COVID-19 deaths in rheumatic diseases

– Earlier reports in early 2020 suggested that lupus patients may not have been at higher risk of COVID-19 complications. This report (referenced below) questions this.
– This report looked at 3729 patient. It included patients with systemic lupus, but it did not specify how many lupus patients nor how they did compared to other patients. However, it looked at the risk for death in patients receiving various drugs, patients with certain comorbidities, disease activity risks, sex, and countries of residence. 

Rheumatic disease patients at highest risk for death after infected with COVID-19 (listed in order)
(these results will be given in odds ratios.
To figure out how to word this (odds ratio findings):
Subtract 1 from the number, move the decimal point 2 to the right, then say “___ greater odds of dying from COVID-19.”
For example, for an 80 year old with a rheumatic disease, they have a 518% greater odds of dying from COVID-19. A man with a rheumatic disease has a 68% greater odds of dying from COVID-19 infection than a woman does.”)

• Age >75 years old, OR 6.18
• Rituximab (Rituxan) treatment, OR 4.04
• Sulfasalazine treatment, OR 3.60 (see commentary below)
• Age 66-75, OR 3.00
• Immunosuppressant treatments listed below, OR 2.22
  (tacrolimus, mycophenolate, cyclosporine, cyclophosphamide, azathioprine)
• Not on a disease modifying agent immunosuppressant, OR 2.11 (compared to patients on methotrexate)
• Moderate to high disease activity, OR 1.87 (compared to patients in remission and low disease activity)
• High blood pressure plus heart disease, history of stroke, or hardening of the arteries, OR 1.89
• Prednisone more than 10 mg daily (or more than 8 mg methylprednisolone), OR 1.69 (compared to no steroids)
• Chronic lung disease (like COPD, asthma, interstitial lung disease, pulmonary fibrosis), OR 1.68
• Men, OR 1.46 (compared to women)

United Kingdom had the highest death rate followed by Germany

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Commentary about sulfasalazine (SSZ)

Do not take away from this that SSZ increases deaths from COVID-19. SSZ is often prescribed by rheumatologists to sicker patients who are at higher risk for infections in the first place. For example, there were more smokers in the SSZ group. SSZ does not suppress the immune system. Also, SSZ is a weak drug (most often used to treat rheumatoid arthritis). Patients on just SSZ are less likely to be in remission or low disease activity (and therefore at higher risk of death from a COVID-19 infection). I suspect that this is an “association” and not a “causality.”
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– Hydroxychloroquine (Plaquenil) and belimumab (Benlysta) treatments were not associated with higher death
– TNF inhibitor, leflunomide, abatacept (Orencia), tocilizumab treatments were not associated with higher death
– The United States had the lowest death rate of all countries in the study
– After the US, countries (in order) of lowest death rates = Germany, then France, then Spain

– It is most important to keep your lupus under control. Do NOT stop any medications.
– Abide by all nondrug ways to lower lupus disease activity so you don’t need as many steroids.
– Work hard with your doctor to control your disease better so you can lower your steroid dose. 
– Get vaccinated against COVID-19!
– Ask everyone around you to get vaccinated (the cocoon strategy)
– Even after vaccination, abide by all isolation, separation, social distancing strategies

Reference: Strangfeld A, Schäfer M, Gianfrancesco MA, et al. Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry. Annals of the Rheumatic Diseases Published Online First: 27 January 2021. doi: 10.1136/annrheumdis-2020-219498