COVID-19 study good news for rheumatic disease patients on immunosuppressants

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A European League Against Rheumatism (EULAR) database containing information on the effects of COVID-19 on patients with rheumatic and musculoskeletal diseases has given some reassurance to patients taking immunosuppressants.

The drugs studied by the team include anti-malarial drugs, methotrexate, biological therapies such as TNF-alpha inhibitors, and nonsteroidal anti-inflammatory drugs such as Naproxen. None of them were associated with hospitalisation and more severe COVID-19 disease among patients who had COVID-19 infection.

The drugs work by suppressing a patient’s overactive immune system which attacks its human host.

Immunosuppressant drugs are thought to contribute to increased risk of more severe COVID-19 disease and many patients taking them are regarded as extremely vulnerable by the UK Government Shielding scheme.

However, treatment with more than 10 mg prednisone per day – corresponding to a moderate to high dose – was associated with a higher probability of hospitalisation.

Prednisone is a steroid frequently used in rheumatology as a fast-acting anti-inflammatory drug.

The study is published in Annals of Rheumatic Diseases.

The current advice for patients is to continue their rheumatology treatments and this advice remains unchanged.

Any patient thinking of changing or stopping their medication should discuss this with their rheumatologist as the benefits of remaining on therapy are still thought to outweigh the risks.

The team did not study the use of immunosuppressants in the context of other diseases and so are not able to say if they are associated with a reduced risk of severe COVID-19 disease in those cases’ However. databases in inflammatory bowel disease and psoriasis are also capturing information.

Kimme Hyrich, Clinical Professor of epidemiology at The University of Manchester took part in the study.

She said: “This paper represents an important step forward for rheumatology. This is one of the largest collections of patients with rheumatic diseases who have acquired COVID. Although this is a biased sample towards those with more severe infection, it shows that a majority of patients recovered from COVID, including those admitted to hospital.”

Professor Hyrich, who is also an Honorary Consultant in Rheumatology at Manchester Royal Infirmary, part of Manchester University NHS Foundation Trust, said “Within the database, we have not observed any strong relationship between disease modifying anti-rheumatic drugs (DMARDs) and development of severe Covid. This initial report is reassuring.”

The EULAR team analysed 600 COVID-19 cases in rheumatic disease patients from 40 countries from the combined EULAR and Global Rheumatology Alliance COVID-19 registries, from 24 March to 20 April.

Rheumatologists from across the world joined forces to establish an international COVID-19 registry , with EULAR creating a mirror COVID-19 registry as a response to the pandemic as data on the course of COVID-19 in patients with rheumatic conditions is rare.

“There is considerable uncertainty about the drug management in the context of rheumatic conditions,” EULAR President Professor Dr Iain B. McInnes from Glasgow.

This paper represents an important step forward for rheumatology. This is one of the largest collections of patients with rheumatic diseases who have acquired COVID. Although this is a biased sample towards those with more severe infection, it shows that a majority of patients recovered from COVID, including those admitted to hospital

Professor Kimme Hyrich

The researchers controlled for age, sex, cigarette smoking, rheumatic disease diagnosis, comorbidities and medication taken immediately before to infection.

“There is an urgent need to understand the outcome of patients who have been infected with SARS-CoV-2 while at the same time receiving steroids, synthetic or biological disease-modifying anti-rheumatic drugs and nonsteroidal antiinflammatory drugs,” Dr Pedro Machado, Chair of the EULAR Standing Committee on Epidemiology and Health Services Research and co-senior author of the study, said.

“This will support rheumatologists and other health care professionals, such as specialist nurses, in advising their patients and improving their care.”

Less than half of the patients on the databases required hospitalisation (277; 46 percent), and 55 fatalities – or 9 percent – of the patients died.

However, the team say the true rate of hospitalisation and death among patients with rheumatic disease infected with SARS-CoV-2 was much lower, although exact rates are not known and may differ between different conditions and different therapies.

The database is also currently limited on which immunosuppressive drugs it can look at and some less common drugs will require more data and more time before any further conclusions can be made.

“Because of the mechanism by which case information is collected, severe cases are more likely to be reported to the database and mild or asymptomatic cases are less likely to be reported,” added Professor Hyrich.

“In particular, as many countries, such as the UK did not have widespread community testing at the outbreak of the pandemic, patients who had mild disease who did not require medical attention may not have reported this to their rheumatologist and therefore would not be included in this database.

“That artificially increases the estimated rate of hospitalisation/death in the group of reported patients.”

The study ‘Characteristics associated with hospitalization for COVID-19 in people with rheumatic disease: Data from the COVID-19 Global Rheumatology Alliance Physician-Reported Registry’ is available on request and published in Annals of Rheumatic Diseases.


The University of Manchester


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