COVID-19 hospitalization: What do the data tell us?
medwireNews: There were a variety of sessions at the EULAR 2020 E-Congress talking about the risk factors associated with COVID-19 hospitalization among patients with rheumatic conditions, as data from the COVID-19 Global Rheumatology Alliance registry and contributing national registries become available.
Risk factors for COVID-19 hospitalization in patients with RMD
Pedro Machado, from the University of London in the UK, presented recently published data on the risk factors associated with hospitalization and a worse prognosis among patients with rheumatic and musculoskeletal diseases (RMDs).
Data were recorded for 600 cases of COVID-19 in patients with RMD, who were sick enough to receive testing. Among these patients, 38% had rheumatoid arthritis (RA) and common comorbidities included hypertension (33%), lung disease (21%), and diabetes (12%); 65% of patients had never smoked.
In total, 46% of the patients were hospitalized and 9% died. Similar to that of the general population, the risk for hospitalization was higher for older patients and those with comorbidities.
In terms of types of RMD, there were no significant differences in the risk for hospitalization. Machado noted a trend toward significance for lupus, at an odds ratio of 1.8, which he said “might be something [...] to pick up on as we get more data.”
Prior to being diagnosed, 45% of patients were taking conventional synthetic (cs)DMARDs with an anti-malarial and 20% without, 21% were taking a combination of biologic and targeted synthetic (ts) or csDMARDs, 21% were taking nonsteroidal anti-inflammatory drugs, 18% were taking biologics or tsDMARDs only, and 9% were taking anti-malarials only. Glucocorticoids were being taken by 32% of patients, of whom 11% were receiving more than 10 mg/day prednisone equivalent.
Reassuringly for rheumatologists, Machado said that the data showed no significant increase in the risk for hospitalization “with any of the medications used by our patients.”
He highlighted a slightly lower risk with biologics or tsDMARDS that was mainly driven by a 40% reduced risk with tumor necrosis factor (TNF) inhibitors, and a 66% increased risk with glucocorticoids at more than 10 mg/day prednisone equivalent, which equates to a moderate to high dose, but Machado cautioned that these findings show associations and do not reflect causal relationships, stressing that “patients who need to take corticosteroids should not stop taking them.”
Do biologics play a role in the risk?
Carlos Gonzalez (Hospital General Universitario Gregorio Marañón, Madrid, Spain) presented findings from the Center for Immune-mediated Inflammatory Diseases in Spain, looking in more detail at the effects of biologic treatment on COVID-19 hospitalization risk.
The data were based on 1668 patients admitted with COVID-19 infection between 8 March and 8 May 2020, with a median age of 53 years (17 to 91 years), and of whom 52.4% were female.
Around half the patients had rheumatic conditions, including 23% with RA, 17% with spondyloarthritis, and 7% with psoriatic arthritis PsA, while the remainder had other conditions, primarily inflammatory bowel disorder.
The vast majority of patients were taking TNF inhibitors, at 63.2%, and among patients receiving treatment with bDMARDs or tsDMARDs overall, 1.14% were admitted to hospital and 21.1% died.
Age was one factor associated with an increased likelihood for admission or death, with those admitted aged 61 years, on average, compared with 53 years among those who were not. Patients who died were also more likely to have comorbidities, at 7.5% versus 2.8%.
Gonzalez highlighted that the proportion of women who were hospitalized and died was high, at 68.4% and 75.0%, respectively, but he said this could be partly explained by the older age of the women compared with men and their overrepresentation among patients with RA.
Importantly, patients treated with biologic drugs were not significantly more likely to be admitted or die than other patients, although those who did were significantly younger.
Gonzalez noted other possible associations with admission and death, including a significantly increased risk among RA patients and a significantly reduced risk among those receiving TNF inhibitors, but he noted that these “may be due to comorbidity, cofounding by indication, and other bias.”
Indeed, RA patients were significantly older than patients with other conditions and patients receiving TNF inhibitor treatment were significantly younger and the proportion of women and patients with RA in this treatment group was significantly lower than in other treatment groups.
Gonzalez concluded: “It seems reasonable that patients with inflammatory diseases treated with bDMARD or tsDMARD continue their treatment during the COVID-19 epidemic.”
The impact of comorbidity
Anne Regierer (German Research Centre Berlin) spoke more on the effects of comorbidities, drawing on data from the German COVID-19-IRD registry.
The data were based on 192 patients with inflammatory rheumatic disease who had positive laboratory results for SARS-CoV-2, all of whom were hospitalized, with 14 requiring ventilation.
The team’s linear regression analysis showed that, as for the general population, the major risk factor associated with hospitalization for SARS-CoV-2 infection among these patients was age, with those older than 65 years 5.08 times more likely to be admitted than younger patients.
Prior or current treatment with glucocorticoids and cardiovascular comorbidities were also associated with a 2.59-fold and 2.27-fold increased risk, respectively.
In addition, respiratory conditions and chronic renal insufficiency were associated with a twofold increase in risk, but this did not reach statistical significance.
Odds ratios were lower, at around 0.5, for female sex, remission, and the use of NSAIDs, which Regierer said may suggest a reduced risk for hospitalization associated with these factors.
She also noted that male gender may be associated with a more severe course of COVID-19, finding that while the proportion of men not hospitalized and hospitalized was 31% and 35%, respectively, this increased to 57% among those who need to be ventilated during hospitalization.
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