TNFi treatment in rheumatic disease not a risk for COVID-19 hospitalization

Analysis of the German COVID-19 registry suggests that patients with rheumatic or musculoskeletal diseases (RMDs) who are treated with tumour necrosis factor (TNF) inhibitors appear to be at lower risk of severe outcomes of COVID-19 compared with those treated with other (non-TNF inhibitor) immunomodulatory treatments (OIDs).

“In this large cohort, RMD patients treated with TNF inhibitors showed a low hospitalization rate and only one fatal course,” said study author Dr Rebecca Hasseli from Justus-Liebig-University Giessen, Giessen, Germany, at EULAR 2021.

The researchers identified 483 patients (median age 53 years, 58 percent female) with RMD treated with TNF inhibitors and a confirmed SARS-CoV-2 infection from the German COVID-19 registry between March 30, 2020 and January 30, 2021. The data of these patients was compared with that of 1,524 patients (median age 58 years, 70 percent female) with RMD who were on OIDs.

The most common diagnoses were rheumatoid arthritis (58 percent [TNF inhibitor] vs 52 percent [OID]), followed by ankylosing spondylitis, and psoriatic arthritis. Nineteen and 44 percent of the TNF inhibitor and OID groups, respectively, were on glucocorticoids. [EULAR 2021, Presentation ID OP0283]

Prior to being diagnosed with COVID-19, 89 and 83 percent of the TNF inhibitor and OID groups, respectively, had low or no disease activity, while 9 and 15 percent, respectively, had moderate or high disease activity. The most common comorbidities in the population were cardiovascular disease (34 and 51 percent, respectively), chronic obstructive pulmonary disease or interstitial lung disease (4 and 9 percent, respectively), and diabetes (8 and 11 percent, respectively).

The most common symptoms of COVID-19 were fever which occurred in 46 and 51 percent of patients in the TNF inhibitor and OID groups, respectively, headache (36 percent vs 29 percent), and shortness of breath (19 percent vs 27 percent).

Hospitalization for COVID-19 occurred less frequently in the TNF inhibitor vs OID group (10 percent vs 26 percent), and fewer patients on TNF inhibitors than OIDs required invasive ventilation (1 percent vs 6 percent).

There was one death from COVID-19 in the TNF inhibitor group compared with 81 deaths in the OID group (0 percent vs 5 percent).

Among TNF inhibitor-treated patients, the use of concomitant glucocorticoid therapy was higher among hospitalized patients than those treated as outpatients (48 percent vs 16 percent), as was the proportion of patients with high disease activity (9 percent vs 2 percent).

“High or moderate RMD activity is an important factor associated with severity of COVID-19 including mortality,” pointed out Hasseli.

“Patients with RMD might have an increased risk for infection due to their immunomodulatory treatment, secondary to their disease and comorbidities. Recent studies have suggested a decreased risk of severe COVID-19 in patients with rheumatic diseases treated with biologics, particularly TNF inhibitors,” she continued.

“[The results of this study are] reassuring for patients and rheumatologists to use TNF inhibitors to control RMD activity,” she said.

Hasseli suggested that high disease activity and the use of glucocorticoids appear to counteract the potential protective effects of TNF inhibitors.