What is the management plan for a patient with Rheumatoid Arthritis (RA) who tests positive for influenza (flu)?

Management of Rheumatoid Arthritis Patient with Influenza

Initiate antiviral treatment with oseltamivir within 48 hours of symptom onset while continuing most RA medications, with specific considerations for glucocorticoids and methotrexate. 1

Immediate Antiviral Treatment

• Start oseltamivir 75 mg orally twice daily for 5 days if the patient presents within 48 hours of influenza symptom onset 1
• Treatment should not be delayed while awaiting confirmatory testing in symptomatic patients 1
• Early antiviral treatment in RA patients with influenza reduces healthcare resource utilization, emergency department visits, and respiratory-related outpatient visits 2

RA Medication Management During Active Influenza

Glucocorticoids (Critical - Cannot Stop Abruptly)

• Continue glucocorticoids at current dose - these cannot be stopped suddenly in patients with RA 3
• Consider stress-dose glucocorticoids if the patient develops severe illness, as acute illness may increase physiologic steroid requirements 3
• This is the most important medication consideration, as abrupt cessation can precipitate adrenal crisis 3

Methotrexate and Other DMARDs

• Discuss temporary discontinuation of methotrexate on a case-by-case basis during symptomatic influenza infection 3
• The decision should weigh disease activity against infection severity - if RA is well-controlled and influenza symptoms are mild, temporary methotrexate hold may be reasonable 3
• For other immunosuppressive medications (biologics, JAK inhibitors, other conventional DMARDs), case-by-case discussion is recommended based on infection severity 3
• There is no universal mandate to stop all DMARDs for mild influenza 3

Biologic DMARDs (TNF Inhibitors, etc.)

• Continue or temporarily hold based on individual assessment of infection severity and RA disease activity 3
• No specific evidence mandates routine discontinuation for uncomplicated influenza 3

Clinical Monitoring

• Monitor for signs of severe influenza requiring hospitalization, as RA patients may be at increased risk for complications 4
• Risk factors for more severe influenza in RA patients include: anti-TNF therapy use, higher body mass index, and pre-existing lung conditions 4
• Watch for respiratory deterioration, particularly in patients on anti-TNF agents who have 2.4 times higher odds of influenza symptoms 4

Prevention for Future Seasons

• Strongly recommend annual influenza vaccination - this is the most effective prevention strategy 3, 5
• For RA patients on immunosuppressive therapy, high-dose or adjuvanted influenza vaccine is conditionally recommended over standard-dose vaccine 3
• Influenza vaccination is safe in RA patients and does not increase disease flares 5
• Hold methotrexate for 2 weeks after influenza vaccination (if disease activity allows) to improve vaccine immunogenicity, but continue all other immunosuppressive medications during vaccination 3

Important Caveats

• The decision to continue or hold DMARDs during active influenza is not black and white - it requires individualized assessment of RA disease activity versus infection severity 3
• Patients with severe influenza manifestations warrant more aggressive consideration of temporary DMARD discontinuation 3
• Never abruptly stop glucocorticoids regardless of infection severity 3
• Ensure the patient understands the importance of annual influenza vaccination to prevent future episodes 3