Rheumatic Diseases, Drugs and COVID-19 Guidelines Save

Several recent publications have focused on the risk and outcomes of rheumatic disease (RDD) and autoimmune patients who become infected with SARs-CoV-2. These observational studies follow on the original publication from the Global Rheumatology Alliance that showed among 600 RDD patients, the risk of COVID hospitalization was unaffected by DMARD or biologic use but was two fold higher with steroids and 60% lower amongst those taking TNF inhibitors.  What follows are summaries and exerpts from recent articles that also address COVID risks and outcomes amoung RDD. The question is - do we need to update or amend our current ACR and rheumatology guidelines?

• Determinants of COVID-19 disease severity in patients with underlying rheumatic disease - a Spanish prospective observational study of 3711 hospitalized COVID-19 patients; 38 (10%) of whom had a rheumatic or musculoskeletal disease. They showed that markers of inflammation and COVID activity (CRP, D-Dimer, LDH, ferritin) and possibly RDD activity was associated with COVID severity and mortality, but DMARD and biologic use did not associate with poorer outcomes. 
• COVID‐19 in Patients with Inflammatory Arthritis: A Prospective Study on the Effects of Comorbidities and DMARDs on Clinical Outcomes - A&R report of 103 inflammatory arthritis (IA; rheumatoid arthritis and spondylarthritis) with symptomatic COVID‐19 infection; 26 hospitalized and 4 died. Those taking oral glucocorticoids had a higher likelihood of being admitted for COVID‐19 (P <0.001) while those on maintenance anti‐cytokine biologic therapies did not.

• Risk factors for hospital admissions related to COVID-19 in patients with autoimmune inflammatory rheumatic diseases (AIRD) - an observational study of 123 patients with AIRD and COVID-19; 54  (44%) patients required hospital admission and 12 patients died (22%). Whereas older age (OR: 1.08; p=0.00) and AIRD (OR: 3.55; p=0.01) were ris factors for hospitalization, use of disease-modifying antirheumatic drugs were not.

• SARS CoV-2 infection among patients using immunomodulatory therapies - a report from Winthrop et al describes a surveyed infectious disease physicians, 38 of whom screened over 2500 COVID-19 cases, 77 (3%) of whom were taking immunomodulatory drugs for rheumatoid arthritis (19, 24.7%), ulcerative colitis (5, 6.5%) and sarcoidosis (5, 6.5%). At time of COVID-19 diagnosis, 31 (40%) were using biologic therapies including TNF inhibitors(n=16), rituximab (n=6), abatacept (n=2), tocilizumab (n=2) and other (n=5). Among those using non-biologics at baseline (46, 60%), the following therapies were in use: janus kinase (JAK) inhibitors (3, 6.5%), DMARDs (11, 24%) and prednisone (5, 11%). Overall, 82% were hospitalised and 12%) died. Interestingly they found no deaths among the small cohort taking TNF inhibitors or JAK inhibitors.

Not unlike those who come into COVID-19 infection with poor risk factors (e.g., age, CV disease, diabetes), those with "active" RDD or AIRD may do poorly if afflicted with COVID-19 infection, with more hospitalizations, disease severity and possibly deaths.  Other than glucocorticoids, the therapies we used to treat AIRD and RDD do not worsen outcomes and may be protective if you want to make a case for TNF inhibitors, anakinra and maybe tocilizumab or JAK inhibitors.  Our rheumatology guidelines on COVID-19 management should be updated such that we do not reflexly discontinue DMARDs or biologics in those who become infected with COVID-19.