Increased Risk of COVID-19 in Patients With Rheumatoid Arthritis: A General Population-Based Cohort Study.

OBJECTIVE: Patients with rheumatoid arthritis (RA) are at an increased risk of acquiring infections owing to immunologic dysfunction and use of potent immunomodulatory medications; however, few data are available on their risk of COVID-19. We estimated the rate of COVID-19 among RA participants and compared it with that of the general population. METHODS: Using the Health Improvement Network, we identified RA patients before February 2020 and followed them to September 2020. We calculated the rate of COVID-19 among participants with RA and compared it with that of the general population using a Cox proportional hazards model, adjusting for potential confounders using overlap weighting of exposure score. We repeated the same analysis among participants with osteoarthritis, a nonautoimmune rheumatic disease, as a negative control exposure. RESULTS: We identified 225 cases of suspected and confirmed COVID-19 among 17,268 RA patients, and 14,234 cases among 1,616,600 participants in the general population (1.4 versus 0.9/1,000 person-months), with the adjusted hazard ratio (HRadj ) being 1.19 (95% confidence interval [95% CI] 1.04-1.36). Confirmed COVID-19 cases developed in 46 RA participants and in 2,249 in the general population (0.3 versus 0.1/1,000 person-months), with the HRadj being 1.42 (95% CI 1.01-1.95). No statistically significant difference was observed for suspected and confirmed (HR 1.00 [95% CI 0.93-1.07]) or confirmed (HR 1.08 [95% CI 0.92-1.27]) COVID-19 rates between participants with osteoarthritis and the general population. CONCLUSION: RA, but not osteoarthritis, was associated with an increased risk of COVID-19. Our findings provide timely evidence to support recommendations that booster vaccines and priority access to anti-SARS-CoV-2 monoclonal antibody treatments should be encouraged for RA patients.

COVID-19 Outcomes in Patients With Systemic Autoimmune Rheumatic Diseases Compared to the General Population: A US Multicenter, Comparative Cohort Study.

OBJECTIVE: Patients with systemic autoimmune rheumatic diseases (ARDs) continue to be concerned about risks of severe coronavirus disease 2019 (COVID-19) outcomes. This study was undertaken to evaluate the risks of severe outcomes in COVID-19 patients with systemic ARDs compared to COVID-19 patients without systemic ARDs. METHODS: Using a large multicenter electronic health record network, we conducted a comparative cohort study of patients with systemic ARDs diagnosed as having COVID-19 (identified by diagnostic code or positive molecular test result) compared to patients with COVID-19 who did not have systemic ARDs, matched for age, sex, race/ethnicity, and body mass index (primary matched model) and additionally matched for comorbidities and health care utilization (extended matched model). Thirty-day outcomes were assessed, including hospitalization, intensive care unit (ICU) admission, mechanical ventilation, acute renal failure requiring renal replacement therapy, ischemic stroke, venous thromboembolism, and death. RESULTS: We initially identified 2,379 COVID-19 patients with systemic ARDs (mean age 58 years; 79% female) and 142,750 comparators (mean age 47 years; 54% female). In the primary matched model (2,379 patients with systemic ARDs and 2,379 matched comparators with COVID-19 without systemic ARDs), patients with systemic ARDs had a significantly higher risk of hospitalization (relative risk [RR] 1.14 [95% confidence interval (95% CI) 1.03-1.26]), ICU admission (RR 1.32 [95% CI 1.03-1.68]), acute renal failure (RR 1.81 [95% CI 1.07-3.07]), and venous thromboembolism (RR 1.74 [95% CI 1.23-2.45]) versus comparators but did not have a significantly higher risk of mechanical ventilation or death. In the extended model, all risks were largely attenuated, except for the risk of venous thromboembolism (RR 1.60 [95% CI 1.14-2.25]). CONCLUSION: Our findings indicate that COVID-19 patients with systemic ARDs may be at a higher risk of hospitalization, ICU admission, acute renal failure, and venous thromboembolism when compared to COVID-19 patients without systemic ARDs. These risks may be largely mediated by comorbidities, except for the risk of venous thromboembolism.

Temporal trends in severe COVID-19 outcomes in patients with rheumatic disease: a cohort study.

BACKGROUND: As the COVID-19 pandemic continues worldwide, severe COVID-19 outcomes remain a major concern for patients with rheumatic and musculoskeletal diseases. We aimed to investigate temporal trends in COVID-19 outcomes in patients with rheumatic and musculoskeletal diseases over the course of the pandemic. METHODS: Using a large, multicentre, electronic health record network (TriNetX), we did a comparative cohort study of patients with rheumatic and musculoskeletal diseases who were diagnosed with COVID-19 (by International Classification of Diseases, Tenth Revision code or positive PCR test) during the first 90 days of the pandemic (early cohort) compared with the second 90 days of the pandemic (late cohort), matched (1:1) for demographics, comorbidities, laboratory results, glucocorticoid use, and previous hospitalisations using an exposure score method. Outcomes were assessed within 30 days of COVID-19 diagnosis, including hospitalisation, intensive care unit admission, invasive mechanical ventilation, renal failure, and death. We did a subgroup analysis among patients with rheumatic and musculoskeletal diseases who were hospitalised with COVID-19. FINDINGS: We identified 8540 patients with rheumatic and musculoskeletal diseases who were diagnosed with COVID-19 during the 6-month study period, including 2811 in the early cohort and 5729 in the late cohort. In the exposure score matched analysis, the risk of hospitalisation was lower in the late cohort than in the early cohort (874 [32·4%] of 2701 patients vs 1227 [45·4%] of 2701 patients; relative risk [RR] 0·71, 95% CI 0·67-0·76). The risks of intensive care unit admission (214 [7·9%] vs 385 [14·3%]; RR 0·56, 95% CI 0·47-0·65), mechanical ventilation (96 [3·6%] vs 247 [9·1%]; 0·39, 0·31-0·49), acute kidney injury (372 [13·8%] vs 560 [20·7%]; 0·66, 0·59-0·75), renal replacement therapy (17 [0·6%] vs 32 [1·2%]; 0·53, 0·30-0·96), and death (122 [4·5%] vs 252 [9·3%]; 0·48, 0·39-0·60) were lower in the late cohort compared with the early cohort. Among the hospitalised subgroup, the risk of the composite outcome of intensive care unit admission, mechanical ventilation, and death was lower in the late cohort than in the early cohort (334 [30·7%] of 1089 patients vs 450 [41·3%] of 1089 patients; RR 0·74, 95% CI 0·67-0·83). INTERPRETATION: The risks of severe COVID-19 outcomes have improved over time in patients with rheumatic and musculoskeletal disease but remain substantial. These findings might reflect ascertainment of milder cases in the later cohort and improvements in treatment and supportive care. FUNDING: None.

Coronavirus disease 2019 outcomes among patients with rheumatic diseases 6 months into the pandemic.

OBJECTIVE: In earlier studies, patients with rheumatic and musculoskeletal disease (RMD) who got infected with COVID-19 had a higher risk of mechanical ventilation than comparators. We sought to determine COVID-19 outcomes among patients with RMD 6 months into the pandemic. METHODS: We conducted a cohort study at Mass General Brigham in Boston, Massachusetts, of patients with RMD matched to up to five comparators by age, sex and COVID-19 diagnosis date (between 30 January 2020 and 16 July 2020) and followed until last encounter or 18 August 2020. COVID-19 outcomes were compared using Cox regression. Risk of mechanical ventilation was compared in an early versus a recent cohort of patients with RMD. RESULTS: We identified 143 patients with RMD and with COVID-19 (mean age 60 years; 76% female individuals) and 688 comparators (mean age 59 years; 76% female individuals). There were no significantly higher adjusted risks of hospitalisation (HR: 0.87, 95% CI: 0.68-1.11), intensive care unit admission (HR: 1.27, 95% CI: 0.86-1.86), or mortality (HR: 1.02, 95% CI: 0.53-1.95) in patients with RMD versus comparators. There was a trend towards a higher risk of mechanical ventilation in the RMD cohort versus comparators, although not statistically significant (adjusted HR: 1.51, 95% CI: 0.93-2.44). There was a trend towards improvement in mechanical ventilation risk in the recent versus early RMD cohort (10% vs 19%, adjusted HR: 0.44, 95% CI: 0.17-1.12). CONCLUSIONS: Patients with RMD and comparators had similar risks of poor COVID-19 outcomes after adjusting for race, smoking and comorbidities. The higher risk of mechanical ventilation in the early RMD cohort was no longer detected in a recent cohort, suggesting improved management over time.