The outcome of COVID‐19 in patients with autoimmune rheumatic diseases: Comparable to the general population or worse?

​Since​the​beginning​of​the​COVID-​19​pandemic,​patients​with​autoimmune​rheumatic​diseases​ (AIRDs)​have​been​a​ focus​of​concern​ due​ to​ the​underlying​ immune​dysregulation​and​ immunosuppressive​drugs​they​are​receiving.​The​data​regarding​the​total​effect​of​ AIRDs​and​ their​ treatment​on​COVID-​19​course​and​outcome​are​ currently​ inconclusive.​ Also,​ it​ is​ challenging,​ if​ not​ impossible,​ to​ dissect​the​ impact​of​ the​underlying​AIRDs​from​the​effect​of​ the​ immunosuppressive​treatment​and​other​comorbidities. Several​factors​associated​with​AIRDs​could​affect​the​COVID-​19​ course​ (Table 1).​ Severe​ COVID-​19​ course​ and​ complications​ of​ COVID-​19​are​generally​caused​by​the​hyperinflammatory​immune​ response​against​SARS-​CoV-​2.​Thus,​the​dysregulated​immune​system​with​a​tendency​to​overreact​could​make​AIRD​patients​more​ prone​to​negative​COVID-​19​outcomes.​The​type​of​AIRD,​disease​ activity,​and​organ​involvements​are​also​important​while​analyzing​ the​impact​of​AIRDs​on​the​COVID-​19​course.1,2​In​addition,​classical​ comorbidities​such​as​hypertension,​obesity,​and​diabetes​mellitus​ are​ generally​ more​ frequent​ among​ AIRD​ patients​ than​ the​ general​population,​and​these​comorbidities​are​associated​with​worse​ COVID-​19​outcomes.3,4​On​the​other​hand,​most​AIRD​patients​are​ on​ chronic​ immunosuppressive​ therapies,​which​may​ limit​ the​hyperinflammation​ before​ the​ cytokine​ storm​ commences.​ But​ also,​ the​ immunosuppressive​ treatment​ could​ lead​ to​ an​ increased​ risk​ for​COVID-​19​and​ the​complications​caused​by​SARS-​CoV-​2​ itself​ rather​than​the​host's​ immune​system.​Regarding​immunosuppressive​treatment,​the​duration​of​therapy,​the​type​of​drugs,​and​the​ dose​of​glucocorticoids​are​ important​ factors​ that​may​differently​ affect​the​disease​course.4– 7​Lastly,​the​response​to​COVID-​19​vaccines​ could​ be​ less​ efficient​ in​AIRD​patients​ due​ to​ immunosuppressive​treatment​or​underlying​immune​dysregulation.7,8​This​may​ contribute​to​the​more​severe​disease​course​in​AIRD​patients​despite​vaccination.​Another​ important​aspect​about​ the​pandemic's​ effects​on​care​of​AIRD​patients​ is​ that​ the​pandemic​has​ caused​ interruptions​in​the​routine​follow-​up​of​patients.​Although​telemedicine​tools​have​been​increasingly​used​in​clinical​practice,​their​efficacy​is​limited​compared​to​in-​person​visits.​George​et​al9​showed​ that​stopping​immunomodulatory​treatment​was​more​likely​for​patients​followed​up​with​telemedicine​visits​than​those​followed​up​ with​office​visits.​These​may​affect​the​adequate​control​of​AIRDs​ during​or​after​SARS-​CoV-​2​infections.​Also,​an​effective​collaboration​between​the​ internist​who​treats​COVID-​19​and​the​rheumatologist​is​of​utmost​importance​for​improving​the​outcome​for​both​ COVID-​19​and​AIRDs. Recently,​Abdulnaby​et​al10​have​compared​COVID-​19​outcomes​ between​66​patients​with​AIRDs​and​64​without​AIRDs.​They​failed​ to​show​significant​differences​between​the​two​groups​regarding​ COVID-​19​ outcome​or​ severity.​However,​ they​ observed​ a​ higher​ frequency​ of​ septic​ shock​ in​ AIRD​ patients,​ a​ longer​ duration​ of​ recovery​in​patients​on​glucocorticoids,​and​that​hypertension​was​ associated​with​more​severe​COVID-​19.10​Although​the​outcome​parameters​seem​similar,​there​were​several​significant​differences​between​the​AIRD​and​control​groups​regarding​general​features.​For​ instance,​male​gender​and​smoking​both​of​which​have​been​associated​with​severe​COVID-​19​in​most​studies,​were​significantly​more​ frequent​among​patients​ in​ the​control​group​ than​AIRD​patients.​ On​the​other​hand,​lung​involvement​was​more​common​in​the​AIRD​ group.​The​negative​effect​coming​from​the​AIRD​and​lung​involvement​in​the​AIRD​group​might​have​been​balanced​with​a​higher​frequency​of​male​gender​and​smoking​in​the​control​group.​Another​ point​is​that​the​duration​until​recovery​was​longer​in​AIRD​patients​ than​in​patients​in​the​control​group​(10.5 days​vs.​6 days;​P < 0.001).​ However,​ treatment​ of​ COVID-​19​ significantly​ differed​ between​ the​two​groups.​Around​40%​of​the​control​group​patients​(n = 27;​ 42.2%)​received​tocilizumab,​while​only​4​patients​(6.3%)​got​tocilizumab​treatment​in​the​AIRD​group.​Tocilizumab,​which​is​a​strong​ anti-​inflammatory​biologic​drug,​might​have​decreased​the​duration​ till​recovery​in​the​control​group.​Furthermore,​tocilizumab​use​had​ possibly​affected​the​laboratory​test​results​which​were​significantly​ different​between​AIRD​patients​and​patients​in​the​control​group​ (i.e.,​higher​ferritin,​D-​dimer,​and​C-​reactive​protein​in​AIRD​patients).​ The​reason​for​the​significant​difference​between​AIRD​patients​and​ controls​ regarding​ tocilizumab​ use​ rate​ could​ be​ the​ concomitant​ immunosuppressive​therapy.​Patients​who​were​already​on​certain​ immunosuppressive​drugs​for​AIRD​might​be​less​likely​to​be​treated​ with​tocilizumab​due​to​concerns​associated​with​the​concomitant​ use​of​immunosuppressive​agents.​Septic​shock​was​only​observed​ in​7​AIRD​patients​in​the​whole​cohort.​However,​this​result​should​ be​evaluated​carefully​considering​that​the​SARS-​CoV-​2​polymerase​