginning of the pandemic&#44; when a patient with RA required hospital admission for COVID-19&#44; immunosuppression was suspended until improvement&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Over time&#44; we have learned about SARS-CoV-2 infection&#44; showing that use of bDMARDs is not associated with worse outcomes<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> except for rituximab and JAK inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; the management is challenging&#46; When a patient with RA without prior interstitial lung disease &#40;ILD&#41; is hospitalized with severe SARS-CoV-2 pneumonia passes the acute phase&#44; and suffers a flare of RA&#44; there is an understandable concern to reintroduce immunosuppression&#46; In this phase&#44; the patient is normally still on low-dose steroid treatment&#44; but the bDMARDs that can be used for SARS-CoV-2 infection have been stopped &#40;such as tocilizumab or bariticinib&#44; also useful for RA&#41;&#46; Therefore&#44; the rheumatologist must decide to reintroduce the RA baseline treatment or to change it due to the new ILD secondary to the virus&#46; We would like to share our experience&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 72-year-old woman with RA since 1997 treated with 25<span class="elsevierStyleHsp" style=""></span>mg of methotrexate &#40;MTX&#41; weekly and 125<span class="elsevierStyleHsp" style=""></span>mg of abatacept weekly&#44; in remission&#46; In 2018 she complained of a dry cough and was studied with CT scan &#40;normal&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; and finally diagnosed with gastric reflux&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In March 2020&#44; she was admitted to the intensive care unit for severe global bilateral SARS-CoV-2 pneumonia&#46; MTX and abatacept were suspended&#44; she was intubated and treated with corticosteroids&#44; antivirals&#44; and later tocilizumab&#46; Her evolution was favorable&#44; but on the 40th day of hospitalization&#44; despite maintaining 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg of prednisone&#44; she presented a severe polyarticular RA flare&#46; At that time&#44; MTX and abatacept were reintroduced&#46; She has been in remission to date&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In September 2020&#44; one month after hospital discharge&#44; she was still reporting stable dyspnea on moderate efforts&#44; the CT scan was as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B &#40;ground glass areas and thickening of interlobular septa in both lower lobes&#44; patchy ground consolidation in all lobes&#44; and honeycomb changes in the left upper lobe&#41;&#44; and the functional tests were as follows&#58; FEV1 2140<span class="elsevierStyleHsp" style=""></span>ml &#40;104&#37; of predicted value&#41;&#44; FVC 2620<span class="elsevierStyleHsp" style=""></span>ml &#40;99&#37;&#41;&#44; DLco &#40;corrected for hemoglobin&#41; 3030<span class="elsevierStyleHsp" style=""></span>mmol&#47;kPa&#47;min &#40;49&#37;&#41;&#46; She was treated by pneumologists with a descending dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg of prednisone for a month&#46; Six months later functional tests improved &#8211; FEV1 2240<span class="elsevierStyleHsp" style=""></span>ml &#40;111&#37;&#41;&#44; FVC 2740<span class="elsevierStyleHsp" style=""></span>ml &#40;105&#37;&#41;&#44; DLco 3950<span class="elsevierStyleHsp" style=""></span>mmol&#47;kPa&#47;min &#40;64&#37;&#41; &#8211; as well as the CT scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; To date&#44; she has not reported dyspnea and her baseline saturation is 99&#37;&#46; She has maintained MTX and abatacept without any adverse event or RA flare&#46; NSAIDs or other corticosteroids have not been needed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is another report of a RA patient maintaining 10<span class="elsevierStyleHsp" style=""></span>mg of MTX during the hospitalization period&#44; and her condition remained stable&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> MTX does not have an increased risk of infections <a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a>and is not associated with an increased risk of RA-ILD in RA&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> We suggest&#44; sustained on current published data&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#8211;9</span></a> that reintroducing baseline treatment when RA patients surpass the critic phase of COVID-19 disease does not worsen the evolution of ILD secondary to SARS-CoV-2&#44; as it appears to be independent&#46; However&#44; given that the bDMARD in our case is abatacept&#44; which has a good ILD profile in patients with RA&#44; it would be of great interest to collect more data with all DMARDs and bDMARDs in these patients&#46;</p></span>"
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