Statistics from Altmetric.com
The recent outbreak of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for COVID-19, has brought about a great concern for the management of patients with inflammatory rheumatic diseases. Rheumatologists and patients are worried about the risk of contagion and suffering a more severe disease, derived from immunosuppressive treatment. Also, for the risk of relapse in case of discontinuing medications. To date, most of these questions remain to be answered.
Accordingly, we read with interest the recent paper from D’Silva and coauthors.1 They analysed the outcomes of 52 patients with rheumatic diseases (18 under biologics or targeted synthetic disease-modifying antirheumatic drugs (DMARDs)) hospitalised for COVID-19, identifying an independent increased risk of intubation and similar to mortality. These results are welcome and of relevance, but some issues need to be commented. Controls were matched for age, gender and disease duration, but multivariate models repeated adjustment for age. For outcome assessment in COVID-19, some laboratory markers—lymphopenia, troponins2— should have been considered as covariates for the model. Besides, the absence of a denominator (population with rheumatic diseases without COVID-19) impedes assessing susceptibility.
Other related works have been published. Monti et al 3 described, after a survey among 320 patients with rheumatic diseases under biological DMARDs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs), eight (2.50%) cases of COVID-19 (four PCR proven), none requiring hospitalisation.
Another survey,4 among 520 patients with inflammatory rheumatic diseases under immunosuppressive treatment, found three (0.58%) cases with COVID-19, one of them hospitalised.
Haberman et al 5 reported a similar incidence of hospitalisation after SARS-CoV-2 contagion in patients with immune-mediated inflammatory diseases than in New York City general population (16% vs 26%, respectively).
Spain is one of the most affected European countries by SARS-CoV-2 infection.6 In Alicante health area (274 122 inhabitants coverage), 306 (0.11%) people have been admitted for severe COVID-19 infection from 3 March to 2 May2020.
In Alicante rheumatology clinics, we see patients with rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, connective tissue diseases, vasculitis, idiopathic juvenile arthritis and other inflammatory conditions such as uveitis, Behcet’s disease, adult-onset Still disease, relapsing polychondritis or IgG4-related disease. Most of them are under conventional DMARDs, and 1037 patients receive bDMARDs or tsDMARDs at the time of the analysis. In accordance to European League Against Rheumatism (EULAR),7 since the pandemic outbreak we advise patients to continue with immunosuppressive therapy (unless patients present symptoms like fever or respiratory symptoms) and, unquestionably, to take measures to prevent contact from infected subjects and virus spread.
Up to 2 May 2020, three (0.29%) patients were hospitalised due to COVID-19 infection. Rheumatic diagnoses were rheumatoid (n=2) and psoriatic (n=1) arthritis (table 1), on anti-TNFα or JAK-inhibitor, and one also received hydroxychloroquine and methotrexate.
All of them were treated for COVID-19 with hydroxychloroquine, two of them combined with azithromycin, and patient 3 also received corticosteroids and colchicine. Unlike D’Silva data,1 none of them required oxygen supply, intensive care or mechanical ventilation. As collateral complications, patient 2 developed acute pyelonephritis. Evolution was favourable in all cases and were discharged after a few days.
Therefore, the occurrence of COVID-19 hospitalisation was 0.29% (3/1037) in patients with rheumatic diseases under bDMARD/tsDMARD, and 0.11% (306/274122) in Alicante population without biologics for rheumatic diseases. Estimated OR was 2.61 (95% CI 0.84 to 8.16) for COVID-19 hospitalisation.
Patients with rheumatic diseases usually require immunosuppressive therapy to achieve disease control, but with a parallel risk of infection. However, during this pandemic, in our health area from a country with high impact of COVID-19, we have noted no increased risk of developing severe COVID-19 compared with the general population. Even the severity of the identified cases might be questionable, as no oxygen support, use of tocilizumab or mechanical ventilation was required; on the other hand, as COVID-19 derives from a hyperinflammatory reaction to SARS-CoV-2, perhaps biologics and DMARDs would have impeded a more aggressive disease. Considering the limitations of D’Silva data,1 this report and previous papers3–5 support the advice to maintain bDMARD/tsDMARD in patients with immune-mediated inflammatory disease during the SARS-CoV-2 pandemic.
Contributors VJ and MA designed the study and wrote the first draft. All authors took part in acquisition of data and approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.