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The paper by Akiyama et al 1 on the prevalence and clinical outcomes of COVID-19 in patients with autoimmune diseases was an interesting read. This systematic review and meta-analysis indicates that glucocorticoid usage increases the risk of developing COVID-19, while monotherapy with biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs, particularly antitumour necrosis factor (TNF) monotherapy, has been associated with a decreased risk of developing severe COVID-19 and related mortality.1 However, certain methodological issues in this meta-analysis study need to be addressed. First, the efficacy and safety of glucocorticoid usage in patients with COVID-19 remain controversial. Glucocorticoids may play a beneficial role in the treatment of COVID-19; a prospective meta-analysis of clinical trials on patients with COVID-19 revealed that administration of systemic corticosteroids was correlated with a lower all-cause mortality rate.2 In addition, glucocorticoid use was linked with active disease, which was associated with a higher probability of infection with COVID-19.3 Therefore, we cannot exclude the possibility that the positive association between the use of glucocorticoids and an increased risk of developing COVID-19 in patients with autoimmune diseases may depend on the concordant effect of disease activity. To prevent the impact of potential confounding factors in meta-analyses, it would be appropriate to analyse the data after adjusting for the confounding risk factors. Second, another meta-analysis had revealed that the mortality rate in tocilizumab-treated patients was lower than that in patients with COVID-19.4 Unlike other bDMARDs, tocilizumab therapy can be continued in patients with COVID-19.5 Investigations on the relationship between serum interleukin 6 and TNF levels and COVID-19 indicated that tocilizumab and anti-TNF agents could reduce mortality in patients with COVID-19.6 However, the current meta-analysis indicated that compared with anti-TNF agents, non-TNF antagonists were not significantly correlated with a reduced probability of mortality.1 Further analysis will be required to confirm whether tocilizumab is associated with decreased mortality in patients with COVID-19 in a manner similar to that observed in case of TNF inhibitors. Therefore, I believe that the results of Akiyama et al 1 should be interpreted considering the methodological issues mentioned above.
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.
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