Study Demonstrates Delay in Treatment Among Patients with Rheumatic Disease Due to COVID-19

Approximately 1/5 of patients with inflammatory rheumatic musculoskeletal diseases (iRMD) receiving biologic and/or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) delayed treatment due to fear of COVID-19 within the first 3 months of the pandemic, according to a study published in The Journal of Infection in Developing Countries.¹ However, patients who restarted treatment as well as the 12-month retention status was high in those who received good communication.

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“In the current study, we aimed to investigate the frequency of interruption/stopping and re-starting the treatment during the pandemic period for patients diagnosed with iRMD and using b/tsDMARDs who followed up in our clinic, to investigate the results of these conditions, and to evaluate the clinical features and outcomes of patients with COVID-19,” wrote a group of investigators associated with the Department of Rheumatology at the Dokuz Eylul University School of Medicine in Turkey.

A COVID-19 diagnosis has led to doubts as to whether immunosuppressive drug treatment should be continued. Regardless of severity, COVID-19 can cause severe pneumonia and hypoxemia in approximately 14% of patients as well as severe clinical manifestations including severe respiratory failure, multiorgan failure, and septic shock. In addition to male gender, advanced age, comorbidities, and smoking, being treated with b/tsDMARDs may contribute to poor clinical outcomes.²

The first stage of the study was assessed during the initial 3 months of the pandemic and the second stage was evaluated in patients who continued treatment after interruption within the 12-month period following the pandemic.

A total of 512 patients (n = 278 women) with a diagnosis of iRMD were included in the analysis, with most (54.3%) diagnosed with spondyloarthritis, 25.7% diagnosed with rheumatoid arthritis, 8.4% diagnosed with psoriatic arthritis, 6.1% diagnosed with vasculitis, and 5.4% diagnosed with other inflammatory conditions. The median disease duration of follow-up was 134.4 months, and the median age was 48 years. Approximately half (46%) of patients had ≥1 comorbidity, and 25.1% had ≥2 comorbidities. Hypertension (29%), diabetes mellitus (13.6%), interstitial lung disease/chronic obstructive lung disease (9.2%), cardiovascular disease (7.5%), and chronic kidney disease/end state renal disease (7.5%) were the most common comorbidities.

Reduced 12-month drug retention rates were seen in patients with concurrent use of hydroxychloroquine (hazard ratio [HR] = 1.49), intravenous bDMARD use (HR = 1.34), and a history of discontinuation of the drug within the first 3 months of the pandemic (HR = 1.19).

The use of glucocorticoids (HR = 3.81) and an interstitial lung disease/chronic obstructive lung disease diagnosis (HR = 4.96) increased the risk of COVID-19 infection.

Investigators noted limitations including enrolling patients in the TURKBIO cohort during the pandemic and continuing b/tsDMARDs treatment unless otherwise stated. However, findings were strengthened by the small number of studies evaluating compliance with b/tsDMARDs during the pandemic.

“The results of this study suggest that the use of CS and the presence of ILD significantly increase the risk of COVID-19,” investigators concluded. “TNF treatment can reduce the risk of infection. These results suggest that continuing b/tsDMARD treatments in iRMD patients during the pandemic period is a logical treatment strategythat can be applied by preventing disease activation and reducing glucocorticoid requirement. It would be appropriate to evaluate rituximab treatment on a patient basis.”

References

1. ^{Gulle S, Erez Y, Karakas A, et al. How has the COVID-19 pandemic affected our rheumatology patients using biological/targeted DMARDs?. J Infect Dev Ctries. 2023;17(7):944-952. Published 2023 Jul 27. doi:10.3855/jidc.17470}
2. ^{Jordan RE, Adab P, Cheng KK (2020) COVID-19: risk factors for severe disease and death. BMJ (Clinical research ed.) 368: p.m1198. doi: 10.1136/bmj.m1198}