COVID-19 outcomes more severe for vasculitis patients taking steroids

Steroid use and comorbid respiratory disease have been identified as significant predictors of severe outcomes in vasculitis patients with COVID-19 in a UK study.

On the back of their findings, the authors which include Dr Matthew Rutherford, a Clinical Research Fellow (Immunology) at Glasgow University, recommend that patients who fit this profile ‘should be closely monitored when presenting with COVID-19, since their risk of progression to a severe state appears to be higher’.

The cohort study, based on registry data from the UK and Ireland, included 65 patients with systemic vasculitis who developed COVID-19, of whom 38% experienced a severe outcome, defined as a need for advanced oxygen therapy or invasive ventilation, or death. Almost all patients – 91% – required hospitalisation, while 11% were admitted to intensive care and 28% died.

The study, published in Arthritis and Rheumatology, found that patients with comorbid respiratory disease, such as chronic obstructive pulmonary disease, asthma and interstitial lung disease, were more than seven times more likely to experience a severe outcome than those without, while patients who had been receiving glucocorticoids were nearly four times more likely to than those who hadn’t.

The authors note that the association between glucocorticoids and worse COVID-19 disease outcomes is “consistent with findings from across the rheumatic autoimmune spectrum”, but conflict with findings from the RECOVERY trial, which showed that low-dose dexamethasone actually had a substantial survival benefit in patients hospitalised with COVID-19.

However, they point out that the patients who benefitted from the glucocorticoid dexamethasone in RECOVERY were those requiring supplemental oxygen, with the greatest benefit observed in those requiring mechanical ventilation, and suggest that “prior to requiring oxygen, it may be that glucocorticoids are deleterious, as observed in this and other studies of autoimmune disease”.

The data did not reveal a link between vasculitis disease activity and treatment with nonglucocorticoid immunosuppressants, such as rituximab and cyclophosphamide, which the study authors said was reassuring given that current guidelines stressed the importance of maintaining immunosuppressive treatment among uninfected patients.

The study is the first to describe a cohort of vasculitis patients with COVID-19. However, as a much larger proportion of patients had small vessel vasculitis (SVV) than giant cell arteritis (GCA), authors stress that “the extent to which its findings can be generalised to other vasculitides is limited”.

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