8 Noteworthy COVID-19 Studies from EULAR 2022

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Although we’re more than two years into the COVID-19 pandemic, there’s still much to learn about the virus and its implications — especially when it comes to those with autoimmune and rheumatic disease. However, new research that sheds light on several lingering questions was recently presented at EULAR Congress 2022, the annual meeting of The European Alliance of Associations for Rheumatology. 

Here, we’ve recapped a few of the top COVID studies from the event, so you can stay up to date with the latest developments (and what they mean for you).  We’ve also asked GHLF’s Associate Director of Community Outreach Zoe Rothblatt, who lives with axial spondyloarthritis (axSpA) and Crohn’s disease, to tell us why this research should matter to our patient community.  

Mental Health During the COVID-19 Pandemic

 Researchers analyzed patient-reported measures of physical health (physical function, pain interference, fatigue, sleep disturbance), mental health (anger, anxiety, depression), and social health (social isolation, emotional support) in more than 2,000 participants from the ArthritisPower research registry to determine the effects of the pandemic on patients with autoimmune and rheumatic disease. Among the patients, rheumatoid arthritis was the most common condition.  

For all measures, the scores of patients were worse than the U.S. population mean during the observed period of January 2020 to April 2021. Over the 15-month study period, mental health assessment scores — including those for anger, anxiety, and depression — varied significantly. For instance, in May and June of 2020, mean scores for anger and anxiety were elevated. Social isolation peaked in June and emotional support dipped in December 2020. The same meaningful variances were not seen in the physical health assessments.  

 Key Takeaways

• Scores for mental health fluctuated significantly in patients with autoimmune and rheumatic disease during the COVID-19 pandemic. 
• These fluctuations were particularly evident during the first U.S. wave of the COVID-19 pandemic. 
• However, scores for physical health remained relatively stable across the pandemic period. 

 Patient Perspective 

“Research on the intersection of physical and mental health matters. Taking care of your mental health is just as important as taking care of your physical health, especially when you live with a chronic illness. Research like this helps me feel less alone, especially during this isolating pandemic.”  

 Flares Following Coronavirus Vaccination

 In this series of six case studies on patients with long-term quiescent rheumatoid arthritis who experienced a flare of disease activity after vaccination, researchers sought to understand the changes to rheumatoid arthritis control. 

 The patients were reviewed in-clinic as part of standard care. This was a review of usual clinical practice (it did not alter the treatment or monitoring of the patient). All flares occurred within two weeks of the vaccine, and of the patients who flared, two required short-term steroid treatment. Meanwhile, three needed an increase in usual medications and one who had been in disease remission needed to restart previous therapy.  

Compared to the AstraZeneca vaccine group, more patients in the Pfizer vaccine group needed an escalation of usual care. The time since diagnosis of the six patients ranges from 7 years to 13 years — and the time since the last flare ranged from two years to 11 years. Four patients experienced a flare after the first dose and two experienced a flare after the second dose.  

 Key Takeaways

• In this series of case studies, there were six cases of a rheumatoid arthritis flare soon after the receipt of the coronavirus vaccine. 
• All patients reclaimed disease control with minimal changes to treatment. 
• Of the patients, 42 percent of patients required either no treatment or an intramuscular steroid alone. 
• Researchers recommend that clinicians counsel patients about the potential effects, but continue to advocate the COVID-19 vaccine, since the risk of complications to underlying arthritis is very low and seemingly easily treatable. 

 Patient Perspective 

“Anecdotally, many patients in the arthritis community have reported arthritis related symptoms and flares after the COVID vaccine. Many studies have said that the chance of flare is minimal, and while that may feel like that brings relief, it also negates the patient experience of many. I think many will feel comforted and less alone now that their experience is represented in research.”  

Musculoskeletal Symptoms After Severe Infection

 Although pneumonia is the main and most severe manifestation of SARS-CoV-2 infection, some sparse cases have reported musculoskeletal symptoms following an infection. To determine the prevalence of these symptoms, researchers collected data on patients who tested positive for COVID-19 and were admitted in any Assistance Publique-Hôpitaux de Paris (APHP) department between March 1, 2020 and December 31, 2020. Patients with a past history of any musculoskeletal condition were excluded.  

Among 15,601 patients, nearly 9 percent (1,370 patients) presented with musculoskeletal symptoms. The most prevalent musculoskeletal symptoms were:  

• Low back pain (32.9%) 
• Joint pain (29.9%) 
• Joint effusion/arthritis (22.8%) 
• Radicular pain (20.2%) 

Patients with musculoskeletal symptoms were older, more frequently obese, hypertensive, and with diabetes. There were no differences in gender or in the ICU admission rate between groups. Treatment for COVID-19 was slightly different in the groups, with higher corticosteroids, antivirals, and immunosuppressive drugs prescription rates in the musculoskeletal group.  

Key Takeaways

• Musculoskeletal symptoms occurred in nearly 9 percent of patients admitted to the hospital with COVID-19. 
• These symptoms were particularly prevalent in older and more comorbid patients. 
• More research evaluating the persistence of these symptoms is needed.

Patient Perspective

“It is well known that it can take a really long time, years even, to be diagnosed with a rheumatic disease. Research like this is important in that it can help someone to recognize their symptoms earlier, and also clue in rheumatologists to the fact that there may be a new cohort of people with musculoskeletal conditions in the coming years.” 

Breakthrough Infections Among Vaccinated Patients

 This study involved an analysis of data from the German COVID-19-IRD registry, collected by treating rheumatologists between February 2021 and January 2022. Researchers identified patients double or triple vaccinated against COVID-19 14 days or more before SARs-CoV-2 infection, and their type of inflammatory rheumatic disease (IRD), vaccine, immunomodulation, comorbidities, and outcomes of the infection were compared with 737 unvaccinated IRD patients with COVID-19.  

 Overall, 271 breakthrough infections were reported. 

• 250 patients (91%) had received two doses of vaccines 
• 21 (9%) had three 

More than 70 percent received the Pfizer/BioNTech vaccine for the first, second, and third vaccination. The median time from the second/third vaccine dose to infection was 148 days (with a range of 14 to 302 days). Most patients were diagnosed with inflammatory joint diseases — and most were treated with methotrexate. Hospitalization rates were higher in unvaccinated IRD-patients than in vaccinated ones. 

 Key Takeaways

• There were no fatal courses and no COVID-19 related complications reported in the cohort of triple-vaccinated IRD patients. 
• However, the median age and rate of comorbidities were higher compared to double-vaccinated and unvaccinated patients. 
• The results support general recommendations to administer three doses of the vaccine to reduce the risk of severe COVID-19, particularly in patients who are older, have comorbidities, and are on immodulatory treatment. 

Patient Perspective

“When I think about the number-one thing I want from the COVID vaccine, it’s to keep me from having a severe infection and out of the hospital. All the unknowns about being immunosuppressed during the pandemic has brought on a great deal of stress and this research brings me comfort and confirms I made the right decision in getting the additional shots of the vaccine.”   

Anti-Spike Antibodies Following Vaccines

Researchers compared the persistence of anti-Spike antibodies after two SARS-CoV-2 doses between patients with immune-mediated inflammatory diseases (IMIDs) using immunosuppressive medication and healthy controls in this new study. Their goal: to identify predictors of antibody decline. A total of 1,097 patients (400 of which had rheumatoid arthritis) and 133 controls provided blood samples. 

 The first assessment was within six to 48 days and the second assessment was within 49 to 123 days following two-dose vaccination against COVID-19. Antibody levels were significantly lower in patients compared to controls at both assessments. At the second assessment, anti-RBD levels were -86% in patients and -77% in controls. (RBD is the receptor-binding domain of the SARS-CoV-2 Spike protein). Most patients using rituximab had low antibody levels at both assessments. Use of tumor necrosis factor (TNF) inhibitors in mono- or combination therapy was associated with the greatest decline compared to controls.  

 Key Takeaways

• Within four months after a second COVID-19 vaccine dose, anti-Spike antibody levels declined considerably in both immune-mediated inflammatory disease patients and controls. 
• Patients had lower antibody levels at the first assessment and a more pronounced decline compared to controls. 
• As such, patients were more likely to have low antibody levels four months after the second vaccine dose. 
• The results show that IMID patients lose protection and need additional vaccine doses sooner than healthy individuals, per the researchers. 

 Patient Perspective

“Data like this helps me have better, more informed conversations with my doctor around vaccine dosing schedule. The more research my doctor or I can point to, the better I feel about making decisions together.”  

Infection and Hospitalization In Vaccinated vs. Unvaccinated

 In this Danish nationwide matched cohort study from January to October 2021, researchers aimed to investigate the incidence of COVID-19 infection and hospitalization in unvaccinated and vaccinated patients with rheumatoid arthritis compared with matched individuals. They also analyzed patients with rheumatoid arthritis according to DMARD treatment.  

Patients with rheumatoid arthritis (regardless of vaccination status) had a higher incidence of COVID-19 hospitalization compared to matched individuals. The absolute risk was 0.20 percent for unvaccinated patients at 60 days and 0.08 percent for comparators — but it remained below 0.05 percent at 180 days of follow-up in both groups when fully vaccinated. Increased COVID-19 rates were only seen among unvaccinated patients with rheumatoid arthritis. There was an increased incidence of COVID-19 hospitalization among rituximab-treated patients compared with conventional DMARd-treated patients. That said, the proportion of patients with previous cancer and treated with prednisolone were higher among the rituximab-treated. 

 Key Takeaways

• COVID-19 hospitalization was higher in both unvaccinated and vaccinated patients with rheumatoid arthritis compared with controls.  
• However, the parallel decreasing risk for patients with rheumatoid arthritis suggests a comparable relative benefit of vaccination.  
• Rituximab should be considered with extra care, based on the less favorable outcomes among rituximab-treated patients. 

Patient Perspective

“While it’s scary to hear about our risk as immunocompromised individuals compared to healthy folks, it’s necessary. Knowing my risk helps me assess situations and what safety precautions I need to take to feel comfortable. As many move forward to ‘normal life,’ I know I need to continue to stay vigilant.”  

Effect of Specialist Counseling on Vaccine Hesitant Patients

The reasons for vaccine hesitancy are complex, arising from an interplay between scientific, religious, and political beliefs. Researchers aimed to understand the possible reasons for vaccine hesitancy in patients with autoimmune rheumatic diseases and the effectiveness of specialist counseling on vaccine-hesitant patients. They conducted an observational survey-based, in-person, cross-sectional study in which patients attending a hospital’s outpatient department were asked about their vaccination status.  

Unvaccinated patients provided reasons for their vaccine hesitancy. The vaccine-hesitant patients were counseled by the treating rheumatologist and asked about their willingness to take the vaccine after counseling.  

 A total of 322 patients participated in the study with a mean age of 40 years, over 70 percent of whom were females. Most patients had rheumatoid arthritis (40 percent), followed by SpA (27 percent), SLE (13 percent), and others.  

 A significant portion of patients (60 percent) had more than one reason for vaccine hesitancy: 

• Nearly 60% feared their disease might flare post-vaccination. 
• Almost half (44.4%) were hesitant to take the vaccine due to the fear of side effects. 
• More than one third (35%) feared the vaccine may not be effective on them as they were on immunosuppressive medications.  

 However, most patients (91 percent) were willing to get vaccinated after specialist counseling.  

 Key Takeaways

• Vaccine hesitancy can be multifactorial. 
• Major reasons for vaccine hesitancy in patients with autoimmune rheumatic diseases include fear of disease flare post-vaccination, fear of vaccine side effects, and doubts whether the vaccine would work in patients taking immunosuppressive medications. 
• However, most patients were willing to get vaccinated after counseling by a rheumatologist. 

 Patient Perspective

“There is so much trial and error that patients go through to find the right medication, and we never want to do something to jeopardize that relief once we feel it. These concerns about the COVID vaccine are very real and valid, and further highlight the rheumatologist’s role in educating and allaying fears for their patients.”    

Post-Traumatic Stress Disorder During the COVID-19 Pandemic

 In this study, researchers wanted to assess post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in a sample of patients with rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic in Italy. Patients with an RMD diagnosis were enrolled from May 2021 to January 2022. Their sociodemographic characteristics and psychopathological data were collected through an online survey, while a physician collected their clinical data.  

 A total of 194 eligible patients were included, 73 percent of which were females and nearly 60 percent of which reported connective tissue diseases. Of the patients, 17 percent reported symptomatological PTSD. The prevalence of partial PTSD (defined by at least two out of the four criteria for diagnosis) was 56.7 percent, with significantly higher rates among females than males.  

 Key Takeaways

• Research suggests high prevalence rates of symptomatological PTSD among patients suffering from rheumatic and musculoskeletal diseases. 
• This highlights the potentially traumatic burden of the COVID-19 pandemic in this particular population, especially for females. 
• More research is needed to address tailored prevention and intervention strategies. 

Patient Perspectives

“This research highlights the need for well-rounded conversations in the rheumatologist’s office. Rheumatologists should be checking in on their patient’s mental health, especially during the ongoing pandemic. If you’re struggling, know you aren’t alone, and that there are resources out there to help you.” 

 Read more about EULAR 2002 in “Patient Perspective: Notable Rheumatic Disease Studies at EULAR,” and check out CreakyJoints on Twitter (#EULAR2022) for even more coverage.

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