Inflammatory joint diseases confer 'low excess risk' for COVID-19 hospitalization, death
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During the early months of the COVID-19 pandemic, increased all-cause mortality in patients with rheumatoid arthritis and other inflammatory joint diseases largely mirrored that of the general population, according to data.
Meanwhile, average absolute risks for hospitalization, intensive care admission and death due to COVID-19 in patients with inflammatory joint diseases were low, albeit higher than in the general population, the researchers wrote. In addition, they found that, with the possible exception of rituximab (Rituxan; Genentech, Biogen) and JAK inhibitors, antirheumatic therapy does not significantly impact the risk for severe COVID-19.
“The SARS-CoV-2 pandemic has raised concerns regarding its impact in individuals with chronic inflammatory joint diseases (IJDs) such as rheumatoid arthritis (RA), with a morbidity and mortality pattern already higher than in the general population, and with treatments (disease-modifying antirheumatic drugs) on the one hand linked with increased risks for serious infections, and on the other hand suggested to exert beneficial effects on severe COVID-19,” Hannah Bower, PhD, MSc, of the Karolinska Institute, in Stockholm, and colleagues wrote in the Annals of the Rheumatic Diseases.
“These concerns have led to considerable challenges in clinical practice and for patient counselling,” they added. “Commendable efforts to address these questions have been carried out. While providing preliminary evidence, interpretation of these results is not straightforward.”
To assess the absolute and relative risks for all-cause mortality and severe COVID-19 in patients with inflammatory joint diseases, as well as for various antirheumatic drugs, Bower and colleagues analyzed data from several nationwide, multi-register Swedish linkages. Using these registers, the researchers identified 53,455 adults with RA, as well as 57,112 adults with other inflammatory joint diseases —spondyloarthropathies, psoriatic arthritis or juvenile idiopathic arthritis — in March 2020.
Bower and colleagues then compared annual all-cause mortality from March through September for the years 2015 through 2020, within and across cohorts. In addition, they used Cox regression to estimate the absolute and relative risks for hospitalization, intensive care admission and death due to COVID-19 for March through September in 2020.
According to the researchers, the absolute all-cause mortality among patients with RA or other inflammatory joint diseases was higher during March 2020 through September 2020 than in 2015 through 2019. However, relative risks compared with the general population remained similar.
Specifically, unadjusted models demonstrated an increased mortality among adults with RA (HR = 1.99; 95% CI, 1.84-2.16), and other inflammatory joint diseases (HR = 1.52; 95% CI, 1.34-1.73), during March 2020 through September 2020. HRs for 2020 were not different from those of 2015 through 2019, according to the researchers.
Moreover, once adjusted for comorbidities and socioeconomic factors, most of the increased mortality in patients with RA (adjusted HR = 1.18; 95% CI 1.09-1.28), and all of the increased mortality in those with other inflammatory joint diseases (adjusted HR = 0.96; 95% CI, 0.84-1.09) in 2020 vanished.
Meanwhile, the risk for hospitalization due to COVID-19 during March through September 2020 among all patients with inflammatory joint disease was 0.5%, compared with 0.3% in the general population. The risks for intensive care admission due to COVID-19 were 0.04% and 0.03%, respectively, while the risks for death due to COVID-19 were 0.1% and 0.07%, respectively.
Antirheumatic drugs were not associated with an increased risk for serious COVID-19 outcomes. However, precision was limited for rituximab and JAK inhibitors, necessitating further verification.
“The increased risks of hospitalization and death due to COVID-19 among patients with IJDs largely mirror those in the general population, at least in relative terms,” Bower and colleagues wrote. “In absolute terms, risks and excess risks are low.”
“[Conventional synthetic] DMARDs, TNF inhibitors, abatacept and tocilizumab as used in clinical practice appear safe, but signals for rituximab and JAK [inhibitors] require verification to determine whether these are specific to COVID-19 or reflective of channeling,” they added. “Finally, in demonstrating that the overall mortality in unselected patients with IJDs remains markedly elevated compared with the general population, also in the absence of COVID-19, our study serves as a reminder of a remaining large unmet need.”
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