Patients with inflammatory rheumatic diseases (IRD) may be more likely to acquire severe pneumonia due to COVID-19, especially in patients with autoimmune disease who are being treated with rituximab.
Patients with inflammatory rheumatic diseases (IRD) may be more likely to acquire severe pneumonia due to COVID-19, according to a study published in the Journal of Rheumatology.1 Additionally, patients with autoimmune disease who are being treated with rituximab are especially at risk compared with the general population.
Admission risk comparing IRD with non-IRD patients and the association with rheumatic disease and immunosuppressive therapy was analyzed in this retrospective, single-center observational study of patients with IRD who were actively monitored in the Department of Rheumatology and had been hospitalized with COVID- 19. Investigators believe that the reason patients with IRD are at an increased risk is due to the presence of comorbidities, disease activities, and immune-modulating therapies. Connective tissue diseases are associated with severe COVID-19 symptoms. Interestingly, common IRD treatments, such as hydroxychloroquine, tocilizumab, anakinra, and baricitinib, have been used as treatment options for COVID-19 as they may have the potential to reduce virus penetration into cells and control respiratory distress.
“Our results show a significant higher risk of severe pneumonia and hospitalization among patients diagnosed with IRD, compared to the reference population,” stated investigators. “These results contrast with the ones found in initial studies in which data was obtained through surveys, among pediatric population, or in studies that did not include patients with systemic lupus erythematosus (SLE) or other autoimmune diseases.”
The Ramón y Cajal Hospital treated 492,745 adult patients, aged 16 years or older, in the northeast of Madrid during March 1 and April 30, 2020. Of these patients, 4592 were previously diagnosed with IRD and 883 were receiving treatment with biologic medications or Janus kinase (JAK) inhibitor therapies. The most commonly impacted rheumatic diseases were patients with Sjögren’s syndrome (SS), vasculitis (VAS), rheumatoid arthritis (RA), and SLE, however patients with spondyloarthritis (SpA), psoriatic arthritis (PsA), myopathy (MYO), rheumatic polymyalgia (RMP), and 12 other diseases were also identified. Affected IRD patients were treated with corticosteroids (27), conventional disease-modifying antirheumatic drugs (DMARDs) (23), biologics (12), and JAK inhibitors (1). More than 65% of patients were receiving corticosteroid treatment daily, with an average dose of 5.2 mg/day of prednisone and no patients were taking more than 10 mg/day. In the DMARDs group, 14 were receiving methotrexate and 4 were taking hydroxychloroquine. During the course of the study, both a higher hospitalization rate and a higher number of deaths were seen in patients who were being treated with rituximab (72), but patients with anti-TNF medications (603) were unaffected.
There were 41 hospitalized patients, 10 of which died. Additionally, 3 of the 13 patients receiving immunosuppressive targeted therapies (ITT) died. All 3 were receiving rituximab treatment. In the non-IRD cohort, data was extracted from the last Spanish nation health survey conducted in 2017. The primary reason for hospitalization was the presence of pneumonia coupled with respiratory failure.
The baseline characteristics between patients in both IRD and non-IRD groups were the same, (female 52.5% vs 53.02%; p = 0.28), arterial hypertension (18.73% vs 17.33%, p = 0.081), diabetes mellitus (7.39% vs 8.14%; p = 0.16) and heart disease (5.32% vs 6.24%; p = 0.054).
The research was limited as it was a retrospective, single-center study, which is inherently impacted by the features of the local population, including sex, age, socioeconomic status, and education level, as well as treatment during the hospital stay. However, the increase in risk of severe disease may be attributed to characteristics of the participants that are not present in the general population, such as higher age, frequency of lung disease, and comorbidities. Further multicenter studies are needed to confirm results and help patients with rheumatic diseases during the pandemic. “We conclude that patients with IRD may be at higher risk of admission for COVID-19 as compared to the reference population,” stated investigators. “This risk seems to be particularly high for those with systemic autoimmune diseases like SLE, SS and VAS and patients undergoing treatment with rituximab.”
Bachiller-Corral J, Boteanu A, Garcia-Villanueva MJ, et al. Risk of severe coronavirus infection (COVID-19) in patients with inflammatory rheumatic diseases [published online ahead of print, 2021 Mar 15]. J Rheumatol. 2021;jrheum.200755. doi:10.3899/jrheum.200755