High rates of severe disease and death due to SARS-CoV-2 infection in rheumatic disease patients treated with rituximab: a descriptive study

Abstract

The objective of this study is to describe the characteristics and outcomes of rheumatic and musculoskeletal disease (RMD) patients who were treated with rituximab and had suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this descriptive study, RMD patients who were treated with rituximab in the last 12 months at the Rheumatology Department of our hospital were screened for SARS-CoV-2 infection via telephone interview and a comprehensive review of clinical health records (01/02/2020-26/05/2020). Those with probable or confirmed SARS-CoV-2 infection were included. In total, 76 patients were screened. Of these, 13 (17.1%) had suspected or confirmed SARS-CoV-2 infection. With regard to these 13 patients, the median age at coronavirus disease (COVID-19) diagnosis was 68 years (range 28-76 years) and 8 (61.5%) were female. Five patients had rheumatoid arthritis, three had systemic vasculitis, two had Sjögren syndrome, and two had systemic lupus erythematosus. Additionally, seven patients (53.8%) had pulmonary involvement secondary to RMD. Eight patients (61.5%) developed severe disease leading to hospitalization, and seven developed bilateral pneumonia and respiratory insufficiency. Of the eight hospitalized patients, five (62.5%) fulfilled the acute respiratory distress syndrome criteria and three developed a critical disease and died. Our cohort had a high rate of severe disease requiring hospitalization (61.5%), with bilateral pneumonia and hyperinflammation leading to a high mortality rate (23.1%). Treatment with rituximab should be considered a possible risk factor for unfavorable outcomes in COVID-19 patients with RMD. However, further study is required to confirm this association.

COVID-19 in patients with systemic lupus erythematosus: lessons learned from the inflammatory disease

“…Moreover, the effect of B-cell depleting therapy on COVID-19 outcomes needs to be addressed, although very limited data to date suggest the potential for detrimental effects. [148][149][150] Overall, the findings of pathogenic adaptive immune responses in COVID-19 further support the notion that the timely implementation of immunomodulatory therapy in selected patients may be beneficial.…”

“…156,182,183 Recently, D 1 5 3 X X2 small studies reported high rates of severe COVID-19 and mortality in patients on RTX for various indications. 148,149 However, larger studies and longer followup are needed to confirm these observations.…”

Use of rituximab and the risk of adverse clinical outcomes in COVID-19 patients with systemic rheumatic disease

“…Although the study by Loarce-Martos et al [1] was limited by its small sample size, it does however indicate a possibility for differential risk of adverse clinical outcomes among patients with systemic rheumatic disease based on the type of biological agents received. Particularly, rituximab causes B cell depletion that can be associated with decreased antibody production.…”

“…We read with interest the descriptive study by Loarce-Martos et al [1] to investigate the clinical characteristics and outcomes of patients with systemic rheumatic disease receiving rituximab who acquired coronavirus disease 2019 (COVID-19) or were presumed to acquire COVID-19 in a Spanish hospital. It was reported in the study that patients with systemic rheumatic disease receiving rituximab had unfavorable prognosis upon hospitalization with COVID-19, of which all experienced clinical worsening upon hospitalization and three out of eight hospitalized patients succumbed to death.…”

Response to: ‘Antirheumatic drugs, B cell depletion and critical COVID-19: correspondence on ‘Clinical course of coronavirus disease 2019 (COVID-19) in a series of 17 patients with systemic lupus erythematosus under long-term treatment with hydroxychloroquine by Mathianet al’ by Notzet al

“…8 Recently, Loarce-Martos et al confirmed that COVID-19 is not only common, but also particularly severe in patients with rheumatic disease who had been on treatment with RTX. 9 Indeed, in an observational study they reported that 13 out of 76 (17.1%) patients with rheumatic disease treated in their centre with RTX in the last 12 months prior to screening for the presence of SARS-CoV-2 had suspected or confirmed infection. A total of eight of these patients (61.5%) developed severe COVID-19 leading to hospitalisation, from which five (38.5%) fulfilled the acute respiratory distress syndrome criteria, whereas three (23.1%) eventually died.…”