Patients With Lupus, Inflammatory Arthritis Have Similar Risk of COVID-19 Hospitalization as General Population

Most people with systemic lupus erythematosus (SLE) and inflammatory arthritis (IA), who use medications that make them immunosuppressed, are not necessarily at greater risk of hospitalization from coronavirus disease 2019 (COVID-19), according to 2 studies published in Arthritis & Rheumatology.

In the first study,¹ the researchers analyzed the associations between comorbidities and medications and infection outcomes for 103 patients (mostly white women) with IA. The patients had been treated at NYU Langone Health clinics between March 3 and May 4 for IA, and they had confirmed (n = 80) or highly suspected (n = 23) symptomatic COVID-19 infection.

The patients were followed for a mean (SD) of 42 (9) days from the time of symptom onset. Prior to the onset of COVID-19 symptoms, 24 patients (23%) considered their arthritis as being in remission, while 39 patients (38%) rated it as mild, 35 patients (34%) as moderate, and 3 (3%) as severe. Nearly all (94%) of the patients were on an immunomodulatory medication, with 60% on an anti-cytokine biologic and 11% on a Janus kinase (JAK) inhibitor.

Approximately one-fourth (26%) of the patients required hospitalization. The hospitalization rate was only 3% for patients between the ages of 18 and 44 compared with 34% for patients between the ages of 45 and 64 and 41% for patients older than 65 years. The rate of death of 4%. There were no deaths in the 18 to 44 age group.

Of the 4 patients who died, 2 had pre-existing comorbidities, 3 were on chronic methotrexate and/or glucocorticoids, and 1 was being treated with a biologic disease-modifying antirheumatic drug. None of the patients who died were on a JAK inhibitor; however, JAK inhibitor use was more common in patients who needed hospitalization.

“Of utmost importance is our finding that the chronic use of pathway-specific anti-cytokine biologic therapies was not associated with worse outcomes of COVID-19 in patients with IA,” the authors wrote. They added that the chronic use of JAK inhibitors may be of potential interest given that patients using these therapies were more likely to require hospitalization. But they added that the higher rate of hospitalization may be because patients prescribed JAK inhibitors have more advanced disease.

In the second study,² the researchers analyzed associations of comorbidities and medications with infection outcomes for 226 patients with SLE who had confirmed or suspected COVID-19. These patients were mostly Black, Hispanic, and female.

Forty-one patients had confirmed COVID-19; 19 patients had tested negative despite suggestive symptoms or contact with a patient who had COVID-19; 42 patients had COVID-19–like symptoms but did not get tested; and 124 patients were asymptomatic without testing. Among the patients with COVID-19, 24 were hospitalized, 4 required intensive care unit–level care, and 4 died. All 4 of the patients who died were on hydroxychloroquine.

Patients who were hospitalized were older than those who were not admitted. The patients who were hospitalized were more likely to be non-White and Hispanic: 83.3% non-White and 41.7% Hispanics in the hospitalized group compared with 58.8% non-White and 29.4% Hispanics in the ambulatory group. Patients who were hospitalized were more likely to have a history of lupus nephritis (45.8% vs 17.7%) or antiphospholipid syndrome (12.5% vs 0%). They were also more likely to have 1 or more comorbid conditions (62.5% vs 29.4%).

Predictors of hospitalization in patients with SLE were similar to those for the general population, the authors noted. They concluded that there was insufficient evidence that SLE-specific factors additionally contributed to the risk of hospitalization.

"Patients receiving therapy for lupus and inflammatory arthritis should not automatically stop taking their medications for fear that they would be worse off if they also caught the coronavirus," Rebecca Haberman, MD, a coauthor on both studies and clinical instructor in the Department of Medicine at NYU Langone, said in a statement. "Instead, rheumatology patients should consult with their medical provider about their overall risk factors for COVID-19 and make plans accordingly.”

References

1. Haberman RH, Castillo R, Chen A, et al. COVID-19 in patients with inflammatory arthritis: a prospective study on the effects of comorbidities and DMARDs on clinical outcomes. Arthritis Rheumatol. Published online July 28, 2020. doi:10.1002/art.41456

2. Fernandez-Ruiz R, Masson M, Kim MY, et al. Leveraging the United States epicenter to provide insights on COVID-19 in patients with systemic lupus erythematosus. Arthritis Rheumatol. Published online July 26, 2020. doi:10.1002/art.41450