COVID-19 registries for rheumatology patients show 'reassuring' trends
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While certain rheumatology drugs are associated with increased hospitalizations in COVID-19, individuals with rheumatologic diseases largely experience outcomes comparable to general population, according to a presenter at the Biologic Therapies Summit.
Jinoos Yazdany, MD, MPH, vice-chair of real-world data infrastructure, registry and IRB/Ethics for the Global Rheumatology Alliance, covered three main questions in her talk. One was whether patients on immunosuppressive drugs were more susceptible to initial SARS-CoV-2 infection; the second pertained to outcomes of the infection in patients being treated with those drugs; and the third dealt with outcomes associated with specific immunosuppressive therapies.
“Thinking back to the early days of the pandemic, we were all wondering what the risk factors were [for rheumatic disease patients],” she said.
Before research into this patient population materialized, a number of risk factors for the general population emerged, including cardiovascular disease, hypertension, diabetes, chronic lung disease, cancer, kidney disease and obesity. “Of course, age was far and away the strongest risk factor,” Yazdany added.
With that, she reviewed some of the data that have since emerged for the rheumatology population.
Early findings for 955 patients in Italy demonstrated comparable COVID-19 incidence rates in patients with rheumatologic diseases and the general population. “These were very reassuring data early in the pandemic,” Yazdany said.
Data for more than 1,000 patients from Hong Kong showed that only five individuals in the study population had a rheumatic or autoimmune disease. “Again, the rate was similar to the general population,” Yazdany said.
Early data for patients being treated with immunosuppressive drugs for inflammatory bowel disease in the U.S. showed a similar trend, according to Yazdany.
“There is a caveat here, and that is that people who are immunosuppressed may be more likely to follow COVID-19 precautions,” Yazdany said. “But based on these data, they do not have increased risk of initial infection.”
Regarding the second question, Yazdany referenced findings from early in the pandemic for some 17 million individuals in the U.K. The study looked at the primary outcome of in-hospital mortality.
“Again, age was the strongest risk factor for poor outcomes,” Yazdany said, noting that comorbidities ranging from obesity to poverty also carried associations with mortality.
While rheumatoid arthritis, lupus and psoriasis carried a slightly higher risk for mortality, Yazdany noted that the risk was not as high as those reported for hematologic malignancies and the other aforementioned comorbidities.
Turning to data from the U.S., a study in a New York hospital showed that hospitalizations were comparable for rheumatology patients and non-rheumatology patients. A study at Harvard, however, showed increased risk for hospitalization and ICU admission for individuals with rheumatic and autoimmune diseases. “What was interesting was that after other comorbidities were added to the analysis, these risks were attenuated,” Yazdany said.
Registry data from Denmark and Sweden yielded “remarkably similar” outcomes, with hospitalization risk slightly higher in rheumatology compared with the general population. However, Yazdany noted that the curves separate with age.
“What do all of these studies tell us?” she said. “It is clear that risk of [poorer outcomes] is really tied to age and comorbidities.”
While the risk for hospitalization is indeed higher for those with rheumatic and autoimmune diseases, Yazdany believes that the sum total of these data is, “relatively reassuring.”
To that point, the American College of Rheumatology and EULAR agree. “ACR and EULAR guidelines say immunosuppressives should be continued,” Yazdany said.
Turning to the final question pertaining to specific immunosuppressive drugs, Yazdany suggested that the Global Rheumatology Alliance Registry has been a critical resource in helping clinicians understand the risks associated with the drugs used by patients.
Early data showed that a prednisone dose of more than 10 mg per day was associated with an increased risk of hospitalization, while TNF inhibitor users had lower hospitalizations.
Slightly higher mortality risks have been associated with a number of drugs in the rheumatology armamentarium, including sulfasalazine, mycophenolate mofetil (MMF; CellCept, Genentech), tacrolimus, azathioprine and cyclophosphamide. “The drug with the highest risk of mortality is rituximab [Rituxan, Genentech],” Yazdany said. “And, again, there is a signal for steroids.”
That said, Yazdany underscored the necessity of keeping patients on treatment. “It is important to control disease activity,” she said. “Patients should follow up and get care during the pandemic. Uncontrolled disease is a risk factor for doing poorly with COVID-19.”
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Yazdany J. What have registries taught us? Presented at: Biologic Therapies Summit IX; May 21-23, 2021 (virtual meeting).
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