Rheumatic disease and COVID-19 mortality

3 minute read

While risk is higher, stopping medication can lead to even worse outcomes

Higher levels of disease activity in rheumatic disease appears to be a risk factor for COVID-19-related mortality, which emphasises the importance of maintaining good disease control during the pandemic, experts say.

The COVID-19 Global Rheumatology Alliance – an international physician-reported registry – has published its analysis of data from 3729 individuals with a range of rheumatic diseases who also had presumed or confirmed COVID-19 infection.

The study, published in the Annals of Rheumatic Disease, recorded 390 deaths, representing just over 10% of the study population, and more than two-thirds of these deaths were in individuals aged over 65 years.

In general, the risk factors for COVID-19 mortality in this population were similar to those seen in the broader community. Those aged 66-75 years had a three-fold greater risk of COVID-19-related death than did those aged under 65 years, and those aged over 75 years had a greater than six-fold increase in mortality.

Men were 46% more likely to die than women, those with chronic lung disease had a 68% higher risk of death, and cardiovascular disease combined with hypertension was associated with an 89% increase in mortality risk.

Current or former smoking was only associated with an increase in mortality risk among individuals with rheumatoid arthritis, and chronic kidney disease was only significantly associated with COVID-19-mortality among individuals with connective tissue diseases or vasculitis.

However, the study found that disease activity was significantly associated with risk of death. Patients with moderate disease activity had a 27% greater odds of death, those with high disease activity had an 87% greater odds, and those with severe disease activity had a 2.7-fold greater odds, compared with patients with low or no disease activity.

Researchers also examined associations between different medications and COVID-19 mortality. The only significant findings were that rituximab was associated with a four-fold increase in mortality, sulfasalazine with a 3.6-fold increase and immunosuppressants with around a 2.2-fold increase.

Higher doses of glucocorticoids – greater than 10mg/day – were also associated with a nearly 70% increase in death overall, and a 93% increase among people with connective tissue diseases or vasculitis.

However, co-author and rheumatologist Associate Professor Rebecca Grainger, from the University of Otago in Wellington, said it was important that the data not be interpreted as cause for alarm about certain medications.

“An understandable response for patients is ‘I don’t want to be immunosuppressed, I’m going to stop or discontinue my medications’,” Professor Grainger said.

“The repercussions of that, if their disease were to flare, is they might be offered glucocorticoids for temporary disease control and that might be a worse state to be in than staying in low disease control and following excellent public health recommendations.”

She also stressed that in Australia and New Zealand, where infection rates are very low, the best protection for patients with rheumatic disease against a poor outcome from COVID-19 was to follow public health advice and avoid infection.

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