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COVID-19 Research

Since the COVID-19 pandemic began, many people with arthritis and rheumatic diseases have worried about whether their chronic condition makes them more likely to contract the coronavirus or puts them at higher risk for severe complications.

At this time, there are still no ironclad answers, but several new studies presented at ACR Convergence 2020, the annual meeting of the American College of Rheumatology, shed some light — and may provide a touch of reassurance.

These recent studies are adding to a growing consensus that simply having a rheumatic disease (such as rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis) isn’t necessarily problematic as far as COVID-19 is concerned, but there are many factors that often coincide with such rheumatic diseases that could influence your prognosis.

Here are four important findings about the interplay of COVID-19 and rheumatic disease that patients should know about — nearly a year into the pandemic.

1. Rheumatic disease patients don’t seem to be contracting COVID-19 at higher rates than other people

In fact, one study presented at ACR Convergence found that rheumatology patients were less likely than the general population to become infected with the coronavirus.

The authors examined coronavirus infection rates among rheumatic disease patients using biologic drugs as well as rheumatic disease patients who were not on biologics. They found that members of both groups were less likely than control groups to contract COVID-19.

While that sounds like good news, a plausible explanation might be that these patient groups are less likely to be exposed to coronavirus because they’re adhering more strictly to social distancing measure and other protective strategies, says rheumatologist Michael Putman, MD, an Assistant Professor at the Medical College of Wisconsin (who was not affiliated with this research).

2. There is some evidence that rheumatic disease patients with COVID-19 are more apt to become seriously ill, but research is mixed

Back in May, researchers behind the COVID-19 Global Rheumatology Alliance, a registry that was created to track the impact of the coronavirus on rheumatic disease patients, reported that people with rheumatic disease who contracted the virus were more likely than others to land in the hospital.

However, the authors noted that the increased hospitalization rate might reflect the fact that these patients were being closely monitored by rheumatologists who were taking extra precautions to keep them safe.

At ACR Convergence, a new study led by Kristin D’Silva, MD, a rheumatology research fellow at Massachusetts General Hospital, also found that people with “systemic autoimmune rheumatic diseases” who got COVID-19 were more likely to be hospitalized. That study also found that this group of patients was more likely to be admitted to the intensive care unit and put on a ventilator. They were more likely than other people with COVID-19 to have kidney damage and heart failure, too.

While that’s certainly alarming, other studies have essentially found the opposite to be true.

A different study presented at the meeting, which was a research review led by Akhil Sood, MD, an internal medicine resident in rheumatology with the University of Texas Medical Branch in Galveston, found that most rheumatic disease patients who developed COVID-19 “had a mild clinical course” and that very few died from it.

What to make of this conflicting research? Part of the challenge is the pandemic is still so new and we need more data. The Massachusetts General Hospital study included just 716 patients. In the University of Texas Medical Branch research review, only 123 people were positive or highly suspicious for COVID-19 infection.

But overall, if rheumatic disease patients were having COVID-19 complications at a rate that was alarmingly disproportionate to that of the general population, we’d likely have a clue by now. And that is mostly good news. “On balance, I suspect that patients with rheumatic diseases are a little more likely to get a little more sick if they get COVID-19,” says Dr. Putman.

3. Comorbid conditions likely explain why some rheumatic disease patients who get COVID become sicker than others

Several studies presented at ACR Convergence highlighted that fact that a combination of rheumatic disease plus another serious condition can be quite dangerous.

The above-mentioned study led by Dr. D’Silva noted that people with rheumatic disease had higher rates of hypertension, asthma, chronic kidney disease, and heart failure (prior to developing COVID) compared to controls — who had COVID-19 but not rheumatic disease — in the study.

The higher prevalence of these comorbidities might explain why the study found that rheumatic patients have an higher risk of COVID-19 complications, Dr. D’Silva told Healio Rhematology.

Other research also pointed to the danger of comorbid conditions. A study conducted by researchers in Spain found that inflammatory rheumatic disease patients were more apt to be admitted to the hospital with COVID-19 if they also had arterial hypertension, diabetes, or interstitial lung disease. Being older than 65 was another important risk factor.

A different study, led by rheumatologist Rebecca Haberman, MD, a Clinical Instructor of Rheumatology at NYU School of Medicine in New York City, similarly found that being older increased the likelihood that someone with rheumatic disease would be hospitalized with COVID-19. Having hypertension or chronic obstructive pulmonary disease (COPD) also increased the risk.

4. Glucorcorticoids (steroids) are far more dangerous than disease-modifying drugs (DMARDs), including biologics

Since the beginning of the pandemic, rheumatologists have warned that glucocorticoids like prednisone were the class of drugs to be most concerned about. Numerous studies have confirmed this risk, including the above-mentioned study led by Dr. Haberman.

Dr. Haberman and her coauthors found that the risk of being hospitalized with COVID-19 was significantly greater for inflammatory arthritis patients who were using glucocorticoids regularly. Those who were taking biologic drugs faced no increased risk.

“Steroids are often given to people who have really out-of-control symptoms, but they shut down every single line of the immune system,” she explains. “Our biologics, in contrast, are much more targeted, so there’s not this same overall immunosuppressive effect.”

What’s more, several biologic medications are actually being studied for their role as a potential COVID-19 treatment, due to their ability to tamp down inflammation in the body.

Dr. Haberman adds that this finding should provide comfort to the large numbers of inflammatory arthritis patients who rely on biology therapies to control their disease.

She says that when COVID-19 first hit New York, many of her patients decided to stop their biologics — and many of them ended up having disease flares.

“Now I can point to our research and other studies and say, ‘I understand your concerns, but we’ve really been looking at this and it’s important [and safer] to stay on your medication.'”

For people who are currently taking steroids to manage their disease, she has slightly different advice, which comes down to working closely with your doctor.

“A lot of people who are on steroids are on them for a reason. Maybe they’re not responsive to any other medication, or their disease is so severe that if they come off of them they might flare or have so much pain they can’t function. It’s really a case-by-case basis,” she says.

If your doctor does suggest stopping steroids or testing out a lower dose, remember that it’s crucial to wean off slowly or you risk serious side effects including dangerously low blood pressure.

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D’Silva K, et al. Outcomes of Coronavirus Disease 2019 Infection Among Patients Living with Rheumatic Diseases: A Matched Cohort Study from a US Multi-Center Research Network [abstract]. Arthritis & Rheumatology. November 2020. https://acrabstracts.org/abstract/outcomes-of-coronavirus-disease-2019-infection-among-patients-living-with-rheumatic-diseases-a-matched-cohort-study-from-a-us-multi-center-research-network.

Haberman R, et al. COVID-19 in Patients with Inflammatory Arthritis: A Prospective Study on the Effects of Comorbidities and DMARDs on Clinical Outcomes [abstract]. Arthritis & Rheumatology. November 2020. https://acrabstracts.org/abstract/covid-19-in-patients-with-inflammatory-arthritis-a-prospective-study-on-the-effects-of-comorbidities-and-dmards-on-clinical-outcomes.

Interview with Michael Putman, MD, Assistant Professor at the Medical College of Wisconsin

Interview with Rebecca Haberman, MD, Clinical Instructor of Rheumatology at NYU School of Medicine in New York City

Laday J. Systemic autoimmune rheumatic disease linked to higher end-organ failure risk in COVID-19. Healio Rheumatology. November 9, 2020. https://www.healio.com/news/rheumatology/20201109/systemic-autoimmune-rheumatic-disease-linked-to-higher-endorgan-failure-risk-in-covid19.

López-Gutierrez F, et al . Does the Type of Rheumatic Disease or Biologic Treatment Increase the Risk of Developing Severe COVID-19? [abstract]. Arthritis & Rheumatology. November 2020. https://acrabstracts.org/abstract/does-the-type-of-rheumatic-disease-or-biologic-treatment-increase-the-risk-of-developing-severe-covid-19.

Simon D, et al. Patients Receiving Cytokine Inhibitors Have Low Prevalence of SARS-CoV-2 Infection [abstract]. Arthritis & Rheumatology. November 2020. https://acrabstracts.org/abstract/patients-receiving-cytokine-inhibitors-have-low-prevalence-of-sars-cov-2-infection.

Sood A, et al. COVID-19 Infection Among Patients with Rheumatic Disease on Biologic & Targeted Therapies: A Systematic Review [abstract]. Arthritis & Rheumatology. November 2020. https://acrabstracts.org/abstract/covid-19-infection-among-patients-with-rheumatic-disease-on-biologic-targeted-therapies-a-systematic-review.