key: cord-0874313-m959us7e
authors: Lwin, May; Holroyd, Christopher; Wallis, Dinny; Davidson, Brian; Goulston, Lyndsey; de Graaf, Hans; Edwards, Christopher J
title: Does COVID-19 cause an increased risk of hospitalisation or death in patients with inflammatory rheumatic diseases treated with bDMARDs or tsDMARDs?
date: 2020-10-21
journal: Rheumatol Adv Pract
DOI: 10.1093/rap/rkaa061
sha: 8b3b3b84ffcc0e423fff18b453c464c93740ae98
doc_id: 874313
cord_uid: m959us7e

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Key message: Poor outcomes from SARS-CoV-2 are not common for patients with inflammatory rheumatic diseases taking advanced therapies.

The world has been gripped by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that causes coronavirus disease-2019 (COVID-19) and has been responsible for more than 38,000 deaths in the United Kingdom (UK) (1) . There are serious concerns that patients with inflammatory rheumatic diseases treated with advanced therapies such as biological disease modifying anti-rheumatic drugs (bDMARDs) and targeted synthetic disease modifying anti-rheumatic drugs (tsDMARDs) may be at increased risk of the severe consequences of SARS-CoV-2. As a result, UK patients have been advised to 'shield' or 'self-isolate' to reduce the likelihood of infection (2) .

To assess the degree of risk in this patient group we used several methods to record cases of severe SARS-CoV-2 in our hospital. This included information from our advanced therapy database and clinics, the department telephone advice line and a real time study of patient status and symptoms (Adult ImmunoCOVID study) (3). The ImmunoCOVID study has recruited patients from the advanced therapy database recording possible COVID-19 symptoms (fever, cough, shortness of breath (SOB), blocked nose, red eye, fatigue, joint pain, muscle pain, nausea, diarrhoea and vomiting (D&V)) and confirmed positive cases of COVID-19 on a weekly basis using an online portal. Using multiple sources of information gave us the greatest hypertension, ischaemic heart disease, atrial fibrillation and a previous pulmonary embolism was admitted with fever and shortness of breath (SOB) along with a cough and mild haemoptysis. Oxygen saturation was normal on air and no antibiotics were required. She recovered and was discharged after nine days. The second patient was a 52-year old female with PsA on ustekinumab and MTX with no relevant comorbidities who presented with fever, cough, SOB, chest tightness, ageusia, anosmia and D&V. Consolidation was present on chest X-ray and she was admitted to hospital and treated with IV antibiotics (levofloxacin). No oxygen was required and she was discharged after 3 days. In both patients MTX and the bDMARD were suspended temporarily but have been subsequently restarted. Among the remaining 5 patients who tested negative, one patient had hypertension and was on Ramipril 5mg per day, the other 4 patients had no comorbidities. Given the multiple methods of recording cases it seems unlikely that we will have missed serious cases of disease resulting in admission to hospital or death. It is very possible that lack of widespread testing means that other patients will have had SARS-CoV-2 infection without serious disease. To put our numbers of patients affected in context, up until the 22 nd April a total of 455 patients had been admitted to University Hospital Southampton with COVID-19.

It appears that individuals with inflammatory rheumatic diseases receiving advanced therapies are not at significantly increased risk of hospitalisation or death as a consequence of SARS-CoV-2 infection during a time of high viral prevalence in our hospital and the local community.

The number of serious infections we have seen in this patient group is in line with the experience of colleagues working in Northern Italy (4) and anecdotally from other colleagues across the UK. The possibility remains that the low level of serious infection is due to the fact that the advice to 'shield' and 'self-isolate' has been very effective at reducing exposure. The chance that certain therapies used by patients with inflammatory rheumatic diseases such as hydroxychloroquine, tocilizumab and baricitinib might be protective remains speculative until robust randomised controlled trials are concluded.

UK government COVID-19 statistics

BSR guidance on identifying patients for shielding

Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies

CE has received honoraria, attended advisory boards, speakers bureau, and received research support from Abbvie

Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript