Increased Risk of COVID-19 in Patients With Autoimmune Diseases, Glucocorticoid Use Plays a Role
By Denise Baez
NEW YORK -- October 15, 2020 -- Patients with autoimmune diseases appear to have an increased risk of coronavirus disease 2019 (COVID-19), primarily attributed to glucocorticoid use, although their clinical outcomes were not considerably worse when compared with individuals without autoimmune diseases, according to a meta-analysis published in the Annals of the Rheumatic Diseases.
The study also found that monotherapy with biologic or targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) was associated with a lower risk of severe COVID-19, suggesting its safety in the COVID-19 pandemic.
Shintaro Akiyama, MD, University of Chicago Medicine, Chicago, Illinois, and colleagues scrutinised data from 62 observational studies including 319,025 patients with autoimmune diseases from 15 countries.
Rheumatic diseases included rheumatoid arthritis, lupus, psoriatic arthritis, spondyloarthritis, ankylosing spondylitis, vasculitis, polymyalgia rheumatica, Sjögren’s syndrome, systemic sclerosis, and other autoimmune-mediated diseases, including Behcet’s syndrome, sarcoidosis, and inflammatory myopathies.
Of the 319,025 patients, 879 tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), for an event rate of 0.011.
Patients with lupus, Sjögren’s syndrome, and systemic sclerosis had a higher prevalence of COVID-19 (58 of 1,641; event rate of 0.034) when compared with the other disease groups, which is likely due to a higher proportion of glucocorticoid use (60.3%). Patients with irritable bowel disease had the lowest prevalence (309 of 251,568; event rate of 0.003).
When the researchers analysed 7 case-controlled studies to compare the prevalence of COVID-19 in patients with and without autoimmune diseases, the results showed that out of 30,771 patients with autoimmune diseases, 278 tested positive for COVID-19 compared with 144,283 of 24,511,773 individuals without autoimmune diseases (odds ratio = 2.19; 95% confidence interval [CI], 1.05-4.58; P = .038). These 7 studies only included individuals with psoriasis (OR = 3.43; 95% CI, 1.68-7.01; P = .001) and rheumatic diseases (OR = 1.60; 95% CI, 1.13-2.25; P = .008), both of which demonstrated an elevated risk of COVID-19 compared with controls.
The researchers also assessed 65 studies that included a total of 2,766 patients with autoimmune diseases who tested positive for COVID-19. Among this group, 1,102 patients were hospitalised, for an event rate of 0.352, and 188 patients died, for a rate of 0.066.
“Patients with rheumatic diseases had the highest mortality rate, which was consistent with the analysis of the hospitalisation rate,” the authors noted.
Another analysis of 6 case-controlled studies showed no differences in hospitalisations (OR = 1.05; 95% CI, 0.78-1.42; P = .73), death (OR = 0.55; 95% CI, 0.081-3.68; P = .53), admission to the intensive care unit ([ICU] OR = 1.22; 95% CI, 0.42-3.60: P = .72), or mechanical/non-invasive ventilation (OR = 1.03; 95% CI, 0.22-4.81; P = .97) when compared with the control population.
“Subgroup analyses according to comorbidities showed that patients age ≥64 years, male gender, hypertension, diabetes, body mass index ≥30, and at least 1 comorbidity had higher rates of hospitalisation, ICU admission, ventilation, and death due to COVID-19 when compared with those without these comorbidities,” the authors wrote. “Subgroup analyses according to medical therapies showed that patients treated with glucocorticosteroids, conventional synthetic DMARDs, or a combination of biologic/targeted synthetic DMARDs and conventional synthetic DMARDs had a 2 to 3 times higher event rate of each clinical outcome when compared with those treated with biologic or targeted synthetic DMARD monotherapy. Importantly, patients with anti-tumour necrosis factor (TNF) monotherapy use tended to have a lower rate of hospitalisation and mortality when compared with those with non-TNF-targeted monotherapy.”
“This study is the first comprehensive meta-analysis which determined the prevalence and clinical outcomes of COVID-19 in autoimmune diseases,” the authors concluded. “Our study suggests that glucocorticoid use increases the risk of SARS-CoV2 infection and might contribute to the higher prevalence of COVID-19 in [patients with] autoimmune disease.”
SOURCE: Annals of the Rheumatic Diseases