Steroid use increases COVID-19 hospitalization risk for patients with rheumatic diseases
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Moderate to high glucocorticoid use, defined as 10 mg per day or more, is associated with a greater risk for hospitalization for COVID-19 among patients with rheumatic disease, according to data published in Annals of the Rheumatic Diseases.
“In general, immunosuppression and the presence of comorbidities are associated with an increased risk [for] serious infection in people with rheumatic diseases; therefore, people with rheumatic disease may be at higher risk for a more severe course with COVID-19, including hospitalization, complications and death,” Milena Gianfrancesco, PhD, MPH, of University of California, San Francisco, and colleagues wrote.
“Importantly, some medications used to treat rheumatic diseases, such as hydroxychloroquine and interleukin-6 (IL-6) inhibitors, are being studied for the prevention and/or treatment of COVID-19 and its complications, including cytokine-storm,” they added. “At present, the implications of COVID-19 for people living with rheumatic diseases remain poorly understood.”
To analyze the demographic and clinical factors linked to COVID-19 hospitalization among patients with rheumatic disease, Gianfrancesco and colleagues studied data from the COVID-19 Global Rheumatology Alliance registry. Established in March, the global registry contains data on more than 1,400 cases reported by 288 organizations and more than 300 investigators. Focusing on information reported from March 24 to April 20, the researchers included 600 cases of COVID-19 among patients with rheumatic diseases across 40 countries.
Gianfrancesco and colleagues used multivariable logistic regression to estimate odds ratios and confidence intervals for hospitalization. Analyzed data included patients’ age, sex, smoking status, rheumatic disease diagnosis, comorbidities and rheumatic disease medications taken immediately prior to infection.
According to the researchers, 46% of included patients were hospitalized and 9% died. In the researchers’ multivariable-adjusted models, prednisone doses of 10mg per day or more were associated with a greater risk for hospitalization (OR = 2.05; 95%CI, 1.06-3.96). Meanwhile, conventional DMARDs, either alone (OR = 1.23; 95%CI, 0.7-2.17) or in combination with biologics or JAK inhibitors (OR = 0.74; 95%CI, 0.37-1.46), were not associated with hospitalization. NSAIDs similarly were not associated with hospitalization for COVID-19 (OR = 0.64; 95%CI, 0.39-1.06).
Anti-TNF therapy was associated with a decreased risk for hospitalization (OR = 0.4; 95%CI, 0.19-0.81). Antimalarials had no impact on hospitalization (OR = 0.94; 95%CI, 0.57-1.57).
“This manuscript describes the largest collection of COVID-19 cases among patients with rheumatic diseases, with 600 cases from 40 countries,” Gianfrancesco and colleagues wrote. “We identified factors associated with higher odds of COVID-19 hospitalization, including older age, presence of comorbidities and higher doses of prednisone (10mg/day). We did not see an association between prior NSAID use or antimalarials and hospitalization for COVID-19.”
“We did find b/ts DMARD monotherapy to be associated with lower odds of hospitalization, an effect that was largely driven by anti-TNF therapies,” they added. “Over half of the reported cases did not require hospitalization, including many patients receiving b/ts DMARDs. The rate of hospitalization was higher than in cohorts of general patients with COVID-19, but this likely reflects the mechanism by which we collected the case information and should not be interpreted as the true rate of hospitalization among patients with rheumatic disease infected with SARS-CoV-2.”
Perspective
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Barbara Kienzle, BSN, RN
It is astounding the amount of information available concerning all aspects of COVID-19. Much of what is reported in the media and scientific journals does not address risks of COVID-19 for individuals with rheumatic diseases. The formation of the COVID-19 Global Rheumatology Alliance and subsequent Adult and Pediatric Registries will provide real world information on how COVID-19 effects our rheumatology patients.
Gianfrancesco and colleagues compiled early information from the Global Rheumatology Alliance adult database looking for commonalities that lead to hospitalization for COVID-19 in individuals with rheumatic disease. A key takeaway point of this analysis for rheumatology health care providers is that age (>65 years old), comorbidities (hypertension, lung disease, diabetes) and use of glucocorticoids (>10 mg/day) put our patients at higher risk of hospitalization should they contract COVID-19. Additionally, use of common synthetic DMARDs and biologic/targeted synthetic DMARDs reduce the chance of hospitalization for COVID-19 while use of NSAIDs and disease activity at the time of illness has little effect on the rate of hospitalization.
This is vital information to pass on to our patients as we continue to educate them on the benefits of a healthy lifestyle and affirms the American College of Rheumatology’s recommendation of continuing immunosuppressing therapy throughout this COVID-19 pandemic.
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David A. McLain, MD, FACP, FACR
This is a very pertinent article during the COVID-19 pandemic as it impacts rheumatology. On a daily basis, we are being asked by patients on conventional synthetic DMARDs and biologics if they are at increased risk for developing COVID.
This article used a large rheumatologist-generated database to examine the issue of medication use for rheumatic conditions and the risk of hospitalization for COVID. The results reveal that the major risk factor for our patients developing COVID and being hospitalized is treatment with corticosteroids, with moderate to high doses of corticosteroids associated with an increased risk of hospitalization with COVID.
This is consistent with other reports of an increased risk of infection with increasing doses of steroids; on the other hand, TNF inhibitors were found to lower the risk of hospitalization. This was a welcome surprise. Conventional synthetic DMARDs — including hydroxychloroquine —had no effect on the risk of hospitalization. This article is reassuring to us, the rheumatology clinicians, and our patients with regards to our treatment with csDMARDs and biologic DMARDS during this pandemic.
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