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Impact of COVID-19 pandemic on patients with SLE: results of a large multicentric survey from India
  1. Mohit Goyal1,
  2. Pravin Patil2,
  3. Himanshu Pathak3,
  4. Sham Santhanam4,
  5. Anshul Goel5,
  6. Vishnu Sharma6,
  7. Akshat Pandey7,
  8. Nikhil Gupta8,
  9. Rahul Jain9,
  10. Shashank Akerkar10,
  11. Parthajit Das11,12,
  12. Rajkiran Dudam13,
  13. Naval Mendiratta14,
  14. Bimlesh Dhar Pandey15,
  15. Mithun CB16,
  16. Bharat K Singh17,
  17. Sharath Kumar18,
  18. Nilesh Nolkha19,
  19. Shriyanka Jain20,
  20. Somya Jain21,22,
  21. Ashish Sharma15,
  22. Durga Prasanna Misra23
  1. 1 Division of Rheumatology, CARE Pain & Arthritis Centre, Udaipur, India
  2. 2 Apex Centre of Rheumatology, Pune, India
  3. 3 Department of Rheumatology, Tricolour Hospitals, Vadodara, India
  4. 4 Department of Rheumatology, Gleneagles Global Hospital, Chennai, India
  5. 5 Department of Rheumatology, Vivekanand Medical Institute, Palampur, India
  6. 6 Department of Rheumatology, Apollo Hospitals International Limited, Ahmedabad, India
  7. 7 Department of Rheumatology, Apollo Hospitals, Indore, India
  8. 8 Centre for Arthritis and Rheumatological Diseases, Delhi, India
  9. 9 Department of Rheumatology, Narayana Multispecialty Hospital, Jaipur, India
  10. 10 Mumbai Arthritis Clinic, Mumbai, India
  11. 11 Department of Rheumatology, Apollo Gleneagles Hospital, Kolkata, India
  12. 12 Department of Rheumatology, Vivekananda Institute of Medical Sciences, Kolkata, India
  13. 13 Hyderabad Rheumatology Centre, Hyderabad, India
  14. 14 Department of Rheumatology, Fortis Memorial Research Institute, Gurgaon, India
  15. 15 Division of Rheumatology, Fortis Hospital, Noida, India
  16. 16 Department of Clinical Immunology & Rheumatology, Amrita Institute of Medical Sciences, Kochi, India
  17. 17 Department of Rheumatology & Clinical Immunology, Santokba Durlabhji Memorial Hospital, Jaipur, India
  18. 18 OPTIMA Arthritis and Rheumatology Clinics, Bengaluru, India
  19. 19 Wockhardt Hospitals, Mumbai, India
  20. 20 Division of Rheumatology, Ram Krishna Care Hospital, Raipur, India
  21. 21 Department of Rheumatology, AKJ Healthcare and Diagnostics, Saharanpur, India
  22. 22 Department of Rheumatology, Max Super Speciality Hospital Dehradun, Dehradun, India
  23. 23 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
  1. Correspondence to Dr Mohit Goyal, Rheumatology, CARE Pain & Arthritis Centre, Udaipur 313002, India; dr.mohitgoyal{at}gmail.com

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We have read the recent report by Mathian et al with great interest where they described the clinical course of COVID-19 in 17 patients with systemic lupus erythematosus (SLE).1 The COVID-19 pandemic has caught the attention of the rheumatology fraternity due to a variety of reasons, such as the in vitro inhibition of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by hydroxychloroquine (HCQ),2 use of tocilizumab in the treatment of cytokine storm3 and concerns regarding cardiac toxicity due to HCQ.4 Patients with SLE are routinely prescribed HCQ and other immunosuppressants. The clinical picture of COVID-19 (such as pneumonia, cardiac injury, renal injury, venous thrombosis and septic shock) in patients with SLE on long-term HCQ described by Mathian et al intrigued the global rheumatology community.1 We assessed the impact of the pandemic on Indian patients with SLE in a larger multicentric survey. We expected that differences in disease expression, ethnicity and treatment may possibly alter the impact of the pandemic in contrast to the aforementioned study. We included patients who had visited their rheumatologist at least once in the preceding 1 year and surveyed them telephonically.

Twenty rheumatology centres across 18 cities in India collaborated, and 845 patients (women 92%, mean (±SD) age 34.8±12 years) with SLE were surveyed. Among these, 9.7% had hypertension; 3.8% had diabetes; and 0.9% had both. At the time of the survey, 813 (96.2%) patients were on HCQ (mean (±SD) dose 257.9±99 mg per day, mean (±SD) duration 30.8±30.7 months). Two-third of patients (559) were on glucocorticoids at a mean (±SD) dose of 6.9±6.8 mg prednisolone equivalent per day.

India reported its first COVID-19 case on 30 January 2020,5 and at the time of the completion of this 3-day survey (on 5 May 2020), there were 46 711 positive cases and 1583 deaths in the country.6 Of the 845 patients surveyed, two had tested positive for SARS-CoV-2. A total of 17 patients reported fever (more than 100°F), cough and/or shortness of breath in the preceding 3 months. The symptoms in these patients were not attributable to SLE. Two of these 17 patients were tested for SARS-CoV-2, and one was found to be positive. The patient who tested positive had been hospitalised for 2 days at the time of the completion of the survey. Symptoms of the remaining 16 patients resolved without any complications (see online supplementary figure S1). Five patients in our cohort, of whom three were healthcare workers, had been traced as close contacts of diagnosed COVID-19 cases. Three of these patients were advised only isolation, whereas two were also tested for SARS-CoV-2. One of these two patients tested positive but remains asymptomatic. Table 1 shows the characteristics of patients with confirmed and suspected COVID-19. For clinical features of patients with confirmed COVID-19, state-wise data of patients surveyed, summary of survey findings and comparisons between groups, see online supplementary tables S1–4.

Table 1

Demographics and clinical characteristics of patients with SLE with confirmed or suspected COVID-19

The patients were also asked if they had palpitations or other cardiac problems ever since initiation on HCQ. None of the 845 patients reported any such symptoms or instances where a symptom was attributed to HCQ by any other doctor.

While in our survey, use of various immunosuppressants by patients with SLE did not result in a high incidence of COVID-19 and a worse outcome, more extensive studies are required to answer this question satisfactorily. Another possible explanation is the fact that a majority of the patients participating were ensuring all possible measures to protect themselves from infection while being on immunosuppressants. While we must monitor all our patients closely during this pandemic, there appears to be neither rationale nor evidence for withdrawing immunosuppressant medications as a preventive strategy for COVID-19. Lack of appropriate comparator group with patients not on HCQ and a low number of either confirmed or suspected COVID-19 patients did not allow us to draw meaningful conclusions regarding the role of HCQ in COVID-19. We plan to follow-up these patients and resurvey the same cohort once the pandemic settles.

Acknowledgments

The authors thank Professor Vikas Agarwal and Dr Vinod Ravindran for their valuable inputs towards the study.

References

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Footnotes

  • Twitter @drmohitgoyal, @RajkiranDudam

  • Contributors Study conception: MG and PP. Study design, data analysis and drafting the manuscript: MG, PP, HP, SS, AG and DPM. Data collection, revising the manuscript and final approval of the manuscript: all authors.

  • 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, conduct, reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This was a survey of practices, and surveys of this nature are exempt from ethics committee review as per local guidelines (see online supplementary text).

  • Provenance and peer review Not commissioned; internally peer reviewed.

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