Autoimmune Disease in the Time of COVID-19: Risks and Management Considerations
Karima Becetti, MD, MS
WCM-Q Class of 2011
Autoimmune rheumatic diseases (ARDs), such as rheumatoid arthritis and systemic lupus erythematosus, are chronic heterogenous systemic disorders characterized by immune dysregulation and inflammation that can lead to organ damage and significant morbidity. They have a wide range of manifestations involving many organ systems. Immunomodulatory and immunosuppressive medications in ARDs include non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) such as hydroxychloroquine and methotrexate, biologic DMARDs such as anti-interleukin 6 (tocilizumab) and anti-tumor necrosis factor (anti-TNF; adalimumab), and targeted synthetic DMARDs such as JAK inhibitors (baricitinib). Despite improvement in disease control, mortality remains higher in patients with ARDs compared to the general population due to increased cardiovascular disease and infection risk. So, how does COVID-19 impact patients with ARDs?
COVID-19’s severity varies from asymptomatic/mild in about 80% of cases to critical in about 5% of cases. Large descriptive studies from China, Europe, and the USA identified risk factors for severe COVID-19 including older age and a number of medical conditions such as diabetes, hypertension, and chronic kidney disease. It is still uncertain, however, whether having an ARD increases the risk of COVID-19 or poor outcomes from this infection. In a study including the first 600 cases of COVID-19 in patients with ARDs enrolled in the Global Rheumatology Alliance registry, nearly half of the cases (46%) were hospitalized and 9% were deceased. Other studies from Spain and Boston comparing patients with ARDs to reference general populations showed similar rates of hospitalization and death. These studies identified older age and the presence of comorbid conditions such as diabetes and hypertension as risk factors for poor outcomes from COVID-19. Variable risk might be carried by different ARDs, but additional studies are needed to further evaluate this risk.
The impact of ARD medications on COVID-19 has also been evaluated. Warnings against the use of ibuprofen in COVID-19 were raised at the beginning of the pandemic but subsequent studies did not show an association between NSAIDs and severe outcomes from COVID-19. Large controlled trials on hydroxychloroquine, which was initially thought to be a promising therapeutic agent in COVID-19, showed a lack of efficacy. With regards to glucocorticoids, observational studies from cohorts of patients with ARDs showed their association with poor outcomes from COVID-19, while a recent clinical trial (the RECOVERY Collaborative Group Trial) showed that dexamethasone, a glucocorticoid, resulted in lower 28-day mortality among patients with COVID-19 who were receiving either invasive mechanical ventilation or oxygen. Conventional, biologic and targeted synthetic DMARDs were not found to be associated with poor outcomes from COVID-19. In fact, some of these agents including tocilizumab, baricitinib, and anti-TNFs are being investigated as potential therapeutic agents in COVID-19 to correct the hyperinflammation that leads to organ failure and death in this infection.
COVID-19 preventative measures remain critical in patients with ARDs. It is important for these patients to continue the needed medical care for their ARDs during the pandemic,
but particular considerations have to be taken in the case of COVID-19 exposure or infection.
1- Goldblatt F, O’Neill SG. Clinical aspects of autoimmune rheumatic diseases. Lancet. 2013; 382: 797-808
2- Gianfrancesco M, Hyrich KL, Al-Adely S, et al. Characteristics associated with hospitalization for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2020; 79: 859-866
3- Sarzi-Puttini P, Giorgi V, Sirotti S, et al. COVID-19, cytokines and immunosuppression: what can we learn from severe acute respiratory syndrome? Clin Exp Rheumatol. 2020; 38: 337-342