Patients with rheumatic disease, COVID-19 more likely to require ventilation
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Patients with rheumatic diseases plus COVID-19 are more likely to require mechanical ventilation, but demonstrated similar clinical features and hospitalization rates as those with COVID-19 only, according to data published in the Annals of the Rheumatic Diseases.
“The COVID-19 pandemic has had an incredible impact on every aspect of health care,” Zachary S. Wallace, MD, of Massachusetts General Hospital, told Healio Rheumatology. “In rheumatology, both patients and providers have had understandable concerns regarding the impact that COVID-19 would have on this unique patient population.”
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“We know that immunosuppressive medications put rheumatic disease patients at higher risk for infection so there was worry that this population would be at particularly high risk for COVID-19 and its complications,” he added. “Adding to this potential risk were the many comorbidities — eg, renal disease, hypertension, cardiovascular disease — that patients with rheumatic diseases often suffer from as a result of the underlying condition and its treatment.”
To analyze the differences in COVID-19 manifestations and outcomes among patients with and without rheumatic diseases, D’Silva and colleagues conducted a comparative cohort study of individuals treated within the Partners Healthcare System in the greater Boston area. This system includes Massachusetts General Hospital and Brigham and Women’s Hospital. Participants included 52 patients with rheumatic diseases — 19 with rheumatoid arthritis, 10 with systemic lupus erythematosus, seven with polymyalgia rheumatica, seven with spondyloarthritis, three with myositis, three with vasculitis and one with sarcoidosis — who had tested positive for COVID-19.
Investigators compared these participants in a 1:2 ratio with 104 control individuals, matched based on age, sex and date of COVID-19 diagnosis. The researchers analyzed differences in demographics, as well as COVID-19 clinical features and outcomes. The main outcomes were hospitalization, intensive care admission, mechanical ventilation and mortality.
According to the researchers, 75% of patients with a rheumatic disease were receiving immunosuppressive medications. Patients with and without rheumatic disease had similar symptoms and laboratory findings. Additionally, a similar proportion of patients with and without rheumatic disease were hospitalized — 44% compared with 40%, respectively. Mortality was also similar between the two groups, at 6% among patients with rheumatic disease, compared with 4% among those without.
However, 48% of those with rheumatic disease required intensive care admission and mechanical ventilation, compared with 18% of those with COVID-19 only (multivariable OR = 3.11; 95% CI, 1.07-9.05).
“We found that patients with rheumatic diseases who had COVID-19 had similar odds of being hospitalized as patients without rheumatic diseases,” Wallace said. “However, those with rheumatic diseases, when sick and hospitalized, seemed to have higher odds of needed mechanical ventilation which is worrisome.”
“We do not know if the increased odds of severe respiratory failure are a result of immunosuppression, comorbidities, or other factors,” he added. “More studies will be needed to clarify factors driving these observations. We did not find a different in mortality between those with rheumatic diseases and comparators, but this may be because many of the patients with rheumatic conditions remained hospitalized.”
Perspective
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Paul J. DeMarco, MD, FACP, FACR, RhMSUS
The epidemiological study published by D’Silva and colleagues provides an important look at the hospital trends of patients with rheumatic disease. The researchers compared COVID-19 patients with rheumatic disease receiving active treatment — including patients with rheumatoid arthritis, SLE, polymyalgia rheumatica, spondyloarthropathies, GCA, small vessel vasculitis, adult patients continuing care for JIA and Kikuchi disease — with non-rheumatic disease patients.
It is important to note that risk factors identified for poor outcome during COVID-19 hospitalization is different between the rheumatic disease and the “control” group: Coronary artery disease [CAD] (23 vs. 10, P=.03) and interstitial lung disease [ILD] ( 6 vs.0, P=.01) and obstructive sleep apnea [OSA] (13 vs. 4, P=.03) suggesting that this population of rheumatic disease patients are already more likely to have a complicated hospital course.
While hospitalization and mortality statistics remained similar between the two groups, the patients with rheumatic diseases had a threefold higher likelihood of admission to ICUs or requiring mechanical ventilation. Reviewing the disparity of comorbidities, this may not be as remarkable a finding at it initially appears. If we want to understand the effect of rheumatic disease on the COVID-19 disease state, there must be a strong match between other diseases, otherwise we may be observing the effects of the comorbidity and not the rheumatic disease.
D’Silva and colleagues provided three adjusted models for the ICU/mechanical ventilation effect, but none specifically used the three identified risk factors; rather, adjusted model 3 offers an assessment of a combined age, hypertension, CAD and lung disease. There is no statistical difference between age, hypertension and the general category of pulmonary disease, so the different in ICU management remains static. This analysis favors the effect to be the same. It would have been a much more powerful study to ensure a match of each comorbidity identified, including age between the two groups; much of what we already understand about COVID-19 focus on the importance of comorbidity in outcomes.
This study offers some important insight into COVID-19 in patients with rheumatic illness, but I am not certain the conclusion is justified. Specifically, the researchers believe that patients with rheumatic diseases had a higher rate of ICU admission and mechanical ventilation but do not adequately account for the effect of higher comorbidities of CAD, ILD and OSA. Similar hospitalization rates and similar mortality statistics are very encouraging. I certainly agree that further study is needed.
It remains unclear to me why these studies never use transplant patients as a comparator group, to determine if immunosuppressive use or the disease state act as the cause for a different outcome. Until such a comparison is made, we will never really understand if the active disease or treatment is the source of disparity in outcome. The efforts of D’Silva and colleagues are to be applauded, however, in providing the published data set. Hopefully, larger trials with more prospectively collected data will be made available to rheumatologists in the near future.
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