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Risk factors for hospital admissions related to COVID-19 in patients with autoimmune inflammatory rheumatic diseases

Last updated: 08-11-2020

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Risk factors for hospital admissions related to COVID-19 in patients with autoimmune inflammatory rheumatic diseases

Risk factors for hospital admissions related to COVID-19 in patients with autoimmune inflammatory rheumatic diseases
Risk factors for hospital admissions related to COVID-19 in patients with autoimmune inflammatory rheumatic diseases
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Lydia Abasolo 1
1Rheumatology Department and IDISSC, La Fundacion para la Investigacion Biomedica del Hospital Clinico San Carlos, Madrid, Spain
2Department of Health and Education, Universidad Camilo Jose Cela, Villafranca del Castillo, Madrid, Spain
3Rheumatology Department, Hospital Clinico San Carlos, Madrid, Spain
4Medicine Department, Universidad Complutense de Madrid, Madrid, Comunidad de Madrid, Spain
Correspondence to Dr Leticia Leon, IdISSC and Rheumatology, La Fundacion para la Investigacion Biomedica del Hospital Clinico San Carlos, Madrid, Spain; lleon.hcsc{at}salud.madrid.org
Abstract
Objectives To describe patients with autoimmune inflammatory rheumatic diseases (AIRD) who had COVID-19 disease; to compare patients who required hospital admission with those who did not and assess risk factors for hospital admission related to COVID-19.
Methods An observational longitudinal study was conducted during the pandemic peak of severe acute respiratory syndrome coronavirus 2 (1 March 2020 to 24 April). All patients attended at the rheumatology outpatient clinic of a tertiary hospital in Madrid, Spain with a medical diagnosis of AIRD and with symptomatic COVID-19 were included. The main outcome was hospital admission related to COVID-19. The covariates were sociodemographic, clinical and treatments. We ran a multivariable logistic regression model to assess risk factors for the hospital admission.
Results The study population included 123 patients with AIRD and COVID-19. Of these, 54 patients required hospital admission related to COVID-19. The mean age on admission was 69.7 (15.7) years, and the median time from onset of symptoms to hospital admission was 5 (3–10) days. The median length of stay was 9 (6–14) days. A total of 12 patients died (22%) during admission. Compared with outpatients, the factors independently associated with hospital admission were older age (OR: 1.08; p=0.00) and autoimmune systemic condition (vs chronic inflammatory arthritis) (OR: 3.55; p=0.01). No statistically significant findings for exposure to disease-modifying antirheumatic drugs were found in the final model.
Conclusion Our results suggest that age and having a systemic autoimmune condition increased the risk of hospital admission, whereas disease-modifying antirheumatic drugs were not associated with hospital admission.
antirheumatic agents
Key messages
What is already known about this subject?
The epidemiological scenario is changing daily. There is little evidence for risk factors of poor outcome with COVID-19 specific to autoimmune inflammatory rheumatic diseases.
What does this study add?
Patients with an autoimmune systemic condition have a higher risk of hospital admission related to COVID-19 compared with those with chronic inflammatory arthritis.
Disease-modifying agents were not associated with a higher risk of hospital admission related to COVID-19.
How might this impact on clinical practice or future developments?
Our data show that, in a real-world setting, a high percentage of patients with autoimmune inflammatory rheumatic diseases and COVID-19 required hospital admission. The patients were mainly elderly, with comorbidities and a systemic autoimmune condition.
Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a myriad of clinical signs and symptoms, together with typical laboratory abnormalities, that manifest as the disease COVID-19. 1
Since the confirmation of the first patient infected with SARS-CoV-2 in Spain in January 2020, the current COVID-19 outbreak has had a considerable impact, especially in the Madrid region, where the highest incidence of COVID-19 cases has been recorded, with more than 41 304 patients admitted to the hospital until the first week of May. 2
The incidence and severity of COVID-19 disease seem to be higher in patients with risk factors, such as advanced age and associated comorbidities, mainly hypertension, diabetes, heart disease and previous respiratory diseases. 3 It is not clear whether patients with rheumatic diseases are more susceptible to SARS-CoV-2 infection, or, when they are infected, whether they have more severe disease or a poorer outcome. Previous outbreaks caused by coronaviruses did not yield overwhelming evidence that patients with rheumatic diseases are at an increased risk, 4 although some patients are candidates for a higher number of infections owing to their rheumatic disease (predominantly systemic) or the treatment they are receiving for rheumatic diseases. 5 Preliminary experiences in patients with COVID-19 show that those with chronic arthritis treated with synthetic conventional or targeted synthetic/biologic disease-modifying antirheumatic drugs (DMARDs) do not seem to be at a greater risk of respiratory or life-threatening complications from SARS-CoV-2 than the general population. 6 7
The epidemiological scenario is changing, and evidence on the risk factors of poor outcome with COVID-19 specific to inflammatory rheumatic disease is scarce. In addition, there are little data on how the hospital admissions of these patients with severe COVID-19 infection have evolved. 8
The aim of our study was to describe patients with autoimmune inflammatory rheumatic diseases (AIRD) who had COVID-19 during the pandemic peak. We also explored possible risk factors associated with hospital admission related to COVID-19 disease in patients with AIRD from a tertiary hospital in Madrid, Spain.
Methods
Setting, study design and patients
The study was performed in a public tertiary hospital, Hospital Clínico San Carlos (HCSC), in Madrid, Spain. The catchment area is home to almost 400 000 people.
We performed a prospective observational study from 1 March 2020 (when our health area had the first hospital admission related to COVID-19) to 24 April 2020. We preselected all patients attended at the rheumatology outpatient clinic of our centre during the study period whose data were recorded in the electronic clinical history of our department (HCR Penelope). The inclusion criteria were age >16 years, a medical diagnosis (according to International Classification of Diseases (ICD-10)) of inflammatory rheumatic disease and symptomatic COVID-19 disease assessed by medical diagnosis or confirmed with a positive SARS-CoV-2 PCR diagnostic test.
Patient data were obtained during routine clinical practice. The study was conducted in accordance with the Declaration of Helsinki and the principles of Good Clinical Practice and was approved by the HCSC Ethics Committee (approval number 20/268-E-BS).
Variables
The primary outcome was admission to hospital with a medical diagnosis of COVID-19 and/or a positive PCR result between 1 March and 15 April compared with outpatients with symptomatic COVID-19 disease.
The covariables recorded were as follows: (1) sociodemographic baseline characteristics including sex, age and rheumatic disease duration. (2) Type of AIRD, including systemic autoimmune conditions (polymyalgia rheumatica, mixed connective tissue disease, systemic sclerosis, Sjogren’s syndrome, vasculitis, Raynaud phenomenon, polymyositis, polychondritis, sarcoidosis, antiphospholipid syndrome, autoinflammatory syndromes and systemic lupus erythematosus) and chronic inflammatory arthritis (rheumatoid arthritis, inflammatory polyarthritis, juvenile idiopathic arthritis, psoriatic arthritis, axial spondyloarthritis, uveitis and inflammatory bowel disease). (3) Baseline comorbid conditions, including hypertension, dyslipidaemia, depression, diabetes mellitus, smoking habit, kidney disease, chronic liver disease, respiratory diseases (chronic obstructive pulmonary disease and interstitial lung disease), thyroid disease, heart disease (valve disease, arrythmias, cardiomyopathy, heart failure and pericarditis), ischaemic vascular disease (stroke, cardiovascular and peripheral vascular disease), venous thrombosis/lung embolism and cancer. (4) Treatment for inflammatory rheumatic disease: (a) glucocorticoids, (b) non-steroidal anti-inflammatory drugs (NSAIDs), (c) conventional synthetic disease-modifying antirheumatic drugs (csDMARDs): antimalarials (hydroxychloroquine and chloroquine), azathioprine, cyclophosphamide, cyclosporine, colchicine, leflunomide, methotrexate, mycophenolate mofetil/mycophenolic acid and sulfasalazine; (d) targeted synthetic/biologic DMARDs (ts/bDMARDs) including: (1) antitumour necrosis factor (TNF)-alpha drugs (infliximab, adalimumab, etanercept, certolizumab and golimumab); (2) other biologics: anti-interleukin (IL)-6 (tocilizumab and sarilumab); rituximab; abatacept; belimumab; anti-IL-17/23; anti-IL-17 (ustekinumab, ixekizumab and secukinumab); (3) Janus kinase (JAK) inhibitors (tofacitinib and baricitinib).
Treatment had to start at least 1 month before the beginning of the study and continue during the study period until the end of the study or hospital admission for antimalarial therapy, glucocorticoids, sulfasalazine, NSAIDs or colchicine. Regarding csDMARDs and ts/bDMARDs, treatment had to start at least 1 month before the beginning of the study and continue until at least 21st March, the end of the study or hospital admission. In the case of rituximab, the last infusion had to be at least in January.
Data sources
Patient sociodemographic, clinical, laboratory and data on treatment of rheumatic disease were obtained through HCR Penelope.
Patients with COVID-19 were detected by warning calls to our rheumatologists or nurses or via routine telephone consultation. Other infected patients were detected through their sick leave forms for COVID-19. The results of SARS-CoV-2 PCR diagnostic assays were obtained from the microbiology/infectious service of HCSC. In addition, our Hospital Central Services registered all medical admissions to HCSC. This information was provided from 1 March to 15 April.
The researchers carried out an exhaustive review of the clinical histories of admitted patients to identify COVID-19 cases and rule out patients admitted for other reasons. Once the COVID-19 cases were identified, we collected clinical, laboratory and treatment data during admission until the end of admission (either discharge or death) in order to describe the progress of the disease. The review was performed until 24th April in order to include follow-up data from patients admitted to the hospital with COVID-19.
Statistical analysis
Patient characteristics are expressed as mean and SD or median and IQR for continuous variables; categorical variables are expressed as percentages. Statistical tests were performed to compare characteristics between patients admitted with COVID-19 and those without hospital admissions. Continuous variables were analysed using the Mann-Whitney test or t-test, and discrete variables were analysed using the χ2 or Fisher exact test. Univariable logistic regression analyses were performed to assess differences between hospital admissions related to COVID-19 risk and covariates. Multivariable logistic regression models (adjusted for age, sex and comorbidity) were run in a stepwise manner to examine the possible effect of sociodemographic, clinical and therapeutic factors on hospital admissions related to COVID-19 The model also included csDMARDs and all other variables with a p


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