DMARDs Not Linked to Poor Outcomes in SARS-CoV-2 RA Patients

Data collected by doctors in Italy when the country was hit by COVID-19 should allow rheumatologists to feel more comfortable in advising patients with chronic arthritis to continue taking immunosuppressive targeted therapies.

Patients with rheumatic disease are considered to be at risk for worse outcomes if they are infected with COVID-19, and immunosuppressive drugs could heighten that risk raising concerns about use of the drugs during the pandemic. However, patients who are well controlled on their medication risk of relapse if they stop their usual drug therapy. The American College of Rheumatology has recommended that disease-modifying anti-rheumatic drugs (DMARDs) should be continued in most patients with inflammatory arthritis not infected with COVID-19.   

Italy has been one of the countries hardest hit by the COVID-19 pandemic and the highest incidence has been in Lombardy in the north of the country.

Concerned about the welfare of patients on immunosuppressive drugs, rheumatologists at the Policlinico San Matteo Pavia Fondazione (IRCCS) in Pavia, Lombardy conducted a survey of patients with chronic arthritis treated with biological disease-modifying antirheumatic drugs (bDMARDs) or targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs). The results of their survey have been published in a letter in the Annals of the Rheumatic Diseases.

The survey asked patients about their health, whether they had been in contact with anyone known to be infected with COVID-19 and their use of DMARDs during the first few weeks of pandemic.

During the first month 320 patients responded to the survey, more than two-thirds were female with a mean age of 55. Most of the patients had rheumatoid arthritis (57%), and 43% had spondyloarthritis. Just over half the patents (52%) were being treated with tumour necrosis factor inhibitors, 40% were taking other bDMARDs and 8% tsDMARDs.

Four of the patients had tested positive for COVID-19 via a rhinopharyngeal swab test, and another four reported covid-like symptoms. Five other patients reported having been in contact with someone with covid-19, but they remained asymptomatic two weeks later.

All patients with symptoms of COVID-19 infection stopped their DMARD treatment temporarily at the onset of symptoms, and “to date, there have been no significant relapses of the rheumatic disease,” the authors write. None of the patients with a confirmed diagnosis of COVID-19 or with symptoms “highly suggestive” of the infection developed severe respiratory complications or died, and only one patient, aged 65, required admission to hospital where they remained for a few days and received oxygen.

All patients with confirmed COVID-19 received at least one course of antibiotics, and the hospitalised patient also received antiviral therapy and hydroxychloroquine. A further five patients with COVID-19 symptoms were on previous stable treatment with hydroxychloroquine, they note.

While the authors, led by Dr. Sara Monti, from the rheumatology department at IRCCS, caution that their findings do not allow any conclusions to be made on the incidence of COVID-19 in patients with rheumatic diseases nor on the outcomes for immunocompromised patients affected by the virus, they say, “Our preliminary experience shows that patients with chronic arthritis treated with bDMARDs or tsDMARDs do not seem to be at increased risk of respiratory or life-threatening complications from SARS-CoV-2 compared with the general population.”

IRCCS was designated a referral centre for COVID-19 patients, and the authors reveal that none of the 700 patients admitted for severe disease during the previous month had been on either bDMARDs or tsDMARDs. They add that there were no reports of increased deaths among patients treated with immunosuppressive drugs for organ transplantation, cancer or autoimmune diseases during other coronavirus outbreaks (SARS and MERS).

“Although continuous surveillance of patients with rheumatic diseases receiving immunosuppressive drugs is warranted, these data can support rheumatologists for the management and counselling of their patients, avoiding the unjustifiable preventive withdrawal of DMARDs, which could lead to an increased risk of relapses and morbidity from the chronic rheumatological condition,” the authors say.