Clinical Course and Outcomes of coronavirus disease 2019 (COVID-19) in Rheumatic Disease Patients on Immunosuppression: A case Cohort Study at a Single Center with a Significantly Diverse Population
Timothy Arleo, M.D David Tong, Julie Shabto, Ghazala O’keefe, M.D Arezou Khosroshahi
doi:10.1101/2020.10.26.20219154
Objectives To determine clinical course and outcomes in rheumatic disease patients with coronavirus disease 2019 (COVID-19) and compare results to uninfected patients.
Methods We conducted a case cohort study of autoimmune disease patients with COVID-19 (confirmed by severe acute respiratory syndrome coronavirus 2 PCR) from 02/01/2020 to 07/31/2020 and compared them in a 1:3 ratio with uninfected patients who were matched based on race, age, sex, and comorbidity index. Patient demographics, clinical course, and outcomes were compared among these patient groups.
Results A total of 70 rheumatic disease patients with COVID-19 (mean age, 56.6 years; 64% African American) were identified. The 34 (49%) patients who were hospitalized used oral glucocorticoids more frequently (p<0.01). All 10 patients on anti-TNFα medications were treated as outpatients (p<0.01). Those hospitalized with COVID-19 more often required ICU admission (17 (50%) vs 27 (26%), OR=2.78 (95% CI: 1.24 to 6.20)) and intubation (10 (29%) vs 6 (6%), OR=6.67 (95% CI: 2.20 to 20.16)) than uninfected patients. They also had higher mortality rates (6 (18%) vs 3 (3%), OR=7.21 (95% CI: 1.70 to 30.69)). Of the six COVID-19 patients who died, one was of African ancestry (p=0.03).
Conclusions . Rheumatic disease patients infected with COVID-19 were more likely to require ICU admission, ventilation, and died more frequently versus uninfected patients with autoimmune disease. Patients on anti-TNFα medications were hospitalized less frequently while those on chronic glucocorticoids were hospitalized more frequently. These findings have important implications for medication choice in rheumatic disease patients during the ongoing spread of COVID-19.
Conflicts of Interest: None declared
Admitted, infected patients who died versus patients who survived In total, six of the 70 COVID-19 patients died, resulting in a 9% overall mortality rate (18% mortality rate among those hospitalized). Among admitted patients with COVID-19, the distribution of sex was similar between patients who died and survived, but patients with COVID-19 who died were older with a mean age of 76.5 vs 62.8 for those that survived (p<0.01) (table 5 ). What is already known? • Not much is known about COVID-19 outcomes in patients with underlying rheumatic disease especially compared to rheumatic disease patients hospitalized for other causes. What does this study add? • We found that rheumatic disease patients with COVID-19 had poorer outcomes including ICU admission, ventilation, and death compared to uninfected rheumatic disease patients. • This study adds further support regarding protective effects of anti-TNFα medications in COVID-19 disease course as 0 of 10 of these patients required hospitalization.
References
Brito, Paiva, Pimentel, Guimarães, Moreira, Rheumatic disease patients with COVID-19 infection may be at significantly higher risk of poor outcomes compared to uninfected rheumatic disease patients, Annals of the Rheumatic Diseases,
doi:10.1136/annrheumdis-2020-218171Feng, Zou, Pan, Wang, Wu et al., Prognostic indicators of hospitalized patients with systemic lupus erythematosus: a large retrospective multicenter study in China, The Journal of rheumatology
Gianfrancesco, Hyrich, Al-Adely, Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry, Ann Rheum Dis,
doi:10.1136/annrheumdis-2020-217871Godeau, Mortier, Roy, Chevret, Bouachour et al., Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients, The Journal of rheumatology
Herold, Jurinovic, Arnreich, Elevated levels of IL-6 and CRP predict the need for mechanical ventilation in COVID-19, Journal of Allergy and Clinical Immunology,
doi:10.1016/j.jaci.2020.05.008Ledingham, Gullick, Irving, Gorodkin, Aris et al., BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology
Li, Fan, Lai, Han, Li et al., Coronavirus infections and immune responses, Journal of medical virology
Monti, Balduzzi, Delvino, Bellis, Quadrelli et al., Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies, Annals of the Rheumatic Diseases,
doi:10.1136/annrheumdis-2020-217424Nm, Dr, Kk, Rheumatologic diseases in the intensive care unit: epidemiology, clinical approach, management, and outcome, Crit Care Clin,
doi:10.1016/s0749-0704(02)00025-8Pourbagheri-Sigaroodi, Bashash, Fateh, Laboratory findings in COVID-19 diagnosis and prognosis, Clinica Chimica Acta
Pourrat, Bureau, Hira, Martin-Barbaz, Descamps et al., Outcome of patients with systemic rheumatic diseases admitted to intensive care units: a retrospective study of 39 cases
Ramos, Shedlock, Langefeld, Genetics of autoimmune diseases: insights from population genetics, Journal of human genetics
Rentsch, Kidwai-Khan, Tate, Covid-19 by Race and Ethnicity: A National Cohort Study of 6 Million United States Veterans
Silva, Boyd, Wallwork, Clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and rheumatic disease: a comparative cohort study from a US 'hot spot, Annals of the Rheumatic Diseases,
doi:10.1136/annrheumdis-2020-217888Strangfeld, Eveslage, Schneider, Treatment benefit or survival of the fittest: what drives the time-dependent decrease in serious infection rates under TNF inhibition and what does this imply for the individual patient?, Ann Rheum Dis
Tay, Poh, Rénia, Macary, Ng, The trinity of COVID-19: immunity, inflammation and intervention, Nature Reviews Immunology
Violi, Cangemi, Romiti, Is Albumin Predictor of Mortality in COVID-19? Antioxidants & Redox Signaling,
doi:10.1089/ars.2020.8142Yehia, Winegar, Fogel, Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals, JAMA Netw Open,
doi:10.1001/jamanetworkopen.2020.18039Zhao, Pang, Wu, Clinical characteristics and outcomes of patients with COVID-19 and rheumatic disease in China 'hot spot' versus in US 'hot spot': similarities and differences, Annals of the Rheumatic Diseases,
doi:10.1136/annrheumdis-2020-218183Zheng, Peng, Xu, Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis, J Infect,
doi:10.1016/j.jinf.2020.04.021DOI record:
{
"DOI": "10.1101/2020.10.26.20219154",
"URL": "http://dx.doi.org/10.1101/2020.10.26.20219154",
"abstract": "<jats:title>ABSTRACT</jats:title><jats:sec><jats:title>Objectives</jats:title><jats:p>To determine clinical course and outcomes in rheumatic disease patients with coronavirus disease 2019 (COVID-19) and compare results to uninfected patients.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We conducted a case cohort study of autoimmune disease patients with COVID-19 (confirmed by severe acute respiratory syndrome coronavirus 2 PCR) from 02/01/2020 to 07/31/2020 and compared them in a 1:3 ratio with uninfected patients who were matched based on race, age, sex, and comorbidity index. Patient demographics, clinical course, and outcomes were compared among these patient groups.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>A total of 70 rheumatic disease patients with COVID-19 (mean age, 56.6 years; 64% African American) were identified. The 34 (49%) patients who were hospitalized used oral glucocorticoids more frequently (p<0.01). All 10 patients on anti-TNFα medications were treated as outpatients (p<0.01). Those hospitalized with COVID-19 more often required ICU admission (17 (50%) vs 27 (26%), OR=2.78 (95% CI: 1.24 to 6.20)) and intubation (10 (29%) vs 6 (6%), OR=6.67 (95% CI: 2.20 to 20.16)) than uninfected patients. They also had higher mortality rates (6 (18%) vs 3 (3%), OR=7.21 (95% CI: 1.70 to 30.69)). Of the six COVID-19 patients who died, one was of African ancestry (p=0.03).</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Rheumatic disease patients infected with COVID-19 were more likely to require ICU admission, ventilation, and died more frequently versus uninfected patients with autoimmune disease. Patients on anti-TNFα medications were hospitalized less frequently while those on chronic glucocorticoids were hospitalized more frequently. These findings have important implications for medication choice in rheumatic disease patients during the ongoing spread of COVID-19.</jats:p></jats:sec>",
"accepted": {
"date-parts": [
[
2020,
10,
27
]
]
},
"author": [
{
"ORCID": "http://orcid.org/0000-0002-0583-8721",
"affiliation": [],
"authenticated-orcid": false,
"family": "Arleo",
"given": "Timothy",
"sequence": "first"
},
{
"affiliation": [],
"family": "Tong",
"given": "David",
"sequence": "additional"
},
{
"affiliation": [],
"family": "Shabto",
"given": "Julie",
"sequence": "additional"
},
{
"affiliation": [],
"family": "O’Keefe",
"given": "Ghazala",
"sequence": "additional"
},
{
"affiliation": [],
"family": "Khosroshahi",
"given": "Arezou",
"sequence": "additional"
}
],
"container-title": [],
"content-domain": {
"crossmark-restriction": false,
"domain": []
},
"created": {
"date-parts": [
[
2020,
10,
27
]
],
"date-time": "2020-10-27T22:15:11Z",
"timestamp": 1603836911000
},
"deposited": {
"date-parts": [
[
2020,
10,
30
]
],
"date-time": "2020-10-30T00:21:58Z",
"timestamp": 1604017318000
},
"group-title": "Epidemiology",
"indexed": {
"date-parts": [
[
2022,
4,
3
]
],
"date-time": "2022-04-03T20:47:13Z",
"timestamp": 1649018833946
},
"institution": [
{
"name": "medRxiv"
}
],
"is-referenced-by-count": 1,
"issued": {
"date-parts": [
[
2020,
10,
27
]
]
},
"link": [
{
"URL": "https://syndication.highwire.org/content/doi/10.1101/2020.10.26.20219154",
"content-type": "unspecified",
"content-version": "vor",
"intended-application": "similarity-checking"
}
],
"member": "246",
"original-title": [],
"posted": {
"date-parts": [
[
2020,
10,
27
]
]
},
"prefix": "10.1101",
"published": {
"date-parts": [
[
2020,
10,
27
]
]
},
"publisher": "Cold Spring Harbor Laboratory",
"reference": [
{
"DOI": "10.1136/annrheumdis-2020-218171",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.1"
},
{
"DOI": "10.1136/annrheumdis-2020-217424",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.2"
},
{
"DOI": "10.1016/j.jaci.2020.04.006",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.3"
},
{
"DOI": "10.1136/annrheumdis-2020-217871",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.4"
},
{
"DOI": "10.1136/ard.2011.151043",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.5"
},
{
"DOI": "10.1136/annrheumdis-2020-217888",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.6"
},
{
"DOI": "10.1136/annrheumdis-2020-218183",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.7"
},
{
"DOI": "10.3899/jrheum.101088",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.8"
},
{
"article-title": "Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients",
"first-page": "317",
"issue": "7",
"journal-title": "The Journal of rheumatology",
"key": "2020102917202238000_2020.10.26.20219154v1.9",
"volume": "24",
"year": "1997"
},
{
"DOI": "10.1016/S0248-8663(00)88243-0",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.10"
},
{
"DOI": "10.1016/S0749-0704(02)00025-8",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.11"
},
{
"DOI": "10.1016/j.jinf.2020.04.021",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.12"
},
{
"DOI": "10.1016/j.semarthrit.2020.05.010",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.13"
},
{
"DOI": "10.1002/jmv.25685",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.14"
},
{
"DOI": "10.1038/s41577-020-0311-8",
"doi-asserted-by": "crossref",
"key": "2020102917202238000_2020.10.26.20219154v1.15",
"unstructured": "Tay, M. Z. , Poh, C. M. , Rénia, L. , MacAry, P. A. , & Ng, L. F. (2020). The trinity of COVID-19: immunity, inflammation and intervention. Nature Reviews Immunology, 1–12."
},
{
"DOI": "10.1093/rheumatology/kew479",
"article-title": "BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs",
"doi-asserted-by": "crossref",
"first-page": "865",
"issue": "6",
"journal-title": "Rheumatology",
"key": "2020102917202238000_2020.10.26.20219154v1.16",
"volume": "56",
"year": "2017"
},
{
"DOI": "10.1089/ars.2020.8142",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.17"
},
{
"DOI": "10.1016/j.jaci.2020.05.008",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.18"
},
{
"DOI": "10.1016/j.cca.2020.08.019",
"doi-asserted-by": "crossref",
"key": "2020102917202238000_2020.10.26.20219154v1.19",
"unstructured": "Pourbagheri-Sigaroodi, A. , Bashash, D. , Fateh, F. , et al. (2020). Laboratory findings in COVID-19 diagnosis and prognosis. Clinica Chimica Acta."
},
{
"DOI": "10.1101/2020.05.12.20099135",
"doi-asserted-by": "crossref",
"key": "2020102917202238000_2020.10.26.20219154v1.20",
"unstructured": "Rentsch, C. T. , Kidwai-Khan, F. , Tate, J. P. , et al. (2020) Covid-19 by Race and Ethnicity: A National Cohort Study of 6 Million United States Veterans. medRxiv."
},
{
"DOI": "10.1001/jamanetworkopen.2020.18039",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.21"
},
{
"DOI": "10.1038/jhg.2015.94",
"doi-asserted-by": "publisher",
"key": "2020102917202238000_2020.10.26.20219154v1.22"
},
{
"key": "2020102917202238000_2020.10.26.20219154v1.23",
"unstructured": "NIH Progress in Autoimmune Diseases Research. hin National Institute of Health Publication No. 05–514 (2005)"
}
],
"reference-count": 23,
"references-count": 23,
"relation": {},
"resource": {
"primary": {
"URL": "http://medrxiv.org/lookup/doi/10.1101/2020.10.26.20219154"
}
},
"score": 1,
"short-title": [],
"source": "Crossref",
"subtitle": [],
"subtype": "preprint",
"title": "Clinical Course and Outcomes of coronavirus disease 2019 (COVID-19) in Rheumatic Disease Patients on Immunosuppression: A case Cohort Study at a Single Center with a Significantly Diverse Population",
"type": "posted-content"
}
