Impact of Corticosteroids and Immunosuppressive Therapies on Symptomatic SARS-CoV-2 Infection in a Large Cohort of Patients with Chronic Inflammatory Arthritis

Abstract

Background: Prevalence and outcomes of Coronavirus Disease (COVID)-19 in relation to immunomodulatory medications are still unknown. The aim of the study is to investigate the impact of glucocorticoids and immunosuppressive agents on COVID-19 in a large cohort of patients with chronic immune-mediated inflammatory arthritis.Methods: The study was conducted in the arthritis outpatient clinic at two large Academic Hospitals in the COVID-19 most endemic area of Northern Italy (Lombardy). We circulated a cross-sectional survey exploring the prevalence of Severe Acute Respiratory Syndrome-Coronavirus-2 nasopharyngeal swab positivity and the occurrence of acute respiratory illness (fever and/or cough and/or dyspnea), administered face-to-face or by phone to consecutive patients from 25th February to 20th April 2020. COVID-19 cases were defined as confirmed or highly suspicious according to the World Health Organization criteria. The impact of medications on COVID-19 incidence was evaluated. Results: The study population included 2050 adults with chronic inflammatory arthritis receiving glucocorticoids, conventional-synthetic (cs), or targeted-synthetic/biological (ts/b) disease-modifying drugs (DMARDs). Laboratory-confirmed COVID-19 and highly suspicious infection were recorded in 1.1% and 1.4% of the population, respectively. Treatment with glucocorticoids was independently associated with increased risk of COVID-19 (adjusted OR [95% CI] ranging from 1.23 [1.04-1.44] to 3.20 [1.97-5.18] depending on the definition used). Conversely, patients treated with ts/bDMARDs were at reduced risk (adjusted OR ranging from 0.46 [0.18-1.21] to 0.47 [0.46-0.48]). No independent effects of csDMARDs were observed.Conclusions: During the COVID-19 outbreak, treatment with immunomodulatory medications appears safe. Conversely, glucocorticoids, even at low-dose, may confer increased risk of infection.Trial registration: retrospectively registered

Clinical management of patients with rheumatoid arthritis during the COVID-19 pandemic

“…Similarly, our data showed a risk of COVID-19 increased in chronic GCs users at dose > 2.5 mg daily (OR 4.22, 95% CI 1.74-10.23) [31]. Finally, a comprehensive meta-analysis of 62 observational studies including 319,025 patients with autoimmune diseases from 15 countries showed that GCs use prior to COVID-19 significantly contributed to the disease prevalence; meanwhile, therapies including csDMARDs and b/tsDMARDs did not contribute to the risk of COVID-19.…”

“…Another survey-based study conducted by our group in a cohort of 2050 patients with chronic inflammatory arthritis showed a decreased risk in b/tsDMARDs users (OR 0.47, 95% CI 0.46-0.48) while csDMARDs did not modify the odds of infection [31]. On a Spanish cohort of 123 patients with autoimmune inflammatory rheumatic disease and COVID-19, 54 patients required hospital admission related to COVID-19; patients exposed to DMARDs were not at higher risk of hospitalization, and those treated with anti-TNF had a statistically significant lower risk (OR 0.13, 95% CI 0.03-0.63) [32].…”

Endocrine risk factors for COVID-19: Endogenous and exogenous glucocorticoid excess

“…Whether or not patients with systemic GC treatment are at an increased risk of SARS-CoV-2 infection and/ or severe outcomes is so far not fully clarified. On the one hand, GCs were discussed theoretically to mitigate hyperimmune reactions responsible for severe disease progression [26]. An enhanced local innate immune defense in respiratory epithelial cells was reported in response to GC exposure, beside the known anti-inflammatory and anti-allergic actions of GCs [27].…”

“…Due to the heterogeneous studies with different sample sizes, variable diseases included, diagnostic criteria and geographic location, these data should be interpreted with caution. However, there are other studies of patients with autoimmune or inflammatory diseases and GC exposure that have described an increased risk of SARS-CoV-2 infection [26,29,30]. Table 1 shows studies with patients under GC treatment and SARS-CoV-2 infection.…”