Changing COVID-19 outcomes in patients with rheumatic disease-are we really getting better at this?

Outcomes of COVID-19 in people with rheumatic and musculoskeletal disease in Ireland over the first 2 years of the pandemic

BACKGROUND

Poor COVID-19 outcomes occur with higher frequency in people with rheumatic and musculoskeletal diseases (RMD). Better understanding of the factors involved is crucial to informing patients and clinicians regarding risk mitigation.

AIM

To describe COVID-19 outcomes for people with RMD in Ireland over the first 2 years of the pandemic.

METHODS

Data entered into the C19-GRA provider registry from Ireland between 24th March 2020 and 31st March 2022 were analysed. Differences in the likelihood of hospitalisation and mortality according to demographic and clinical variables were investigated.

RESULTS

Of 237 cases included, 59.9% were female, 95 (41.3%) were hospitalised, and 22 (9.3%) died. Hospitalisation was more common with increasing age, gout, smoking, long-term glucocorticoid use, comorbidities, and specific comorbidities of cardiovascular and pulmonary disease, and cancer. Hospitalisation was less frequent in people with inflammatory arthritis and conventional synthetic or biologic disease-modifying antirheumatic drug use. Hospitalisation had a U-shaped relationship with disease activity, being more common in both high disease activity and remission. Mortality was more common with increasing age, gout, smoking, long-term glucocorticoid use, comorbidities, and specific comorbidities of cardiovascular disease, pulmonary disease, and obesity. Inflammatory arthritis was less frequent in those who died.

CONCLUSION

Hospitalisation or death were more frequently experienced by RMD patients with increasing age, certain comorbidities including potentially modifiable ones, and certain medications and diagnoses amongst other factors. These are important 'indicators' that can help risk-stratify and inform the management of RMD patients.

Perceived Risk of SARS-CoV-2 at the Start of the COVID-19 Pandemic and Subsequent Vaccination Attitudes in Patients With Rheumatic Diseases: A Longitudinal Analysis

OBJECTIVE

In a cohort assembled at the start of the pandemic in New York City, objectives of this longitudinal study were to ascertain whether perspectives about SARS-CoV-2 risks obtained at enrollment were associated with clinical course and vaccination intent obtained at follow-up with the advent of vaccines.

METHODS

Patients with diverse rheumatologist-diagnosed diseases taking immunosuppressive medications were interviewed in April 2020 during the height of mortality-associated COVID-19 in New York City and were asked whether they perceived greater infection risk due to rheumatic diseases/medications. Patients were interviewed again when vaccines became available and asked about flares, medication changes, disease activity during the pandemic, and current disease status. They also reported SARS-CoV-2 testing, vaccination intent, and vaccination concerns.

RESULTS

Ninety-six patients had follow-ups (January-March 2021; 83% women; mean age, 50 years). At enrollment, 53%/57% perceived much greater infection risk from autoimmune disease/medications; at follow-up, patients reported flares (63%), greater/unpredictable disease activity (40%), and more medications (44%). Current disease was excellent/very good/good (73%) and fair/poor (27%). Enrollment perspectives were not associated with follow-up status. Seventy percent had SARS-CoV-2 testing. Twenty-three percent would not/were hesitant about vaccination. In multivariable analysis, younger age, concern about effects on rheumatic disease, and distrusting vaccine information were main reasons for not intending/hesitancy to be vaccinated. Eighty-six percent did not report rheumatologists as sources of vaccine information.

CONCLUSIONS

Clinical status at follow-up and vaccination intent were not associated with perceived SARS-CoV-2 risk at the start of the pandemic. Concern about vaccine effects on rheumatic disease and distrust in vaccine information deterred patients from vaccination.

Gout and the risk of COVID-19 diagnosis and death in the UK Biobank: a population-based study

BACKGROUND

There is a paucity of data on outcomes for people with gout and COVID-19. We aimed to assess whether gout is a risk factor for diagnosis of COVID-19 and COVID-19-related death, and to test for sex- and drug-specific differences in risk.

METHODS

We used data from the UK Biobank, which included 15 871 people with gout. We used multivariable-adjusted logistic regression in the following analyses using a case-control study design: to test for an association between gout and COVID-19 diagnosis in the entire UK Biobank cohort (n=459 837); to test for an association between gout and COVID-19-related death in people who were known to have died or survived with COVID-19 (n=15 772); to test for an association between gout and COVID-19-related death in the entire UK Biobank cohort (n=459 837); and to assess risk of COVID-19-related death in a subset of patients from the UK Biobank cohort with prescription data, stratified by prescription of urate-lowering therapy and colchicine (n=341 398). Models 1 and 2 were adjusted for age group, sex, ethnicity, Townsend deprivation index, BMI, and smoking status. Model 2 was also adjusted for diagnosis of 16 other diseases that are established comorbidities of gout or established risk factors for COVID-19-related death.

FINDINGS

Gout was associated with diagnosis of COVID-19 (odds ratio [OR] 1·20, 95% CI 1·11-1·29) but not with risk of COVID-19-related death in the cohort of patients diagnosed with COVID-19 (1·20, 0·96-1·51). In the entire cohort, gout was associated with COVID-19-related death (1·29, 1·06-1·56); women with gout had an increased risk of COVID-19-related death (1·98, 1·34-2·94), whereas men with gout did not (1·16, 0·93-1·45). We found no significant differences in the risk of COVID-19-related death according to prescription of urate-lowering therapy or colchicine. When patients with gout were stratified by vaccination status, the risk of diagnosis with COVID-19 was significant in the non-vaccinated group (1·21, 1·11-1·30) but not the vaccinated group (1·09, 0·65-1·85).

INTERPRETATION

Gout is a risk factor for COVID-19-related death in the UK Biobank cohort, with an increased risk in women with gout, which was driven by risk factors independent of the metabolic comorbidities of gout.

FUNDING

Health Research Council of New Zealand.

Non-alcoholic Fatty Liver Disease and COVID-19 Susceptibility and Outcomes: a Korean Nationwide Cohort

BACKGROUND

Evidence for the association between underlying non-alcoholic fatty liver disease (NAFLD), the risk of testing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive, and the clinical consequences of coronavirus disease 2019 (COVID-19) is controversial and scarce. We aimed to investigate the association between the presence of NAFLD and the risk of SARS-CoV-2 infectivity and COVID-19-related outcomes.

METHODS

We used the population-based, nationwide cohort in South Korea linked with the general health examination records between January 1, 2018 and July 30, 2020. Data for 212,768 adults older than 20 years who underwent SARS-CoV-2 testing from January 1 to May 30, 2020, were obtained. The presence of NAFLDs was defined using three definitions, namely hepatic steatosis index (HSI), fatty liver index (FLI), and claims-based definition. The outcomes were SARS-CoV-2 test positive, COVID-19 severe illness, and related death.

RESULTS

Among 74,244 adults who completed the general health examination, there were 2,251 (3.0%) who were SARS-CoV-2 positive, 438 (0.6%) with severe COVID-19 illness, and 45 (0.06%) COVID-19-related deaths. After exposure-driven propensity score matching, patients with pre-existing HSI-NAFLD, FLI-NAFLD, or claims-based NAFLD had an 11-23% increased risk of SARS-CoV-2 infection (HSI-NAFLD 95% confidence interval [CI], 1-28%; FLI-NAFLD 95% CI, 2-27%; and claims-based NAFLD 95% CI, 2-31%) and a 35-41% increased risk of severe COVID-19 illness (HSI-NAFLD 95% CI, 8-83%; FLI-NAFLD 95% CI, 5-71%; and claims-based NAFLD 95% CI, 1-92%). These associations are more evident as liver fibrosis advanced (based on the BARD scoring system). Similar patterns were observed in several sensitivity analyses including the full-unmatched cohort.

CONCLUSION

Patients with pre-existing NAFLDs have a higher likelihood of testing SARS-CoV-2 positive and severe COVID-19 illness; this association was more evident in patients with NAFLD with advanced fibrosis. Our results suggest that extra attention should be given to the management of patients with NAFLD during the COVID-19 pandemic.

Autoimmune inflammatory rheumatic diseases and COVID-19 outcomes in South Korea: a nationwide cohort study

BACKGROUND

Real-world evidence on the association between autoimmune inflammatory rheumatic diseases, therapies related to these diseases, and COVID-19 outcomes are inconsistent. We aimed to investigate the potential association between autoimmune inflammatory rheumatic diseases and COVID-19 early in the COVID-19 pandemic.

METHODS

We did an exposure-driven, propensity score-matched study using a South Korean nationwide cohort linked to general health examination records. We analysed all South Korean patients aged older than 20 years who underwent SARS-CoV-2 RT-PCR testing between Jan 1 and May 30, 2020, and received general health examination results from the Korean National Health Insurance Service. We defined autoimmune inflammatory rheumatic diseases (inflammatory arthritis and connective tissue diseases) based on the relevant ICD-10 codes, with at least two claims (outpatient or inpatient) within 1 year. The outcomes were positive SARS-CoV-2 RT-PCR test, severe COVID-19 (requirement of oxygen therapy, intensive care unit admission, application of invasive ventilation, or death), and COVID-19-related death. Adjusted odds ratios (ORs) with 95% CIs were estimated after adjusting for the potential confounders.

FINDINGS

Between Jan 1 and May 30, 2020, 133 609 patients (70 050 [52·4%] female and 63 559 [47·6%] male) completed the general health examination and were tested for SARS-CoV-2; 4365 (3·3%) were positive for SARS-CoV-2, and 8297 (6·2%) were diagnosed with autoimmune inflammatory rheumatic diseases. After matching, patients with an autoimmune inflammatory rheumatic disease showed an increased likelihood of testing positive for SARS-CoV-2 (adjusted OR 1·19, 95% CI 1·03-1·40; p=0·026), severe COVID-19 outcomes (1·26, 1·02-1·59; p=0·041), and COVID-19-related death (1·69, 1·01-2·84; p=0·046). Similar results were observed in patients with connective tissue disease and inflammatory arthritis. Treatment with any dose of systemic corticosteroids or disease-modifying antirheumatic drugs (DMARDs) were not associated with COVID-19-related outcomes, but those receiving high dose (≥10 mg per day) of systemic corticosteroids had an increased likelihood of a positive SARS-CoV-2 test (adjusted OR 1·47, 95% CI 1·05-2·03; p=0·022), severe COVID-19 outcomes (1·76, 1·06-2·96; p=0·031), and COVID-19-related death (3·34, 1·23-8·90; p=0·017).

INTERPRETATION

Early in the COVID-19 pandemic, autoimmune inflammatory rheumatic diseases were associated with an increased likelihood of a positive SARS-CoV-2 PCR test, worse clinical outcomes of COVID-19, and COVID-19-related deaths in South Korea. A high dose of systemic corticosteroid, but not DMARDs, showed an adverse effect on SARS-CoV-2 infection and COVID-19-related clinical outcomes.

FUNDING

National Research Foundation of Korea.

Trends in COVID-19 cases and clinical management in Veterans Health Administration medical facilities: A national cohort study

OBJECTIVE

We explored longitudinal trends in sociodemographic characteristics, reported symptoms, laboratory findings, pharmacological and non-pharmacological treatment, comorbidities, and 30-day in-hospital mortality among hospitalized patients with coronavirus disease 2019 (COVID-19).

METHODS

This retrospective cohort study included patients diagnosed with COVID-19 in the United States Veterans Health Administration between 03/01/20 and 08/31/20 and followed until 09/30/20. We focused our analysis on patients that were subsequently hospitalized, and categorized them into groups based on the month of hospitalization. We summarized our findings through descriptive statistics. We used Cuzick's Trend Test to examine any differences in the distribution of our study variables across the six months.

RESULTS

During our study period, we identified 43,267 patients with COVID-19. A total of 8,240 patients were hospitalized, and 13.1% (N = 1,081) died within 30 days of admission. Hospitalizations increased over time, but the proportion of patients that died consistently declined from 24.8% (N = 221/890) in March to 8.0% (N = 111/1,396) in August. Patients hospitalized in March compared to August were younger on average, mostly black, urban-dwelling, febrile and dyspneic. They also had a higher frequency of baseline comorbidities, including hypertension and diabetes, and were more likely to present with abnormal laboratory findings including low lymphocyte counts and elevated creatinine. Lastly, there was a decline from March to August in receipt of mechanical ventilation (31.4% to 13.1%) and hydroxychloroquine (55.3% to <1.0%), while treatment with dexamethasone (3.7% to 52.4%) and remdesivir (1.1% to 38.9%) increased.

CONCLUSION

Among hospitalized patients with COVID-19, we observed a trend towards decreased disease severity and mortality over time.