Glucocorticoids, not anti-cytokine therapies, may worsen COVID-19 outcomes
medwireNews: Findings from the WORCOV study provide further evidence that glucocorticoid use, older age, and comorbidities are associated with worse COVID-19 outcomes among patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA).
Rebecca Haberman (New York University, USA) and colleagues analyzed data for 103 patients with RA (n=47) or SpA (n=56), referred from specialists across New York, who had confirmed (n=80) or highly suspected (n=23) SARS-CoV-2 infection between 3 March and 4 May 2020.
Within a mean 42 days of COVID-19 symptom onset, 27 patients required hospitalization, giving a rate of 26%, which was comparable to the 21% rate reported for the general New York population as of 4 May 2020. Eighteen of these patients received supplementary oxygen, four required mechanical ventilation, and four died.
Overall, patients with RA were more likely to be hospitalized than those with SpA, with corresponding rates of 38.0% versus 16.0%, but death rates were comparable between the two groups, at 4.2% and 3.6%.
Chronic use of oral glucocorticoids was significantly more common among patients who were hospitalized than those who were not (37 vs 4%), with an odds ratio (OR) of 26.22 after adjusting for multiple variables including age, sex, BMI, and comorbidities. When stratified by disease, the OR remained significant among RA patients, at 40.30, whereas there was not sufficient data to analyze the risk among SpA patients.
The researchers add that COVID-19 outcomes remained worse even with low-dose corticosteroids, of less than 10 mg/day.
They say it is “certainly not surprising” that, in line with previous findings, “patients on background corticosteroids appear to fare worse than those not on these medications,” given that they “are global suppressors of the host inflammatory response.”
In addition, a significantly greater proportion of hospitalized versus nonhospitalized patients were taking Janus kinase (JAK) inhibitors (16 vs 5%), with an OR of 10.23. This association remained significant among SpA patients (OR=17.63) after taking into account age and sex, but not RA patients (OR=2.50).
“Of utmost importance,” according to the investigators, was their finding that the chronic use of pathway-specific anti-cytokine biologic therapies – including tumor necrosis factor inhibitors and interleukin-17 and 23 inhibitors – was not significantly associated with worse COVID-19 outcomes. They emphasize that this is also consistent with previous data, including results from the Global Rheumatology Alliance, as previously reported by medwireNews.
They say that “[f]urther work is needed to understand whether immunomodulatory therapies affect COVID-19 incidence.”
The patients who died were aged 70 years on average, and all four had other comorbidities, including advanced age, hypertension, and glucocorticoid use. Three patients were taking methotrexate with or without glucocorticoids and one patient was taking a biologic DMARD.
Older age was significantly associated with increased hospitalization rates; the mean age of patients who required hospitalization was 61 years versus 50 years for those who did not. The average BMI of hospitalized patients was also higher than that of nonhospitalized patients, but not significantly so (31 vs 28 kg/m2).
Comorbid hypertension and chronic obstructive pulmonary disease were both significantly associated with higher rates of hospitalization, with corresponding rates of 48% and 15% among hospitalized patients, compared with a respective 15% and 1% among nonhospitalized patients.
“Although the underlying reasons for this association are still elusive, currently available data reveals that hypertension appears to be associated with more severe COVID-19 disease, a higher risk of [ acute respiratory distress syndrome], and increased mortality. This is certainly applicable to RA and SpA, as hypertension and cardiovascular disease are frequent comorbid conditions,” the researchers conclude in Arthritis & Rheumatology.
medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2020 Springer Healthcare Ltd, part of the Springer Nature Group
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