medwireNews: Findings from a US database study suggest that with the exception of rituximab, prior treatment with immunosuppressive medications is not associated with an increased risk for mechanical ventilation or death among hospitalized patients with COVID-19.
The study, published in The Lancet Rheumatology, included 222,575 people (mean age 59 years, 50% men) from the National COVID Cohort Collaborative who were hospitalized with confirmed or suspected SARS-CoV-2 infection between January 2020 and June 2021.
A total of 16,494 patients were receiving immunosuppressive medications at the time of hospital admission, most commonly for rheumatic diseases (33%), cancer (22%), or solid organ transplants (26%). Among the 5366 people with rheumatic diseases, 4281 were on glucocorticoids, while 377 were taking interleukin inhibitors, 343 tumor necrosis factor inhibitors, 132 rituximab, 85 Janus kinase (JAK) inhibitors, and 994 other immunosuppressants.
G Caleb Alexander (Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA) and colleagues report that the 12,841 patients on immunosuppressive treatments included in a propensity score-matched analysis had a significantly lower risk for invasive mechanical ventilation than the 29,386 who were not taking such agents (8 vs 9%), while rates of in-hospital mortality were not significantly different between the two groups (14 vs 12%).
When the different drug classes were analyzed separately, rituximab use was associated with a significantly increased risk for in-hospital mortality, with a hazard ratio (HR) of 1.72 among patients with rheumatic disease and 2.57 for those with cancer. Conversely, JAK inhibitor use was associated with reduced mortality risk (HR=0.42), while there were no significant associations for any of the other drug classes.
Writing in an accompanying comment, David Liew (University of Melbourne, Victoria, Australia) and Philip Robinson (University of Queensland, Brisbane, Australia) say that observational studies on COVID-19 outcomes to date “have been reassuring” for most DMARDs, but “the same cannot be said of rituximab.”
In addition to the association of rituximab with more severe COVID-19 outcomes, “the protective effect of COVID-19 vaccination is probably threatened by concomitantly administered rituximab, hindering the most viable solution to address this pandemic,” they add.
Liew and Robinson say “[i]t is unfortunate that the COVID-19 pandemic has occurred at a time when the potential utility of rituximab has been shown across multiple diseases,” including antineutrophil cytoplasmic antibody-associated vasculitis, systemic sclerosis, and polymyalgia rheumatica, and the persistence of COVID-19 has “dampened enthusiasm for rituximab in contemporary practice.”
The commentators address the question of what rheumatologists and their patients should do when “faced with a scenario in which rituximab is a good therapeutic option,” proposing that administering COVID-19 vaccination prior to rituximab initiation and strict adherence to public health measures may represent sensible strategies.
They stress that a number of questions about rituximab and COVID-19 vaccination still need to be addressed, including the impact of booster doses, the importance of T cell-mediated immunity, and the optimal timing of rituximab therapy.
“As we enter this next endemic stage of the pandemic, the flurry of intuition must be replaced by data, and we must determine the optimal solutions for our patients: solutions that encompass both good rheumatic disease outcomes and good COVID-19 outcomes,” they conclude.
medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2021 Springer Healthcare Ltd, part of the Springer Nature Group
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Lancet Rheumatol 2021; doi:10.1016/S2665-9913(21)00325-8
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