The study focuses on COVID-19 patients with inflammatory rheumatic diseases

The study focuses on COVID-19 patients with inflammatory rheumatic diseases

The ongoing COVID-19 pandemic has caused nearly five million cases and over 327,000 deaths worldwide. The signs and symptoms of this disease are varied, but there are typical features that support the diagnosis.

In Madrid, Spain, over 66,000 cases have been reported and over 40,000 hospitalizations have occurred as of the first week of May. In most cases, symptoms are mild or non-existent. Another smaller group of patients show moderate disease, while about 5 percent develop life-threatening complications, apparently due to an overactive immune response.

Novel coronavirus SARS-CoV-2 Colorized scanning electron microscope image of an apoptotic cell (green) heavily infected with SARS-COV-2 virus particles (purple) isolated from a patient sample. Image captured and color enhanced at the NIAID Integrated Research Facility (IRF) at Fort Detrick, Maryland. Photo credit: NIAID

This news article was a review of a preliminary scientific report that had not been peer-reviewed at the time of publication. Since its initial publication, the scientific report has now been peer-reviewed and accepted for publication in an academic journal. Links to the preliminary and peer-reviewed reports can be found in the Sources section at the end of this article.View sources

Reason for investigating the connections between COVID-19 and rheumatic diseases

Researchers have found that COVID-19 has a higher case rate and severity in patients with risk factors such as older age or pre-existing conditions such as high blood pressure, diabetes, heart disease and a history of lung disease. The impact of a rheumatic history on the risk of COVID-19 is not clear, nor is it known whether this increases the risk of a more severe infection or worse outcome in COVID-19 patients. This is not the case in previous outbreaks of respiratory diseases caused by coronaviruses, such as SARS or MERS.

Early studies in COVID-19 patients show that the presence of chronic rheumatic diseases or treatment with disease-modifying anti-rheumatic drugs (DMARDs) does not confer an increased risk of respiratory or fatal complications compared to the general risk.

Now a new study has been published on the preprint servermedRxiv*examines the risk factors for hospitalization in patients with inflammatory rheumatic diseases (IRD) and COVID-19.

How was the IRD COVID-19 risk factor study conducted?

The study was conducted from March 1, 2020 to April 24, 2020 in a tertiary hospital in Madrid. All patients who attended the rheumatology outpatient clinic during this period were included in the study if they were over 16 years of age, diagnosed with IRD, and had symptomatic COVID-19 disease, either based on clinical criteria or based on the reverse transcription-polymerase chain reaction (RT-PCR) test.

Data collected from these patients included sociodemographic characteristics, type of inflammatory rheumatic disease, and incidence of other diseases at baseline, such as lung or liver disease, diabetes, hypertension, smoking, renal disease, and hyperlipidemias. Thyroid, heart and vascular diseases were also identified. Researchers also considered each treatment for IRD and type, if applicable. Treatment with disease-modifying anti-rheumatic drugs (DMARDs) had to start one month or more before the study, continue until March 21 or longer, or until approval or end of the study.

Hospitalizations were reviewed to ensure all were related to COVID-19 and not other illnesses.

There were 123 IRD patients with symptoms of COVID-19, predominantly women, with an average age of 60 years, with the disease developing over an average of 10.7 years. The primary diagnosis was rheumatoid arthritis in 41% of patients, followed by axial spondyloarthritis in 15% of patients. Many patients also had one or more additional medical conditions, usually high blood pressure, high blood cholesterol and lung disease.

Most patients were taking conventional synthetic DMARDs at the start of the study, half were taking glucocorticoids and a quarter were taking nonsteroidal anti-inflammatory drugs (NSAIDs). One fifth received biologic DMARDs, 6.5% adalimumab and 4% rituximab. About 15% of patients who received biologics also received synthetic DMARDs.

Of those 123 patients, 54 required hospitalization due to COVID-19. Approximately 60% were women and the median age was 70 years, with the median time from first symptom to admission being five days. The median length of stay was 9 days.

Most patients (86%) received hydroxychloroquine and 52% were treated with corticosteroids. Another 18 received antiviral drugs and 3 received the anti-IL-6 drug tocilizumab.

Approximately 20 patients experienced complications in the hospital, most commonly myocarditis, thrombosis, and renal failure. Only 2 people required admission to the intensive care unit.

What conclusion did the researchers come to?

The analysis found that older people and any of the following conditions increase the risk of hospitalization: chronic inflammatory arthritis, high blood pressure, diabetes, heart disease and lung disease. Use of NSAIDs or biologics against TNF had a smaller association. Glucocorticoids tended to increase the risk, while antimalarials decreased the risk.

Multivariate analysis failed to confirm any statistical difference between different types of DMARDs. The only risk factors were older age and the presence of systemic autoimmune diseases. Glucocorticoids, one of the diseases listed below and the female gender also showed a trend towards a higher risk of admission. However, this was not statistically significant - diabetes mellitus, pulmonary disease, ischemic vascular disease, hypertension, venous thrombosis/pulmonary embolism, pulmonary disease and/or liver disease.

COVID-19 patient hospitalization flowchart

The mean age of the admitted patients was a good 15 years higher than that of the patients not admitted, and the average age of the deaths was over 80 years. This is consistent with mortality trends in the general population, where more than half of all deaths occurred in the 80 and older age group and 95% in the 60+ age group.

Diabetes has been found to be an independent risk factor for COVID-19, intensive care unit admission and death from this disease. The higher the number of coexisting diseases, the worse the clinical outcome, starting with a single comorbidity.

The study shows that approximately 44% of patients with IRD and COVID-19 require hospitalization, with most of this subgroup being older patients with other medical conditions and systemic autoimmune diseases. However, it supports previous evidence that DMARDs do not increase the risk of hospitalization for COVID-19-related symptoms and signs.

Women did not have a higher risk of admission, although they did have an increased risk of rheumatic diseases. Systemic autoimmune diseases were associated with the highest risk of admission.

Due to the observational nature of the study and the recording of data in a standard, heavy workload environment, it is likely that much information was incomplete. In the non-hospitalized group, many patients could be lost to follow-up. In about a fifth of cases, the diagnosis was not confirmed by RT-PCR.

Ethnic diversity related to varying severity of COVID-19 has also not been examined. Nevertheless, the study identifies some possible risk factors that may help patients with IRD minimize risk and predict increased risk of hospitalization in these patients.

This news article was a review of a preliminary scientific report that had not been peer-reviewed at the time of publication. Since its initial publication, the scientific report has now been peer-reviewed and accepted for publication in an academic journal. Links to the preliminary and peer-reviewed reports can be found in the Sources section at the end of this article.View sources

Article revisions

• 21. März 2023 – Das vorab gedruckte vorläufige Forschungspapier, auf dem dieser Artikel basiert, wurde zur Veröffentlichung in einer von Experten begutachteten wissenschaftlichen Zeitschrift angenommen. Dieser Artikel wurde entsprechend bearbeitet und enthält nun einen Link zum endgültigen, von Experten begutachteten Artikel, der jetzt im Abschnitt „Quellen“ angezeigt wird.

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