ACR CONVERGENCE 2020—On March 12, a gastroenterologist tweeted about a registry that had been started to track outcomes for patients with gastrointestinal disorders who’d been diagnosed with COVID-19. A rheumatologist reposted it, asking whether such a registry had been started in rheumatology.
It hadn’t. But just two weeks later, the registry—now known as the Global Rheumatology Alliance registry—had been launched, and more than 20 cases were reported in the first 24 hours.
Dr. Grainger
Global Rheumatology Alliance
The quick action, said Rebecca Grainger, MBChB, PhD, associate professor of rheumatology at the University of Otago, New Zealand, in a talk at ACR Convergence, is a dramatic example of how the rheumatology community worldwide has come together during the pandemic.
Since then, data collected through the registry has helped point the way forward, identifying suitable treatment options and vulnerable populations, Dr. Grainger said. The Alliance, now a section of the ACR, includes data and support from approximately 300 professional and patient organizations, including the European League Against Rheumatism.
From early data—about 600 cases from March and April—researchers found that being 65 years or older was associated with hospitalization from COVID-19, with an odds ratio (OR) of 2.55, as were hypertension, lung disease, diabetes and chronic kidney or end-stage renal disease (OR≈1.83–3.07). A daily prednisone dose of 10 mg or more per day was also associated with hospitalization (OR=2.12). Treatment with a biological or targeted synthetic disease-modifying anti-rheumatic drug (DMARD) was associated with a lower hospitalization risk (OR=0.46).
Researchers have also looked at disparities in outcomes, using U.S. data from about 1,300 cases from March to August. They’ve found that being Black (OR=2.8), Asian (OR=2.7) or Latinx (OR=1.7) is associated with higher risk of hospitalization. Being Latinx is also associated with a higher risk of requiring ventilation support (OR=3.3).
Based on about 3,300 cases from March to July, researchers found the risk of death from COVID-19 is associated with increased age, male sex, moderate to high rheumatic disease activity and, in the case of patients with rheumatoid arthritis (RA), ever having smoked.
Two studies based on Alliance data have already been published, with a third publication expected soon, Dr. Grainger noted.1,2
“As rheumatologists, we are in a strong position to advocate [for our patients],” she said. “We must advocate for measures that protect people with rheumatic disease, in particular people from racial and ethnic minorities. We must advocate for information, reduced infection risk” and more widespread testing.
Dr. Liew
Should DMARDs Be Stopped Preemptively?
In further discussion, Jean Liew, MD, MS, assistant professor of rheumatology at Boston University School of Medicine, described the hypothetical case of a 46-year-old man with stable RA, taking etanercept and methotrexate, who is concerned about COVID-19 exposure because he is a nurse in an outpatient clinic. Should he stop his medicines preventatively? If not, what if he gets exposed?
Overall, Dr. Liew said, the evidence suggests that conventional DMARDs should not be stopped preemptively, although some evidence from observational, registry-based data suggests sulfasalazine may be associated with higher odds of a poor outcome for someone who gets COVID-19.3,4 Not enough information for a hard conclusion exists, Dr. Liew said.
Regarding biologics and targeted small molecule drugs, the infection risk likely depends on the drug class. Tumor necrosis factor inhibitors have been found to be associated with lower odds of hospitalization.3 But is this a true protective effect?
“We cannot come to causal conclusions using these observational data,” Dr. Liew said. “We really need the results of ongoing trials.”
The picture surrounding Janus kinase inhibitors remains complicated: Baricitinib has been linked with a shorter time to recovery when used along with the antiviral remdesivir, compared with remdesivir alone, according to information on the ACTT-2 trial released by the manufacturer, although that phase 3 trial continues.5 Concern lingers about the effects on the interferon response and the infection risk, as well as the risk of thrombosis in those with COVID-19, she said.
Data collected through the registry has helped point the way forward, identifying suitable treatment options & vulnerable populations.
Big-picture messages, Dr. Liew said, are for patients with rheumatic and musculoskeletal diseases to continue their medications if their disease is under control and they do not have a COVID-19 diagnosis or exposure, and to use the lowest glucocorticoid dose possible.
For patients with exposure to SARS-CoV-2, patients should hold conventional DMARDs other than hydroxychloroquine and sulfasalazine, along with biologics, targeted synthetic drugs and other immunosuppressives, while they wait for test results. Patients diagnosed with COVID-19 should hold all medications other than hydroxychloroquine.
Those are the recommendations from the ACR COVID-19 Task Force, updated in July and based on the evidence available then.
Physicians should also remember that quarantine can contribute to higher disease activity and worse physical and mental health by decreasing activity levels and leading to sedentary behavior, Dr. Liew said.
“As clinicians, it’s important to recognize this and help patients adapt as well as possible.”
Thomas R. Collins is a freelance medical writer based in Florida.
References
- Gianfrancesco MA, Leykina LA, Izadi Z, et al. Race/ethnicity association with COVID-19 outcomes in rheumatic disease: Data from the COVID-19 Global Rheumatology Alliance Physician Registry. Arthritis Rheumatol. 2020 Nov 3. Online ahead of print.
- Gianfrancesco MA, Hyrich KL, Al-Adely S, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: Data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2020 Jul;79(7):859–866.
- Kilian, A, Chock YP, Huang IJ, et al. Acute respiratory viral adverse events during use of antirheumatic disease therapies: A scoping review. Semin Arthritis Rheum. 2020 Oct;50(5):1191–1201.
- Brenner EJ, Ungaro RC, Gearry RB, et al. Corticosteroids , but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: Results from an international registry. Gastroenterology. 2020 Aug;159(2):481–491.
- Eli Lilly & Company. News release: Baricitinib in combination with remdesivir reduces time to recovery in hospitalized patients with COVID-19 in NIAID-sponsored ACTT-2 trial. 2020 Sep 14.
