Interplay of diabetes mellitus and rheumatic diseases amidst the COVID-19 pandemic: influence on the risk of infection, outcomes, and immune responses

Examining the clinical and radiological landscape of rhupus: navigating the challenges in disease classification

Rhupus, in the broad sense, refers to an overlap between rheumatoid arthritis (RA) and lupus. However, there is a paucity of data on the appropriate diagnostic/classification criteria that should be used to define rhupus. Hence, we undertook this narrative review to analyze the clinical characteristics, radiology, and treatment with a focus on diagnostic challenges and defining features of rhupus. The databases of Medline/PubMed, Scopus, and DOAJ were searched for relevant articles using the following keywords: ("Rhupus"), ("lupus" AND "erosive" AND "arthritis"), and ("lupus" AND "rheumatoid arthritis" AND "overlap"). Studies have used a variety of classification criteria for rhupus of which a combination of the latest classification criteria for RA and lupus along with positive anti-cyclic citrullinated peptide, anti-Smith, and anti-dsDNA antibodies seem most relevant. The majority of rhupus cohorts report the onset of the disease as RA (two-thirds of rhupus patients) followed by the development of features of lupus at an average interval of 3-11.3 years. The radiographic features and distribution of erosions are similar to RA. However, ultrasonography and MRI reveal erosions in pure lupus related arthritis as well. This makes the reliability of radiologic tools for the evaluation of rhupus supportive at the most. Extra-articular features in rhupus are mild with major organ involvement in the form of neuropsychiatric lupus and lupus nephritis being rare. We have further discussed the fallacies of the various classification criteria and proposed a theme for classifying rhupus which needs to be tested and validated in future studies. Our current state of understanding supports rhupus as an overlap of SLE and RA with articular disease similar to RA with the extra-articular disease being milder than SLE. Developing standardized classification criteria for rhupus will help in the early diagnosis and prevention of articular damage in patients with rhupus.

Methods to predict heart failure in diabetes patients

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is one of the leading causes of cardiovascular disease and powerful predictor for new-onset heart failure (HF).

AREAS COVERED

We focus on the relevant literature covering evidence of risk stratification based on imaging predictors and circulating biomarkers to optimize approaches to preventing HF in DM patients.

EXPERT OPINION

Multiple diagnostic algorithms based on echocardiographic parameters of cardiac remodeling including global longitudinal strain/strain rate are likely to be promising approach to justify individuals at higher risk of incident HF. Signature of cardiometabolic status may justify HF risk among T2DM individuals with low levels of natriuretic peptides, which preserve their significance in HF with clinical presentation. However, diagnostic and predictive values of conventional guideline-directed biomarker HF strategy may be non-optimal in patients with obesity and T2DM. Alternative biomarkers affecting cardiac fibrosis, inflammation, myopathy, and adipose tissue dysfunction are plausible tools for improving accuracy natriuretic peptides among T2DM patients at higher HF risk. In summary, risk identification and management of the patients with T2DM with established HF require conventional biomarkers monitoring, while the role of alternative biomarker approach among patients with multiple CV and metabolic risk factors appears to be plausible tool for improving clinical outcomes.

Rehabilitation of patients with inflammatory rheumatic diseases and comorbidities: unmet needs

Comorbidities may contribute to inadequate response to therapy and accelerate disability in various rheumatic diseases such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and psoriatic arthritis (PsA). Cardiovascular, oncological, and infectious comorbidities are common in rheumatic patients. The rehabilitation of patients with inflammatory rheumatic diseases (IRDs) with comorbidities requires a multidisciplinary approach to improving patients' functional mobility, slowing down the disease progression and minimizing the risks of complications. The evidence suggests that cardiac rehabilitation can be implemented in daily practice in patients with IRDs to reduce mortality for those with established risk factors. Physical exercises reduce the severity, improve the clinical course, and reduce hospitalization rates in patients with rheumatic diseases. A rehabilitation program with focused physical therapy can lead to functional improvements and reduction of disease activity in patients with lowered quality of life (QoL). Health professionals should provide evidence-based recommendations for patients with rheumatic diseases and comorbidities to initiate the self-management of their diseases and prevent complications.

Diabetes mellitus in rheumatic diseases: clinical characteristics and treatment considerations

New pathophysiological insights are now available on comorbidities in rheumatic diseases (RDs). Several nationwide studies point to the fact that comorbid diabetes mellitus (DM) increases the risk of adverse outcomes in patients with various RDs. Genetic factors, intensity of systemic inflammation, anti-inflammatory potential of therapeutic agents, and duration of RDs have been insufficiently explored in the context of comorbidities. Some disease-modifying antirheumatic drugs (DMARDs) have demonstrated a potential to improve the glycemic control while glucocorticoids (GCs) have worsened it, particularly in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Anti-TNFalpha agents in combination with hydroxychloroquine (HCQ) have been associated with a reduced risk of DM in patients with RA, ankylosing spondylitis (AS), Sjögren syndrome (SS), and SLE. Better understanding of confounding factor of currently available antirheumatic therapies in patients with DM and RDs will pave the way for a tailored approach, limiting the severity of clinical manifestations and reducing the mortality risk.

Risk factors for severe COVID-19 among patients with systemic lupus erythematosus: a real-world analysis of a large representative US administrative claims database, 2020-2021

OBJECTIVES

To identify risk factors for progression to severe COVID-19 and estimate the odds of severe COVID-19 associated with vaccination among patients with systemic lupus erythematosus (SLE).

METHODS

This retrospective cohort study identified adults with SLE in the Merative™ MarketScan® Databases. Patients were continuously enrolled the year before 1 April 2020 (baseline) and had a COVID-19 diagnosis between 1 April 2020 and the earliest of death, enrolment end or 31 December 2021. Severe COVID-19 was defined as hospitalisation with a COVID-19 diagnosis. Demographics on 1 April 2020, baseline comorbidities, corticosteroid use ≤30 days before COVID-19 diagnosis and other SLE medication use ≤6 months before COVID-19 diagnosis were assessed. Vaccination was identified by claims for a COVID-19 vaccine or vaccine administration. Backward stepwise logistic regression estimated odds of progression to severe COVID-19 associated with patient characteristics and vaccination.

RESULTS

Among 2890 patients with SLE with COVID-19, 500 (16.4%) had a COVID-19-related hospitalisation. Significant risk factors for progression to severe COVID-19 included rituximab (OR (95% CI) 2.92 (1.67 to 5.12)), renal failure (2.15 (95% CI 1.56 to 2.97)), Medicaid (vs Commercial; 2.01 (95% CI 1.58 to 2.57)), complicated hypertension (1.96 (95% CI 1.38 to 2.77)) and time of infection, among others. Vaccination had a significant protective effect (0.68(95% CI 0.54 to 0.87)) among all patients with SLE with COVID-19, but the effect was not significant among those with prior use of belimumab, rituximab or corticosteroids.

CONCLUSIONS

Certain chronic comorbidities and SLE medications increase the odds of progression to severe COVID-19 among patients with SLE, but vaccination confers significant protection. Vaccine effectiveness may be attenuated by SLE treatments. Protective measures such as pre-exposure prophylaxis and booster vaccines should be encouraged among patients with SLE.

Humoral response after a BNT162b2 heterologous third dose of COVID-19 vaccine following two doses of BBIBP-CorV among healthcare personnel in Peru

Background

The inactivated virus vaccine, BBIBP-CorV, was principally distributed across low- and middle-income countries as primary vaccination strategy to prevent poor COVID-19 outcomes. Limited information is available regarding its effect on heterologous boosting. We aim to evaluate the immunogenicity and reactogenicity of a third booster dose of BNT162b2 following a double BBIBP-CorV regime.

Methods

We conducted a cross-sectional study among healthcare providers from several healthcare facilities of the Seguro Social de Salud del Perú - ESSALUD. We included participants two-dose BBIBP-CorV vaccinated who presented a three-dose vaccination card at least 21 days passed since the vaccinees received their third dose and were willing to provide written informed consent. Antibodies were determined using LIAISON® SARS-CoV-2 TrimericS IgG (DiaSorin Inc., Stillwater, USA). Factors potentially associated with immunogenicity, and adverse events, were considered. We used a multivariable fractional polynomial modeling approach to estimate the association between anti-SARS-CoV-2 IgG antibodies' geometric mean (GM) ratios and related predictors.

Results

We included 595 subjects receiving a third dose with a median (IQR) age of 46 [37], [54], from which 40% reported previous SARS-CoV-2 infection. The overall geometric mean (IQR) of anti-SARS-CoV-2 IgG antibodies was 8,410 (5,115 - 13,000) BAU/mL. Prior SARS-CoV-2 history and full/part-time in-person working modality were significantly associated with greater GM. Conversely, time from boosting to IgG measure was associated with lower GM levels. We found 81% of reactogenicity in the study population; younger age and being a nurse were associated with a lower incidence of adverse events.

Conclusions

Among healthcare providers, a booster dose of BNT162b2 following a full BBIBP-CorV regime provided high humoral immune protection. Thus, SARS-CoV-2 previous exposure and working in person displayed as determinants that increase anti-SARS-CoV-2 IgG antibodies.