PsA and COVID-19

Psoriatic Arthritis and COVID-19

Patients with rheumatic disease who are immunosuppressed or have significant comorbidities are at increased risk for serious infection. The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, is of particular concern for these patients. Rheumatic disease and/or an immunocompromised status may place patients at higher risk for a more severe course of COVID-19, including complications, hospitalization, and death.1

Epidemiologic studies have found that patients with significant comorbidities, including cardiovascular disease, hypertension, and diabetes, are at increased risk for developing severe complications with COVID-19 infection. Current research is investigating the risk of severe COVID-19 in patients with PsA as the disease is associated with a higher incidence of comorbid cardiovascular disease, metabolic syndrome, obesity, diabetes mellitus, dyslipidemia, and inflammatory bowel disease.2

A comparative cohort study of patients with and without rheumatic disease found that both groups of patients had similar symptoms and laboratory findings. Although a similar proportion of patients with and without rheumatic disease was hospitalized in the study (44% vs 40%; P=0.50), patients with rheumatic disease were more likely to require intensive care admission and mechanical ventilation (48% vs 18%). The mortality rate was similar between the two groups (6% vs 4%; P=0.69).4

However, a small cohort study in Italy found that the presence of rheumatic disease or the degree of pharmacologic immunosuppression did not differ between patients with confirmed or suspected COVID-19 and those without. In this study, poor outcome was associated with older age and the presence of arterial hypertension and obesity.5 A large cohort study of 456 rheumatic and non-rheumatic patients found that chronic inflammatory arthritis or previous immunosuppressive therapies did not increase the risk of death, invasive ventilation, intensive care unit admission, or serious complications from COVID-19. However, older age, male sex, and previous comorbidity (obesity, diabetes, hypertension, cardiovascular or lung disease) were associated with increased risk in the rheumatic cohort.6

Treating PsA During the COVID-19 Pandemic

An additional concern for rheumatologists is the impact of PsA therapy on the risk of SARS-CoV-2 infection or the development of severe COVID-19. A case series of individuals with rheumatic disease and COVID-19 from the COVID-19 Global Rheumatology Alliance registry investigated the rate of hospitalization for COVID-19 in patients with rheumatic disease. The study found that a prednisone dose >10 mg/day was associated with a higher risk of hospitalization (OR, 2.05). However, use of conventional disease-modifying antirheumatic drugs (DMARDs) alone or in combination with biologics or Janus kinase inhibitors was not associated with an increased risk of hospitalization. No association between hospitalization and non-steroidal anti-inflammatory drugs (NSAIDs) or antimalarial use was observed. Tumor necrosis factor inhibitor (anti-TNF) use was found to significantly reduce the risk of COVID-19 hospitalization in this study (OR, 0.40).1 Another study in patients with inflammatory bowel disease and COVID-19 found that systemic corticosteroids increase the risk of severe COVID-19 (aOR, 6.9). Anti-TNF therapy was not associated with severe COVID-19 in this study (aOR, 0.9).7

HCQ = hydroxychloroquine; CQ = chloroquine; SSZ = sulfasalazine; MTX = methotrexate; LEF = leflunomide; CSA = cyclosporine; MMF = mycophenolate mofetil; AZA = azathioprine; JAK = Janus kinase; NSAID = non-steroidal anti-inflammatory drug; IL = interleukin

Some therapies for the management of PsA may need to be withheld in patients with confirmed or suspected COVID-19. For patients with uncomplicated COVID-19 infections, such as those who experienced mild or no pneumonia treated in the ambulatory setting or by self-quarantine, therapies to manage rheumatic disease may be reinitiated within 7-14 days of symptom resolution. For patients who are asymptomatic despite a positive PCR (polymerase chain reaction) test for SARS-CoV-2, PsA therapies may be restarted 10-17 days after the positive PCR result. Decisions regarding the timing of reinitiating PsA therapies in patients who recover from more severe COVID-19-related illness should be made on a case-by-case basis.8

References

  1. Gianfrancesco M, Hyrich KL, Al-Adely S, et al. Characteristics associated with hospitalization for COVID-19 in people with rheumatic disease: Data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2020;79:859-866.
  2. Wollina U, Fioranelli M, Goldust M, et al. Psoriatic arthritis and COVID-19 pandemic: Consequences in medical treatment? Dermatol Ther. 2020;33:e13743.
  3. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323:1239-1242.
  4. D’Silva KM, Serling-Boyd N, Wallwork R, et al. Clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and rheumatic disease: A comparative cohort study from a US ‘hot spot’. Ann Rheum Dis. 2020;79:1156-1162.
  5. Fredi M, Cavazzana I, Moschetti L, et al. COVID-19 in patients with rheumatic disease in northern Italy: A single-centre observational and case-control study. Lancet Rheumatol. 2020;2:e549-e556.
  6. Pablos JL, Galindo M, Carmona L, et al. Clinical outcomes of hospitalized patients with COVID-19 and chronic inflammatory and autoimmune rheumatic diseases: A multicentric matched cohort study [published online ahead of print, 2020 Aug 12]. Ann Rheum Dis. 2020;218296.
  7. Brenner EJ, Ungaro RC, Gearry RB, et al. Corticosteroids, but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: Results from an international registry. Gastroenterol. 2020;159:481-491.e3.
  8. Mikuls TR, Johnson SR, Fraenkel L, et al. American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 2. Arthritis Rheumatol. 2020;72:e1-e12.
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Updates in the Treatment and Prevention of COVID-19

Emergency use authorization for casirivimab/imdevimab in patients with mild-to-moderate COVID-19

The combination of the monoclonal antibodies casirivimab and imdevimab (previously known as REGN-COV2) has been authorized for emergency use for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients (≥12 years of age and ≥40 kg) who are at high risk for progressing to severe COVID-19 or hospitalization.1

Interim results from 275 nonhospitalized patients in a placebo-controlled trial of casirivimab plus imdevimab found that the combination therapy reduced viral load, with a greater effect in patients whose immune response had not yet been initiated or who had a high viral load at baseline. Patients who received casirivimab/imdevimab required fewer medical visits for COVID-19 than patients who received placebo (3% vs 6%, respectively). Among patients who were serum antibody-negative at baseline, 15% in the placebo group and 6% in the treatment group required COVID-19-related medical care.2

Baricitinib in combination with remdesivir authorized for emergency use in hospitalized patients

Baricitinib, in combination with remdesivir, is authorized for emergency use in adult and pediatric patients ≥2 years of age hospitalized for COVID-19 who require supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).3

A recent trial of 1033 patients hospitalized for COVID-19 found that baricitinib plus remdesivir was superior to remdesivir alone in reducing recovery time (7 days vs 8 days, respectively; P= .03). Patients receiving high-flow oxygen or noninvasive ventilation at enrollment had a time to recovery of 10 days with combination therapy and 18 days with the control (rate ratio for recovery, 1.51). The addition of baricitinib to remdesivir was associated with 30% higher odds of improvement in clinical status at day 15 compared with remdesivir alone.4

References

  1. Emergency use authorization (EUA) of casirivimab and imdevimab. Available at www.fda.gov/media/143892/download. Accessed 12/23/2020.
  2. Weinreich DM, Sivapalasingam S, Norton T, et al. REGN-COV2, a neutralizing antibody cocktail, in outpatients with Covid-19. N Engl J Med. 2020;Dec 17:Epub ahead of print. Available at www.nejm.org/doi/full/10.1056/NEJMoa2035002. Accessed 12/23/2020.
  3. Emergency use authorization (EUA) of baricitinib. Available at www.fda.gov/media/143823/download. Accessed 12/23/2020.
  4. Kalil AC, Patterson TF, Mehta AK, et al. Baricitinib plus remdesivir for hospitalized adults with Covid-19. N Engl J Med. 2020;Dec 11:Epub ahead of print. Available at www.nejm.org/doi/full/10.1056/NEJMoa2031994. Accessed 12/23/2020.