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Risk of Respiratory Failure Tripled in COVID-19 Patients with Existing Rheumatic Disease

Key findings

  • In this comparative cohort study, 52 adults with COVID-19 who had rheumatic disease were matched 1:2 with COVID-19 patients who did not have rheumatic disease
  • Patients with or without rheumatic disease had similar symptoms and similar odds of hospitalization and mortality
  • The group with rheumatic disease had threefold higher odds of requiring mechanical ventilation (adjusted OR, 3.11; 95% CI, 1.07–9.05; P = .04)

Whether patients with rheumatic disease are at higher risk of COVID-19 and its complications is unknown. Understanding outcomes in these patients is of particular interest because several classes of immunosuppressive medications are being studied as treatments for the "cytokine storm" that accounts for much of the morbidity and mortality associated with COVID-19.

Research fellows Kristin M. D'Silva, MD, and Naomi Serling-Boyd, MD, and physician Zachary S. Wallace, MD, MSc, of the Division of Rheumatology, Allergy and Immunology at Massachusetts General Hospital, and colleagues recently conducted the first comparative cohort study of COVID-19 outcomes in patients with existing rheumatic disease. Their report appears in Annals of the Rheumatic Diseases.

Study Design

Between January 30, 2020, and April 8, 2020, the Mass General Brigham identified 2,154 adults who tested positive for SARS-CoV-2. Due to the national shortage of PCR test kits during that period, testing was prioritized for symptomatic patients who were inpatients or in the emergency room.

52 of the patients (2.2%) had a systemic autoimmune rheumatic disease. Each was matched by sex, age (±5 years) and test date (±3 days) with two COVID-19 patients who did not have rheumatic disease. The average follow-up time was 29 days for both groups.

Characteristics of Patients with Rheumatic Disease

  • Diseases represented were rheumatoid arthritis (37%), systemic lupus erythematosus (19%), polymyalgia rheumatica (13%), spondyloarthritis (13%), myositis (6%), vasculitis (6%) and sarcoidosis (2%)
  • 33 patients (63%) had active disease at the time of COVID-19 diagnosis
  • 39 patients (75%) were on an immunosuppressive medication at the time of COVID-19 diagnosis, including:
    • 9 (17%) on hydroxychloroquine
    • 19 (37%) on an oral glucocorticoid

Manifestations of COVID-19

Symptoms of COVID-19 were similar in patients with or without rheumatic disease. Baseline laboratory values were similar in both groups except that those with rheumatic disease had significantly higher white blood cell counts and significantly lower peak ferritin.

Medication Management

Of the 39 patients receiving immunosuppressive medications before COVID-19 diagnosis:

  • Medications were held in 12 (23%)
  • Medications were continued in 6 (12%)
  • This status was unknown in 34 (65%)

Only five patients had documentation of medication management or notification of the rheumatologist.

Outcomes of COVID-19

In adjusted analyses, similar proportions of patients with or without rheumatic disease were hospitalized because of COVID-19 (44% vs. 40%). Significantly more patients with rheumatic disease required ICU admission/mechanical ventilation (48% vs. 18%; P = .01). Patients with rheumatic disease had threefold higher odds of requiring mechanical ventilation than patients without (OR, 3.11; 95% CI, 1.07–9.05; P = .04). There was no significant difference between groups in mortality (3 vs. 4 deaths).

Continued Scrutiny Needed

The American College of Rheumatology currently recommends holding immunosuppressive medications for patients who develop COVID-19, with the possible exception of interleukin-6 receptor inhibitors. Medications were held in a minority of cases in this study, so the impact on COVID-19 outcomes is unclear.

Differences in exposures to immunosuppressive medications might explain the higher odds of respiratory failure among COVID-19 patients who had rheumatic disease, compared with those who did not. Studies with larger samples are needed to address that issue and to understand whether specific immunosuppressive medications are particularly risky.

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