COVID-19 death data highlights importance of control in rheumatic diseases

Moderate or high disease activity in people with rheumatic disease is significantly associated with a higher risk of death from COVID-19, analysis of data from a large global registry suggests.

The finding highlights the importance of disease control in people with rheumatic diseases, the international team of researchers concluded in the Annals of Rheumatic Diseases.

It follows previous analysis from the COVID-19 Global Rheumatology Alliance physician-reported registry, which was set up in March 2020, which found that older age and comorbidities were associated with hospitalisation, as is the case in the general population.

But this latest paper looking more closely at factors associated with death as well as analysis by disease type and treatment showed a more complex picture.

Of the more than 3,700 patients with rheumatic disease and COVID-19 diagnosis, in the register up to July 2020, 10.5% died. This did vary by country with with the highest proportions in the UK (20.9%) and Italy (16.8%) and lower reported deaths in the US (7.0%), Germany (7.6%), France (7.8%) and Spain (8.5%).

Although there were some of the same risk factors as in the general population, including age, male sex and cardiovascular disease, researchers also found that moderate or high disease activity was associated with 87% higher odds of death (1.27 to 2.77) compared with remission or low disease activity.

Further analysis showed that rituximab, sulfasalazine, use of immunosuppressants (azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus) and not receiving any disease-modifying anti-rheumatic drug (DMARD) were associated with higher risk of death, compared with methotrexate monotherapy.

Other synthetic/biological DMARDs were not associated with COVID-19-related death when compared with methotrexate monotherapy, they reported.

Rates of death seen in this population will be affected by reporting bias and population factors so should not be taken a precise guide for mortality risk, they pointed out.

They called for more research to address the observed association of rituximab and sulfasalazine with poor outcomes. In particularly the association with sulfasalazine was also reported in results from an international registry of patients with inflammatory bowel disease and COVID-19 and is surprising as it is usually considered to have a low immunosuppressive effect, they note.

For some therapies, including interleukin inhibitors, there was not enough data to make any firm conclusions. Trials of IL-6 inhibitors in treating COVID-19, are still ongoing but ‘it is reassuring that they were not associated with COVID-19-related death in our analyses’, the researchers said.

‘There is differential risk of COVID-19-related death according to disease activity and treatments in patients with rheumatic disease, highlighting the need for adequate disease control with DMARDs, preferably without increasing the glucocorticoid dosage,’ they concluded.

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