Different systemic rheumatic diseases as risk factors for COVID-19-related mortality

Paucity of viral infection symptoms in patients with immune-mediated inflammatory diseases

OBJECTIVES

Although patients with immune-mediated inflammatory diseases (IMID) are thought to be more susceptible to viral infections, it is unclear whether their presentation differs between patients with IMID and healthy controls. This study aimed to investigate the symptom pattern of common viral infections in patients with IMID and compare it with controls without IMIDs.

DESIGN

A cross-sectional study conducted between 1 February and 30 April 2020, using a questionnaire.

SETTING

Seven tertiary regional care centers in Germany, which specialised in the care of patients with IMID (namely, in gastroenterology, dermatology, rheumatology and immunology clinical care).

PARTICIPANTS

One thousand nine hundred nine participants completed the survey (757 patients with IMID; 1152 non-IMID controls).

PRIMARY OUTCOME MEASURE

The occurrence of 11 common viral illness symptoms within the preceding 3 months in patients with IMID and non-IMID controls.

RESULTS

Symptom data were clustered, based on number and co-occurrance, into 3 major clusters and 2 subclusters ranked by the average number of symptoms. Patients with inflammatory bowel disease and psoriasis were significantly overrepresented in the lower-frequency subcluster of the polysymptomatic cluster. Patients with rheumatoid arthritis were overrepresented in the lower-frequency subclusters of the intermediate and oligo-/asymptomatic clusters. Controls were over-represented only in the higher-frequency subclusters of each major cluster where none of the IMIDs were over-represented. Spondyloarthritis and other IMIDs were also overrepresented in the low-frequency subcluster, but the results were not significant. Overall, patients with rheumatoid arthritis patients reported fewer symptoms (rate ratio=0.68, 95% CI, 0.59 to 0.80) than non-IMID controls.

CONCLUSION

Patients with IMID are over-represented in low-frequency subclusters, even among individuals who have reported a broad range of viral infection symptoms. This pattern suggests that the manifestations of viral infections are different between patients with IMID and controls, thus challenging the accurate and early diagnosis of infections.

Increased prevalence of inflammatory arthritis, systemic lupus erythematosus and systemic sclerosis, during 2020-2023 versus 2016-2019 in a Nation-Wide Cohort Study

Although several studies have explored the geoepidemiology of autoimmune rheumatic diseases (ARD), trends of their frequency overtime are under-investigated. Herein, in a nation-wide study, we examine trends in the prevalence of various ARD over-time, taking also into account the Covid-19 pandemic. In this retrospective study in the entire Greek adult population (approximately 10.000.000 people), we searched the electronic prescription database of the e-Government Centre for Social Security Services using prespecified ICD-10 codes to capture all adult patients with Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ankylosing Spondylitis (AS), Systemic Lupus Erythematosus (SLE), Systemic Sclerosis (SSc) and Polymyalgia Rheumatica or Giant Cell Arteritis (PMR/GCA). Two sequential 4-year periods, namely 2016-2019 and 2020-2023 were compared. Prevalence of RA, PsA, AxSpA, SLE and SSc increased significantly during 2020-2023 compared to 2016-2019. This applies to both genders and to all age groups for RA, PsA and AxSpA, to female patients in SLE and SSc and to patients 18-39 years in SLE and ≥ 60 years in SSc. Overall, there was 47% increase in prevalence for AxSpA (0.100% in 2016-19 vs 0.147% in 2020-23), 36.5% for PsA (0.148% vs 0.202%), 20.6% for RA (0.467% vs 0.563%), 19% for SLE (0.137% vs 0.163%) and 13% for SSc (0.023% vs 0.026%). A 16.3% decrease was evident in GCA/PMR, limited to those ≥ 40 years old. In a nation-wide study we confirm that ARD prevalence increases over-time, whereas a contribution of Covid-19 pandemic to our results during 2020-2023, cannot be excluded. Additional human, medical and financial resources will be needed to cover the increased needs of ARD patients.

Prophylaxis with tixagevimab/cilgavimab is associated with lower COVID-19 incidence and severity in patients with autoimmune diseases

OBJECTIVE

To describe the clinical efficacy of tixagevimab/cilgavimab in pre-exposure prophylaxis in patients at risk of severe coronavirus disease 2019 (COVID-19) and unresponsive to vaccination (anti-severe acute respiratory syndrome coronavirus 2 antibodies <260 binding antibody units/ml) in rheumatology.

METHODS

In this multicentre observational study we included patients with autoimmune or inflammatory diseases who received pre-exposure prophylaxis with tixagevimab/cilgavimab between December 2021 and August 2022. The endpoint was incidence of COVID-19 and its severity.

RESULTS

Tixagevimab/cilgavimab was administered to 115 patients with a median age of 62 years [interquartile range (IQR) 52-71], chronic arthritis (n = 53), connective tissue disease (n = 38) or vasculitis (n = 11). The main background immunosuppressants were rituximab (n = 98), corticosteroids [n = 62; median dose 5 mg (95% CI 5-8)] and methotrexate (n = 48). During a median follow-up of 128 days (IQR 93-173), COVID-19 occurred in 23/115 patients (20%) and the omicron variant was identified for the eight genotyped patients. During the study period, the average weekly incidence was 1071/100 000 inhabitants in Île-de-France vs 588/100 000 in our patients. Patients who received a two-injection regimen had a lower risk of infection than those with a single injection [16/49 (33%) vs 5/64 (8%), P = 0.0012]. The COVID-19-positive patients did not differ from uninfected patients concerning age, comorbidities, underlying rheumatic disease and immunosuppressants. All COVID-19 cases were non-severe. The tolerance of injections was excellent.

CONCLUSION

In a population with autoimmune or inflammatory diseases at risk of severe COVID-19 unresponsive to vaccination, pre-exposure prophylaxis withy tixagevimab/cilgavimab was associated with a lower incidence of COVID-19 and no severe infections.

Outcomes of COVID-19 Omicron variant in patients with rheumatoid arthritis: a nationwide Greek cohort study

OBJECTIVES

Patients with RA were at increased risk for COVID-19-associated hospitalization and death during the first year of the pandemic in Greece. We aimed to examine their outcomes after the SARS-Cov-2 Omicron, a more contagious but with milder clinical impacts variant, prevailed.

METHODS

A retrospective, nationwide study was conducted between 1 January 2022 and 30 June 2022 in all RA patients under treatment and matched (1:5) on age, sex and region of domicile random general population comparators. Confirmed SARS-CoV-2 infections, hospitalizations and deaths, anti-rheumatic medications, prior COVID-19, vaccinations and anti-viral medications were recorded.

RESULTS

Among 34 182 RA patients, infections (n = 5569, 16.29%), hospitalizations (n = 489, 1.43%) and deaths (n = 106, 0.31%) were more frequent than among comparators. Incidence rates per 1000 person/years of infection [IRR (95% CI):1.19 (1.16, 1.23)], hospitalization [IRR (95% CI):2.0 (1.82, 2.24)], and death [IRR (95% CI):1.81 (1.44, 2.27)] were increased in RA despite better vaccination coverage (89% vs 84%) and more frequent use of anti-viral medications (2.37% vs 1.08). Logistic regression analysis after correcting for age, sex, vaccinations, prior COVID-19, and anti-viral medications in SARS-CoV-2 infected RA patients and comparators revealed increased risk of hospitalization (OR: 2.02, 95% CI: 1.79, 2.27) and death [OR: 1.73, (95% CI: 1.36, 2.20)] in RA. Among infected RA patients, rituximab treatment conferred increased risks for hospitalization [OR: 6.12, (95% CI: 2.89, 12.92)] and death [OR: 12.06 (95% CI: 3.90, 37.31)], while JAK inhibitors increased only hospitalization risk [OR: 2.18 (95% CI: 1.56, 3.06)].

CONCLUSION

RA remains a risk factor for hospitalization and death in an era of a relatively low COVID-19 fatality rate, pointing to the need of perseverance in vaccination programs and wider use of anti-viral medications.

COVID-19 and protection of vaccination in patients with systemic sclerosis-associated interstitial lung disease

OBJECTIVES

Data on COVID-19 in patients with interstitial lung disease are scarce and whether SARS-CoV-2 may trigger interstitial lung disease progression remains unknown. We aimed to analyze outcomes of COVID-19 in patients with systemic sclerosis-associated interstitial lung disease, including possible thoracic radiographic progression.

PATIENTS AND METHODS

All 43 patients with systemic sclerosis-associated interstitial lung disease followed in our center (mean ± SD, 55.2 ± 11.6 years, 36 female) with confirmed SARS-CoV2 infection up to 1 September 2022 were analyzed. Individual interstitial lung disease extent on high resolution CT (HRCT) performed before (up to 3 months) and after COVID-19 (2-5 months) was compared.

RESULTS

At SARS-CoV-2 infection, 9/43 patients were unvaccinated, whereas 5, 26, and 3 had received 2, 3, or 4 doses of an mRNA vaccine, respectively. Thirty-one patients were either on monotherapy with immunosuppressives (mycophenolate, n = 7; cyclophosphamide, n = 2; methotrexate, n = 10; tocilizumab, n = 7; rituximab, n = 1; etanercept, n = 1), or their combinations (n = 3). Eight patients (20%), of whom four unvaccinated, required hospitalization for pneumonia and three (7%) died of acute respiratory failure (n = 2, both unvaccinated) or cardiac arrest. Lack of vaccination was the only independent predictor for hospitalization (OR = 7.98, 95% CI: 1.25-51.09) and marginally for death (OR = 32.7, 95% CI: 0.97-1110.98), regardless of the presence of diffuse systemic sclerosis, interstitial lung disease extent greater than 20% or immunosuppressive treatment. In 22 patients with available HRCT pairs (vaccinated = 20), the interstitial lung disease extent before COVID-19 (20.4%± 17.8%) remained unchanged (22.4% ± 18.5%) in all but one patient.

CONCLUSION

SARS-CoV-2 vaccination is of outmost importance for every systemic sclerosis patient with interstitial lung disease. COVID-19 does not seem to promote progression of systemic sclerosis-associated interstitial lung disease in vaccinated patients, but further studies are warranted.

How Did the Two Years of the COVID-19 Pandemic Affect the Outcomes of the Patients with Inflammatory Rheumatic Diseases in Lithuania?

Background and objectives: the COVID-19 pandemic globally caused more than 18 million deaths over the period of 2020-2021. Although inflammatory rheumatic diseases (RD) are generally associated with premature mortality, it is not yet clear whether RD patients are at a greater risk for COVID-19-related mortality. The aim of our study was to evaluate mortality and causes of death in a retrospective inflammatory RD patient cohort during the COVID-19 pandemic years. Methods: We identified patients with a first-time diagnosis of inflammatory RD and followed them up during the pandemic years of 2020-2021. Death rates, and sex- and age-standardized mortality ratios (SMRs) were calculated for the prepandemic and pandemic periods. Results: We obtained data from 11,636 patients that had been newly diagnosed with inflammatory RD and followed up until the end of 2021 or their death. The mean duration of the follow-up was 5.5 years. In total, 1531 deaths occurred between 2013 and 2021. The prevailing causes of death in the prepandemic period were cardiovascular diseases, neoplasms, and diseases of the respiratory system. In the pandemic years, cardiovascular diseases and neoplasms remained the two most common causes of death, with COVID-19 in third place. The SMR of the total RD cohort was 0.83. This trend was observed in rheumatoid arthritis and spondyloarthropathy patients. The SMR in the group of connective-tissue diseases and vasculitis was higher at 0.93, but did not differ from that of the general population. The excess of deaths in the RD cohort during the pandemic period was negative (-27.2%), meaning that RD patients endured the pandemic period better than the general population did. Conclusions: The COVID-19 pandemic did not influence the mortality of RD patients. Strict lockdown measures, social distancing, and early vaccination were the main factors that resulted in reduced mortality in this cohort during the pandemic years.

Different COVID-19 outcomes among systemic rheumatic diseases: a nation-wide cohort study

OBJECTIVES

To investigate coronavirus disease 2019 (COVID-19)-associated risk of hospitalization and death in RA, AS, PsA, SLE and SSc in comparison with the general population during the first year of the pandemic, and compare their overall mortality with 2019.

METHODS

Interlinking nationwide electronic registries, we recorded confirmed COVID-19-associated infections, hospitalizations and deaths, and all-cause deaths between 1 March 2020 and 28 February 2021 in all adults with RA, AS, PsA, SLE and SSc under treatment (n = 74 970, median age 67.5, 51.2, 58.1, 56.2 and 62.2 years, respectively) and in random comparators from the general population matched (1:5) on age, sex and region of domicile. Deaths from all causes during 2019 were also recorded.

RESULTS

Compared with the general population, incidence rates (IR) for COVID-19-associated hospitalization were higher in RA [IR ratio (IRR) 1.71(1.50-1.95)], SLE [2.0 (1.4-2.7)] and SSc [2.28 (1.29-3.90)], while COVID-19-associated death rates were higher in RA [1.91 (1.46-2.49)]. When focusing only on severe acute respiratory syndrome coronavirus 2-infected subjects, after adjusting for age and gender, the odds ratio for COVID-19 associated death was higher in RA [1.47 (1.11-1.94)] and SSc [2.92 (1.07-7.99)] compared with the general population. The all-cause mortality rate compared with the general population increased in RA during the first year of the pandemic (IRR 0.71) with reference to 2019 (0.59), and decreased in SSc (IRR 1.94 vs 4.36).

CONCLUSION

COVID-19 may have a more severe impact in patients with systemic rheumatic disease than in the general population. COVID-19-related mortality is increased in subgroups of patients with specific rheumatic diseases, underscoring the need for priority vaccination and access to targeted treatments.

COVID-19 in Patients with Psoriatic Arthritis

The COVID-19 pandemic has a negative impact on all aspects of human life and can lead to the exacerbation of chronic diseases. At the same time, it is known that a higher risk of infection and a more severe course of coronavirus infection is found in the elderly, as well as in people with serious comorbidities. Psoriatic arthritis (PsA) is a type of inflammatory arthritis that is often diagnosed in patients with psoriasis. Specific treatment of patients with chronic inflammatory joint disease include nonsteroidal anti-inflammatory drugs, glucocorticosteroids, disease-modifying antirheumatic drugs, new biological agents, including monoclonal antibodies to IL-6, IL-1, TNF-a, target disease modifying drugs. Medications used for PsA treatment can potentially have both negative and positive effects on the course of COVID-19. The objective: to analyze the features of COVID-19 in patients with PsA and to study the comorbid pathology after coronavirus infection. Materials and methods. The study involved 174 people with a verified diagnosis of PsA. Patients were divided into two groups. Group I included 112 (64.4%) persons who had COVID-19, and group II - 62 (35.6%) who had not had coronavirus infection at the time of first examination. Patients in group I significantly differed from group II in age (p <0.001) and duration of PsA (p <0.001), showed a significantly higher degree of psoriatic skin lesions and activity of the underlying disease (p = 0.001) compared to patients from group II. The participants of the study underwent examination characterize the course of the psoriatic disease and skin lesions and risk of cardiovascular disease. Results. To date, there are no clear scientific data that reveal the specific features of COVID-19 infection and the effect of antirheumatic therapy on the development of dangerous complications associated with coronavirus infection in patients with PsA. The analysis of comorbid pathology has found cardiovascular pathology in 67 (59.8%) of patients, including arterial hypertension – in 58 (51.8%) people, metabolic syndrome – in 34 (30.4%), diseases of the digestive system – in 32 (28.6%) and respiratory system – in 24 (21.4%) of persons. Conclusions. Patients with higher activity and duration of the PsA were significantly more likely to get COVID-19 and demonstrated higher total cardiovascular risk for the next 10 years. Further research is needed to study the impact of specific basic rheumatological drugs on the outcomes of COVID-19 and to analyze the broader effects of the pandemic on the course of psoriatic arthritis.