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Rheumatology at the Epicenter
RHEUMATOLOGY
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Rheumatology at the Epicenter

Lessons learned during the COVID surge in New York City
HSS rheumatologists share their experiences and insights from the spring surge.
AT THE START OF 2020,

no one could have predicted the breadth and severity of the COVID-19 global health crisis, or the unexpected similarities to rheumatic diseases. But as New York City emerged as an epicenter of the disease, HSS rheumatologists sprang into action, making a series of rapid and urgent pivots to offer their clinical and laboratory expertise.

While some shifted their clinical duties to meet the pressing informational needs of rheumatologic patients concerned for their health and the availability of medications, others volunteered on the frontlines of COVID-19 patient care, serving as hospitalists at both HSS and neighboring Weill Cornell Medicine.

Meanwhile, an essential research role for many of our physician-scientists surfaced during the height of the pandemic, as the remarkable relevancy of their decades-long studies of mechanisms of autoimmune diseases to the clinical manifestations and immune mechanisms operative in COVID-19 became increasingly clear. In particular, two research activities at HSS — established patient cohorts and the HSS Research Institute’s findings on rheumatic patients’ aberrant immune responses — provided key understandings into cytokine regulation and interferon pathways in autoimmune disease that were relevant to COVID-19 treatment. These were the same pathways identified as central to the overactive inflammatory process that causes severe disease and mortality in COVID-19 patients.

Equipped with these insights, in mid-March an interdisciplinary COVID-19 Research Committee, led by HSS Chief Scientific Officer Lionel B. Ivashkiv, MD, and then Physician-in-Chief Mary K. Crow, MD, began greenlighting interventional, clinical and translational studies that have since entered the scientific, administrative and safety approval pathways. HSS experts approached pharmaceutical companies to suggest that approved drugs for rheumatic diseases be repurposed as treatments for COVID-19.

Two research activities at HSS provided key understandings into cytokine regulation and interferon pathways that were relevant to COVID-19 treatment.

In August, the New York Times Magazine published a story highlighting the experiences of Iris Navarro-Millán, MD, who served as a hospitalist on the COVID-19 unit at Weill Cornell Medicine during the surge.

It included the results of a case study she published in Arthritis & Rheumatology showing that the immunosuppressive drug anakinra may allow certain people with COVID-19 to avoid having to go on a ventilator.

How COVID Sends Some Bodies to War With Themselves
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HSS rheumatologists also initiated discussions on investigational drugs targeting novel pathways that could limit the exuberant and damaging inflammatory response responsible for the most severe manifestations of COVID-19.

Today, while our rheumatologists have resumed regular patient care, their engagement continues through an active program of clinical trials related to COVID-19 on both the basic/translational and clinical sides.

HSS clinician-scientists’ current areas of focus include the following:

Mechanisms of Cytokine Storm in Patients with COVID-19

The objectives of this study are to describe the process of the cytokine storm in people with COVID-19 and to identify biologic predictors of a favorable outcome in patients with severe cases of the disease.

The project aims to characterize immune cell populations seen in COVID-19 patients who experience cytokine storm versus those who do not, comparing immune responses before and after the anti-inflammatory drug anakinra is administered. The ultimate goal would be to identify measures that suggest when patients are more likely to decline and eventually require mechanical ventilation.

The research will employ blood samples from HSS patients who are being treated for COVID-19 at NewYork–Presbyterian Hospital and who meet certain other qualifications.

Principal Investigator: Mary K. Crow, MD

Association of Immunomodulatory Medication Use and Social Determinants of Health with COVID-19 Infection in Systemic Rheumatic Disease Patients

Using data from the INSIGHT Clinical Research Network, a central repository containing longitudinal electronic health data for residents of New York City, investigators are assembling a cohort of patients being treated with immunomodulatory medications for rheumatic disease. This patient population will then be used to study the effect of these medications on COVID-19 incidence and outcomes. Retrospective data will be used to evaluate the incidence and severity of COVID-19 in these patients.

Patients will also be studied prospectively to determine whether a relationship exists between COVID-19 infection and future rheumatic disease as well as to study connections between infection and future psycho-social issues.

Principal Investigator: Medha Barbhaiya, MD, MPH

Implications of Prior COVID-19 Infection on Perioperative Management

The sequelae in patients who have recovered from severe COVID-19 disease are poorly understood but can be devastating and include profound weakness, fatigue and catastrophic events such as avascular necrosis (death of bone).

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Another major complication seen in people with COVID-19 is thrombosis due to endothelial dysfunction, persistent inflammation and potentially antiphospholipid antibodies. We are currently engaged in studies to assess complication rates in orthopaedic patients with prior COVID-19 infection as well as to predict and prevent blood clots in this cohort.

Principal Investigators: Friedrich Boettner, MD; Kethy M. Jules-Elysee, MD; Lisa A. Mandl, MD, MPH

Covid-19 Response at HSS
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COVID-19: An Unprecedented Threat, a Historic Response
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Impact on Research Shifts to Support the Pandemic
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