Patients with connective tissue disease who maintain their rheumatic therapy do not have an increased risk for COVID-19, according to a group of physicians in Italy who presented findings in an editorial published in the Journal of Rheumatology.
“Along with the spread of the pandemic, there has been a growing concern about the management of fragile rheumatic patients, for whom there is still very little data available,” Ennio Giulio Favalli, MD, of the ASST Gaetano Pini-CTO Institute, in Milan, and colleagues wrote.
“In particular, subjects affected by connective tissue diseases (CTD) are known to have an increased infectious risk compared to the healthy population due to a general impairment of the immune system intrinsic to the autoimmune disease itself, the iatrogenic effect linked to the use of immunosuppressive drugs, and the high number of comorbidities that often complicate the clinical picture,” they added. “On the other hand, the progressive increase in the knowledge about the pathogenesis of the infection is paving the way for the use of certain drugs used in rheumatology to treat also COVID-19.”
To analyze the impact of COVID-19 among patients with connective tissue disease, Favalli and colleagues conducted a survey of individuals admitted and followed at the Research Center for Adult and Pediatric Rheumatic Diseases, at the ASST Gaetano Pini-CTO. The survey comprised123 adults, including 61 with systemic lupus erythematosus, 43 with systemic sclerosis, 10 with Sjogren’s syndrome and nine with undifferentiated connective tissue disease. Among the participants, 100 were identified as women, and the mean age was 49.3 years, with a mean disease duration of 10.2 years.
Patients with connective tissue disease who maintain their rheumatic therapy do not have an increased risk for COVID-19, according to a group of physicians in Italy who presented findings in an editorial.
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The survey included demographic and clinical information, as well as COVID-19 status as determined by a nasopharyngeal swab. The researchers also recorded the frequency of respiratory symptoms of suspected viral infections, and how the outbreak impacted the patient's behavior and rheumatic disease course. All surveys were performed between Feb. 25 and March 25, either in face-to-face sessions or over the telephone.
According to the authors, approximately 60% of patients received conventional synthetic DMARDs, including 31 treated with hydroxychloroquine, 22 with mycophenolate, 11 with methotrexate, eight with azathioprine and one with cyclosporine. Twenty-five patients received treatment with biologics, including 18 who received belimumab (Benlysta, GlaxoSmithKline), five who received rituximab (Rituxan, Genentech) and two who received tocilizumab (Actemra, Genentech). Corticosteroids were used to treat 64.2% of participants, with a mean dose 5.3 mg daily.
Only one patient was confirmed via swab to have COVID-19 — a 32-year-old woman with SSc and pulmonary involvement, treated with hydroxychloroquine and rituximab. This patient eventually died, the authors wrote.
“She developed a severe pattern of COVID-19 interstitial pneumonia requiring hospitalization in intensive care, where, despite intubation and an attempt with tocilizumab, the patient died,” Favalli and colleagues wrote. “In the same period of observation, the incidence of COVID-19 positivity in our region (Lombardy) was consistent with what we observed in our cohort (0.62 vs. 0.81%, respectively). A further 14 patients reported respiratory symptoms consistent with a viral infection, but they did not have access to the swab.”
According to the authors, these patients demonstrated a mild infectious disease with a rapid resolution of symptoms. They did not require the discontinuation of ongoing rheumatological therapy and did not experience a relapse of their connective tissue disease. Among the latter group, 44.4% were treated with hydroxychloroquine, compared with 24.2% among those who did not develop respiratory symptoms.
Ultimately, only five participants discontinued their rheumatological therapy, and 115 have maintained stable disease activity without flare-ups. Among the total study population, 84.1% reported adopting specific precautions, included social distancing, the use of masks, non-working or working from home.
“This positive propensity is likely to depend on the very fact of being carriers of a disease with increased infection risk and should certainly be taken into account when assessing the overall incidence of COVID-19 in the cohort of CTD patients compared with the general population,” Favalli and colleagues wrote.
“These preliminary data seem to suggest that our approach of encouraging CTD patients to maintain ongoing rheumatological therapy and adhere strictly to the norms to prevent infection has avoided rheumatic disease relapse without increasing the risk of COVID-19,” they added. “Waiting for our results to be confirmed on larger samples, this information can certainly be useful to all rheumatologists worldwide facing the pandemic.” – by Jason Laday
Disclosures: The authors report no relevant financial disclosures.