Rheumatoid Arthritis Linked to Adverse COVID-19 Outcomes


New data show rheumatoid arthritis and immunosuppressive treatment associated with more severe risks of COVID-19, including hospitalization and death.

Bryant R. England, MD

Bryant R. England, MD

The COVID-19 pandemic has resulted in adverse effects among vulnerable populations, particularly those with chronic diseases such as cardiovascular (CV) disease and diabetes.

Infections in patients with rheumatoid arthritis often complicate the natural course of RA, while treatment with disease-modifying anti-rheumatic drugs (DMARDs) are associated with an increased risk of infection.

Previous data found immunosuppressants did not lead to increased rates of COVID-19 in patients with immune-mediated inflammatory disease.

However, in a new study, investigators, led by Bryant R. England, MD, PhD of the Nebraska Medical Center, found that patients with RA have an increased risk for COVID-19 and hospitalization or death from COVID-19, compared to patients with non-RA.


The study compared the risk of SARS-CoV-2 infection and the development of severe COVID-19 between patients with RA and a comparator patient group in an at-risk population.

The team hypothesized that patients with RA would have a higher risk of acquiring an infection and were more likely to require hospitalization or die from COVID-19.

To test this hypothesis, investigators conducted a retrospective, matched-cohort study using data from the National Veterans Health Administration (VHA).

Patients active in the VHA system were identified as of January 2020, using algorithms for multiple RA diagnostic codes, a rheumatologist diagnosis of RA, and a DMARD or positive RA autoantibody test.

The team matched RA patients to non-RA patients (1:1) on age, sex, and Department of Veterans Affairs (VA) site. Patients were followed up with from January 2020 to the first COVID-19 diagnosis, death, or end of the study period in December 2020.

Data on COVID-19 outcomes was collected through the VA COVID-19 surveillance database, including positive tests and hospitalization or death within 30 days of infection.

Investigators used multivariable regressions models to assess the COVID-19 risk in both RA patients versus non-RA patients, including adjustment for demographics, comorbidities, health behaviors, and county-level COVID-19 rates as of November 2020.


The team identified 33,866 patients with RA and 33,866 patients without RA, including 84.5% male and a mean age of 67.8 years.

Patients with RA were more likely to be smokers, have a higher BMI, with a greater comorbidity burden, and more hospitalizations within the past year.

Investigators found in over 62,894 patient-years of follow-up, there were 1503 diagnoses of COVID-19.

In a subset of 338 severe COVID-19 cases, 345 resulted in hospitalization and 84 resulted in death. Within the same observation period, there were 288 non-COVID-19 related deaths.

The data show RA was associated with a significantly higher risk of COVID-19, with a 25% higher risk of COVID-19 with a hazard ratio (HR) of 1.25 (95% CI, 1.13, 1.39) and a 35% higher risk of COVID-19 hospitalization or death with an HR of 1.35 (95% CI, 1.10, 1.66).

Other factors in addition to RA status associated with the higher risk included patients treated with DMARDs and prednisone, as well as demographic including Black race and Hispanic ethnicity.

Patients with treated with DMARDs and prednisone were at the highest risk of COVID -19 with a hazard ratio of 1.66 (95% CI, 1.36,2.03), as well as hospitalization or death with a HR of 2.12 (95% CI, 1.48, 3.03), compared to non-RA patients.


Investigators concluded that patients with RA have a significantly increased COVID-19 risk, with immunosuppressive therapy treatment associated with a more severe risk of COVID-19.

“Consideration should be given to establishing RA, and potentially other conditions that require treatment with similar immunosuppressive medications, as a chronic condition that receives prioritization for COVID-19 prevention and management strategies,” investigators wrote.

The study, “Risk of COVID-19 in Rheumatoid Arthritis: A National Veterans Affairs Matched Cohort Study in At-Risk Individuals,” was published online in Arthritis & Rheumatology.

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