Characteristics associated with poor COVID-19 outcomes in people with psoriasis, psoriatic arthritis and axial spondyloarthritis: data from the COVID-19 PsoProtect and Global Rheumatology Alliance physician-reported registries

Pedro M Machado; Martin Schäfer; Satveer K Mahil; Jean Liew; Laure Gossec; Nick Dand; Alexander Pfeil; Anja Strangfeld; Anne Constanze Regierer; Bruno Fautrel; Carla Gimena Alonso; Carla G S Saad; Christopher E M Griffiths; Claudia Lomater; Corinne Miceli-Richard; Daniel Wendling; Deshire Alpizar Rodriguez; Dieter Wiek; Elsa F Mateus; Emily Sirotich; Enrique R Soriano; Francinne Machado Ribeiro; Felipe Omura; Frederico Rajão Martins; Helena Santos; Jonathan Dau; Jonathan N Barker; Jonathan Hausmann; Kimme L Hyrich; Lianne Gensler; Ligia Silva; Lindsay Jacobsohn; Loreto Carmona; Marcelo M Pinheiro; Marcos David Zelaya; María de los Ángeles Severina; Mark Yates; Maureen Dubreuil; Monique Gore-Massy; Nicoletta Romeo; Nigil Haroon; Paul Sufka; Rebecca Grainger; Rebecca Hasseli; Saskia Lawson-Tovey; Suleman Bhana; Thao Pham; Tor Olofsson; Wilson Bautista-Molano; Zachary S Wallace; Zenas Z N Yiu; Jinoos Yazdany; Philip C Robinson; Catherine H Smith

doi:10.1136/ard-2022-223499

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Spondyloarthritis

Characteristics associated with poor COVID-19 outcomes in people with psoriasis, psoriatic arthritis and axial spondyloarthritis: data from the COVID-19 PsoProtect and Global Rheumatology Alliance physician-reported registries

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Letter to the Editor: comment on the contradiction and standardization of the study.
Chi-Jen Hsu, Mei Na Fok, Peilun Xiao, Chia-Chien Hsu and James Cheng-Chung Wei
Published on: 3 March 2023

Published on: 3 March 2023
Letter to the Editor: comment on the contradiction and standardization of the study.
- Chi-Jen Hsu, doctor Department of Orthopedics, The Fifth Affiliated Hospital of Sun Yat-sen University, Guangdong, China
- Other Contributors:
  Mei Na Fok, doctor
  
  Peilun Xiao, doctor
  
  Chia-Chien Hsu, doctor
  
  James Cheng-Chung Wei, doctor
We have some comments on the retrospective study that looked at risk factors for severe COVID-19 in people with axial spondyloarthritis (axSpA), psoriasis (PsO), and psoriatic arthritis (PsA).1

First, according to the findings of the study, the use of tumor necrosis factor (TNF) inhibitors was associated with decreased probabilities of severe COVID-19 outcomes. The author cites some previous studies using clinical database analysis to support the result. However, in recent research, Rebecca H Haberman et al obtained postvaccination blood samples from participants with immune-mediated inflammatory diseases and healthy controls and analyzed SARS-CoV-2-spike-specific antibody titers and neutralization capacity. Their results showed that TNF inhibitors might lead to a dampened humoral response to COVID-19 vaccinations, and the persistence of an adequate humoral response is significantly decreased by month 6. This finding supports the use of supplemental booster dosing in patients with immune-mediated inflammatory diseases, specifically for those being treated with TNF inhibitors. Larger basic research is required to clarify these contradictions and evaluate the impact of other immunomodulatory strategies, which will assist in determining the appropriate timing and method for COVID-19 vaccinations. 2

Second, based on the results of one sensitivity analysis, Janus kinase (JAK) inhibitor use was associated with a higher risk of death owing to COVID-19 (binary outco...
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We have some comments on the retrospective study that looked at risk factors for severe COVID-19 in people with axial spondyloarthritis (axSpA), psoriasis (PsO), and psoriatic arthritis (PsA).1

First, according to the findings of the study, the use of tumor necrosis factor (TNF) inhibitors was associated with decreased probabilities of severe COVID-19 outcomes. The author cites some previous studies using clinical database analysis to support the result. However, in recent research, Rebecca H Haberman et al obtained postvaccination blood samples from participants with immune-mediated inflammatory diseases and healthy controls and analyzed SARS-CoV-2-spike-specific antibody titers and neutralization capacity. Their results showed that TNF inhibitors might lead to a dampened humoral response to COVID-19 vaccinations, and the persistence of an adequate humoral response is significantly decreased by month 6. This finding supports the use of supplemental booster dosing in patients with immune-mediated inflammatory diseases, specifically for those being treated with TNF inhibitors. Larger basic research is required to clarify these contradictions and evaluate the impact of other immunomodulatory strategies, which will assist in determining the appropriate timing and method for COVID-19 vaccinations. 2

Second, based on the results of one sensitivity analysis, Janus kinase (JAK) inhibitor use was associated with a higher risk of death owing to COVID-19 (binary outcome). In a recent meta-analysis, patients with COVID-19 who were hospitalized did not experience an increase in infections, adverse events, or secondary infections as a result of receiving JAK inhibitor treatment (RR = 0.62, 95% CI: 0.49-0.78).3 Although venous thromboembolism (VTE) risk warnings have restricted their use, JAK inhibitor treatments are still good options for treating immune-mediated inflammatory disorders (IMIDs).4 According to research by Saskia Middeldorp et al, there is a significant observed risk for VTE in COVID-19, especially in patients in the intensive care unit. 5 The usage of JAK inhibitors in IMID patients with COVID-19 requires more evaluation.

Third, the study did not standardize the number of shots of the COVID-19 vaccine, the brand of vaccine, whether there were associated complications after the shots, etc. This may affect the severe COVID-19 outcome of the study. Although the author has stated that in the limitation and explained that the model adjustment for pandemic calendar period used in this study may act as a surrogate for vaccination status, we felt that the impact of the outcome was underestimated. Joseph Fraiman et al pointed out that most of the serious adverse event (SAE)-affected findings are quite typical occurrences, such as ischemic stroke, acute coronary syndrome, and brain hemorrhage. While clinical suspicion of an adverse vaccination reaction following a clinically relevant occurrence will be lower than for SAEs, signal detection is made more difficult as a result. 6

References
1 Machado PM, Schafer M, Mahil SK et al. Characteristics associated with poor COVID-19 outcomes in people with psoriasis, psoriatic arthritis and axial spondyloarthritis: data from the COVID-19 PsoProtect and Global Rheumatology Alliance physician-reported registries. Ann Rheum Dis 2023.
2 Haberman RH, Um S, Axelrad JE et al. Methotrexate and TNF inhibitors affect long-term immunogenicity to COVID-19 vaccination in patients with immune-mediated inflammatory disease. Lancet Rheumatol 2022; 4 (6): e384-e387.
3 Zhang X, Shang L, Fan G et al. The Efficacy and Safety of Janus Kinase Inhibitors for Patients With COVID-19: A Living Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8: 800492.
4 Yates M, Mootoo A, Adas M et al. Venous Thromboembolism Risk With JAK Inhibitors: A Meta-Analysis. Arthritis Rheumatol 2021; 73 (5): 779-788.
5 Middeldorp S, Coppens M, van Haaps TF et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost 2020; 18 (8): 1995-2002.
6 Fraiman J, Erviti J, Jones M et al. Serious adverse events of special interest following mRNA COVID-19 vaccination in randomized trials in adults. Vaccine 2022; 40 (40): 5798-5805.
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Conflict of Interest:
None declared.
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