Medication use for rheumatoid arthritis affects COVID-19 outcomes

People with rheumatoid arthritis treated with rituximab or JAKi have worse COVID-19 severity than those on TNFi

INTRODUCTION
COVID-19 is the disease caused by a new type of coronavirus called severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). It was declared a pandemic by the World Health Organization on 11 March 2020. COVID-19 has forced people to change their behaviours to try to limit the spread of infection.

Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, and may cause pain and disability. Rheumatoid arthritis can affect people of all ages, but it most often starts between the ages of 30 and 50. Rheumatoid arthritis is more common in women than men. There are many different treatments available for rheumatoid arthritis. The available medications include biologic or targeted synthetic disease-modifying antirheumatic drugs (usually shortened to bDMARD or tsDMARD).

WHAT DID THE AUTHORS HOPE TO FIND?
The authors wanted to see whether using bDMARDs or tsDMARDs for rheumatoid arthritis might affect a
person’s chances of COVID-19 outcomes such as hospitalisation, needing oxygen, or dying.

WHO WAS STUDIED?
The study looked at 2,869 people with RA that were taking a bDMARD or tsDMARD when they got COVID19. Most people were from Europe and North America, and the average age was 57 years.

HOW WAS THE STUDY CONDUCTED?
This was a retrospective observational study, which means that the authors used existing databases of patient records to look back and find people for each group. There was no interventional treatment given.

All the data came from people who took part in the Global Rheumatology Alliance (GRA) Physician Registry. The GRA is an ongoing study that is collecting information on people with systemic rheumatic diseases and COVID-19. Details are entered into the database by a person’s doctor. No identifying information is included, so all the data are anonymous.

In this analysis, the authors used data for people with rheumatoid arthritis who were taking a bDMARD or tsDMARD at the time of COVID-19 onset. The bDMARD drugs being used were abatacept, rituximab, interleukin-6 receptor inhibitors (IL-6Ri), and tumour necrosis factor inhibitors (TNFi). The tsDMARD medicines were all types of janus kinase inhibitors (JAKi).

WHAT WAS THE MAIN FINDING?
The authors found that people with rheumatoid arthritis treated with rituximab or JAKi had an increased risk of worse COVID-19 outcomes compared with people taking TNFi. These poor COVID-19 outcomes included
hospitalisation, need for oxygen (including mechanical ventilation), and death. The outcomes for people whose rheumatoid arthritis was treated with abatacept or IL-6Ri were generally similar to those taking TNFi.

ARE THESE FINDINGS NEW?
Some previous studies have found that people treated with rituximab may have poor COVID-19 outcomes.
However, those studies included several different types of diseases (not just rheumatoid arthritis), and did not directly compare the results to other drugs that may be considered for a specific disease. In this study, the association of JAKi with poor COVID-19 outcomes was new.

WHAT ARE THE LIMITATIONS OF THIS STUDY?
One limitation is that medications were grouped by class, rather than by individual drugs. It is possible that specific drugs within a class may have differences. For example, tofacitinib, baricitinib, and upadacitinib are all JAKi medications, but may have different biologic effects. While the GRA contains good quality data, some specific information about a person’s rheumatoid arthritis such as duration, severity, and previous medications were not available. Finally, the GRA Registry contains voluntarily entered cases. It is possible that doctors may be more likely to enter more severe cases that come to their attention rather than mild COVID-19 cases that get better quickly. This may affect the results.

WHAT DO THE AUTHORS PLAN TO DO WITH THIS INFORMATION?
The authors plan to replicate the findings and extend to different patient populations. Prospective studies to follow people with rheumatoid arthritis and other rheumatic diseases with COVID-19 are ongoing. Other studies that might be considered include seeing whether antibody levels to COVID-19 vaccines are protective, and whether booster doses may be needed for people who require immunosuppression.

WHAT DOES THIS MEAN FOR ME?
If you have rheumatoid arthritis, these findings suggest that the type of medication you use may affect the severity of COVID-19. Your doctor should be aware that you could be susceptible to poor outcomes, and you may be monitored more closely than usual. Controlling your rheumatoid arthritis is still very important during the pandemic. Do not stop taking any medicines you have been prescribed without talking to your doctor first.

Protect yourself from COVID-19 by following the advice of the government in your country. The best protection is getting vaccinated, but you should also wash your hands regularly, and avoid touching your face. Where recommended, follow social distancing rules, and use protective masks. Maintaining good ventilation may also help stop the virus spreading.

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Date prepared: August 2021
Summary based on research article published on: 2 April 2021
From: Sparks JA, et al. Associations of baseline use of biologic or targeted synthetic DMARDs with COVID-19 severity in rheumatoid arthritis: Results from the COVID-19 Global Rheumatology Alliance physician registry. Ann Rheum Dis 2020;80:1137–1146. doi:10.1136/annrheumdis-2021-220418

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