COVID-19 was center-stage at this year's EULAR meeting. Dr. Pedro Machado, a rheumatologist with the University College London and chair of EULAR's Standing Committee for Epidemiology and Health Service Research shared the results of a study on patients with rheumatic disease who contracted COVID-19. He and his team found that patients taking a higher dose of prednisone, had an increased of being hospitalized. But patients receiving TNF blockers were less likely to be hospitalized. In this interview, Dr. Machado talks with us about the findings.
The European Congress of Rheumatology took place as a virtual meeting this year broadcasting into the homes of 18,000 registered attendees who are self-isolating at home this year due to the COVID-19 pandemic.
COVID-19 was center-stage this year. Dr. Pedro Machado, a rheumatologist with the University College London and chair of EULAR's Standing Committee for Epidemiology and Health Service Research shared the results of a study on patients with rheumatic disease who contracted COVID-19.
He and his team found that patients taking a higher dose of prednisone, had an increased of being hospitalized. But patients receiving TNF blockers were less likely to be hospitalized.
Initially, one of the concerns with COVID-19 in patients with rheumatic diseases is that it could potentially have a more severe outcome on these patients either because of the underlying condition or because of extra-articular manifestations associated with rheumatic conditions, such as involvement of the kidneys and heart. And, because these patients need immunosuppressants to control their underlying condition, the thinking was that they may be more likely to have more severe outcomes from a COVID-19 infection. The data from this study, which is observational in nature and only reflects a small subset of a larger international database, shows that hasn't necessarily been the case.
In this interview, Dr. Machado talks with us about the findings.
"So, concerns about the potential outcomes for patients with rheumatic diseases who had COVID-19 were justifiable.
"It was really important to study this group of patients as soon as possible and EULAR embraced this project together with an international effort through the Global Rheumatology Alliance. So EULAR is collecting data from the European region and the EULAR countries and the Alliance is collecting data from non-European countries.
"The rheumatology community has done an amazing job. By the end of this week, we will probably have around 2,000 cases reported to our database and around 1,000 reported to the global database.
"Now the data that we reported so far was the first data set: The first 600 patients who were submitted to the database and that was published just a few days ago in the Annals of Rheumatic Diseases. So, in that report, we looked at risk factors for hospitalization in patients with rheumatic diseases who got COVID-19. And, what we found, rather similarly to the general population, patients who were older or patients who had comorbidities like lung disease, cardiovascular disease, renal disease, diabetes---those patients were more likely to be hospitalized, but that's not surprising and it's not something that's specific to patients with rheumatic conditions.
"But what we found that all of these patients who were taking disease modifying drugs, which includes immunosuppressants, but also other drugs like hydroxychloroquine, methotrexate, TNF inhibitors, biologics, IL-6 blockers and JAK inhibitors. Now, some of these drugs are actually being explored as potential treatments for COVID-19.
"We found that taking these drugs did not increase the likelihood of the patient being hospitalized, which is very reassuring both for the patient and the carers and healthcare professionals. We did find the steroids in moderate to high dosages of more than 10 mg of prednisone, that did increase the likelihood of the person being hospitalized. But there is a caveat there because patients taking steroids, they take it for a reason and often because the baseline disease is more active. So there might be something in epidemiology we all confounded by indications.
"But patients taking steroid should not stop them because it can exasperate the underline condition and that would be deleterious rather than beneficial. In fact, sometimes when patients get an infection, they need more steroids.
"And, finally, another key finding and also very interesting is that patients on TNF blockers were less likely to be hospitalized compared to who were not taking biologic drugs.
"Overall, this is the first large dataset reporting the outcome of COVID-19 in patients with rheumatic diseases and I think overall, it's very reassuring data for our patients, for healthcare professionals. This data will inform the recommendations and guidelines for the management of patient with rheumatic diseases.
"COVID-19 ended up being quite an enigmatic disease. And, we're still learning about it. There's a very diverse phenotype. Some patients, or people, are completely asymptomatic. They may not even realize they have the virus. Some people have very mild symptoms and they may think they have a cold and may not even know it is related to COVID-19 if it wasn't for the pandemic.
"But then there is this small group of patients who get this really severe disease. And, some of them get a very hyper inflammatory state. During this state, the most damaging thing is actually this hyper inflammation rather than the direct affect of the virus. This is very damaging for the organs, for the lungs
"The hypothesis is that perhaps some of these medications might act as some kind of protective factor against severe COVID and in fact these drugs---interleukin 6 blockers, JAK inhibitors, TNF blockers---they are either in trial already or there are plans to trial them in COVID-19.
"Obviously, this is an observational dataset. There are always important caveats with observational data and the potential for confounders, but the only way to really find out if this drug can help patients with COVID-19 is to do appropriate adequately powered randomized controlled trials which are ongoing.
"In any case, it's not possible to conduct those clinical trials in a short period of time. And, seeing this observational data, it is very reassuring. It may change practice in terms of things that we are doing in advising our patients, but no only patients with rheumatic disease, but patients with other conditions taking immunosuppressants.
"This data is not adequate to look at the mortality rate because it's not representative of the entire group of patients with rheumatic diseases that is getting COVID. It's probably just a subset of that population and probably a subset that has more severe disease. Many countries are probably not doing mass screening and we're not capturing those patients who are either asymptomatic or only have mild symptoms---so those patients are not being captured. So, at the moment until that widespread screening is done in all patients, it's very difficult to determine the exact rate of mortality among a specific group of patients. So, I would not look at the mortality ratios as representative of the accurate mortality ratio in this subgroup of patients."
"Well now that we a larger number of patients, we'll be able to look at less frequent outcomes with death being one. As the sample size increases, our estimate will become robust but we an also look at outcomes that are less common. And, things like cytokine storm which is that hyper-inflammatory state that we see in some patients. So as the data grows we'll be able to look at more granular things and hopefully this dataset will inform even more the current practices."