Managing Patients with Immune-Mediated Inflammatory Diseases on Disease-Modifying Antirheumatic Drug Therapy in a COVID-19 Endemic World: A Narrative Review and Expert Insights

Introduction

Literature Review

Understanding the Effects of IMIDs on Risk of COVID-19

IMIDs are associated with higher risks of infection and poorer outcomes: IMIDs and COVID-19 share common features of cytokine dysregulation and increased expression of proinflammatory cytokines [7]. These mechanisms play a critical role in the host’s defense and response against SARS-CoV-2, and in severe cases, can trigger a cytokine storm, resulting in acute respiratory distress syndrome, multiorgan failure and death [12]. Since the onset of the pandemic, numerous studies and meta-analyses have consistently demonstrated an association between IMIDs and an elevated risk of COVID-19.

Specifically, individuals with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and psoriasis face a higher risk of poor COVID-19-related outcomes compared to the general population [10]. A meta-analysis of 23 studies found that patients with rheumatic diseases have a relative risk of 1.52 (95% confidence interval [CI], 1.16–2.00) for SARS-CoV-2 infection compared to the general population [10]. Another meta-analysis conducted across different regions, including Asia, Europe, North America, and South America, reported a high incidence of COVID-19 among patients with rheumatic diseases, with an estimated 44% hospitalization rate and elevated rates of mortality, intensive care unit (ICU) admission, and mechanical ventilation [9].

While early studies suggested a higher risk of hospitalization or death among those with RA or connective tissue disease, these risks became non-significant after adjusting for factors like age, sex and comorbidities [10]. However, a subsequent Danish study found a 46% increased risk of COVID-19 hospitalization in patients with rheumatic diseases compared to the general population, with RA patients showing a significantly elevated risk of severe outcomes (hazard ratio [HR] 1.72; 95% CI, 1.29–2.30).[10] Consistent findings were observed across RA phenotypic subgroups, especially in patients with interstitial lung disease (ILD) [8]. Analyses of the UK health records database OpenSAFELY indicated an increased risk of COVID-19-related death, critical care admission or death, and hospital admissions in people with IMIDs compared to non-IMID individuals of similar demographics [13]. Among IMID individuals, those with inflammatory joint diseases like RA, psoriatic arthritis (PsA) and ankylosing spondylitis faced a greater risk of severe outcomes than those with inflammatory skin or bowel disease [13]. Similarly, studies of patients with SLE reported a significantly increased risk of severe COVID-19 outcomes, including mortality, mechanical ventilation, hospitalization, and ICU admissions compared to matched controls, even when considering the presence of other associated comorbidities [14].

The available evidence aligns with the clinical experience of our expert group, indicating that certain IMIDs, such as SLE, inflammatory conditions like RA, PsA and idiopathic inflammatory bowel disease, other autoinflammatory conditions, and comorbidities associated with metabolic syndrome confer a heightened vulnerability to COVID-19 [15].

Comorbidities and clinical risk factors linked to COVID-19 outcomes in IMIDs: Certain clinical characteristics, such as age and sex, and comorbid conditions are predictors of poor outcomes in patients with IMIDs (Figure 1), highlighting the varying levels of risk and their correlation with adverse COVID-19 outcomes [9,16,17]. In the UK, 90% of COVID-19-related deaths occurred in people over 60, and 60% in men [16].

In the COVID-19 Global Rheumatology Alliance (C19-GRA) physician-reported registry of adults with rheumatic diseases and COVID-19 in Japan, older age (≥65 years) was associated with a higher risk of severe COVID-19 progression (defined as death or requiring oxygen inhalation) (odds ratio [OR] 3.52; 95% CI, 1.69–7.33) [17]. The likelihood of progression to severe disease, along with rates of mortality and critical disease, increased across age groups [17].

Additionally, comorbidities strongly correlate with adverse COVID-19 outcomes in patients with rheumatic diseases [9,16,17]. In the C19-GRA registry studies, pre-existing conditions like diabetes, lung disease (including chronic obstructive pulmonary disease, asthma and ILD), hypertension, cardiovascular disease, and chronic renal insufficiency were identified as potential risk factors for severe COVID-19 outcomes [17]. These findings align with an analysis of RA patients in a US COVID-19 health record database (Optum^®) [18]. Unsurprisingly, higher disease activity in rheumatic patients correlated with higher odds of poor outcomes, including death [19]. In the case of SLE patients, severe disease activity increased the risk of mechanical ventilation (OR 5.83; 95% CI, 2.60–13.07) and hospitalization (OR 3.97; 95% CI, 2.37–6.65) [14].

Figure 1. Clinical risk factors and patient characteristics associated with poor COVID-19 outcomes in IMIDs.

Figure 1. Clinical risk factors and patient characteristics associated with poor COVID-19 outcomes in IMIDs.

COVID-19 burden remains high among patients with rheumatic disease during the Omicron era: The Omicron variant, although more transmissible, is associated with milder disease compared to the Delta variant. Factors like reduced social distancing measures, relaxed masking policies, and waning vaccination efficacy have influenced its spread and effect [3]. Emerging data from the Omicron phase provide important insights on the evolving impact of COVID-19 on patients with rheumatic diseases [3].

Real-world data from China during the Omicron wave showed a high COVID-19 infection rate (84.3%) among patients with rheumatic diseases, with a shorter time since last vaccination (<3 months) reducing the risk of hospitalization [20]. Age over 60 years and comorbidities were independent risk factors for hospitalization, while booster vaccinations protected against hospitalization [20]. Interestingly, among rheumatic conditions, RA patients had a lower likelihood of infection, whereas SLE patients tended to have more severe COVID-19 [20].

Reassuringly, recent findings from Israel demonstrated improved outcomes among patients with rheumatic diseases during the Omicron period compared to Delta.[3] Hospitalization and mortality rates decreased markedly from 3.9% to 1.3% and 3.2% to 1.1%, respectively [3]. The study did not find significant differences in hospitalization risks between the Omicron and Delta periods based on rheumatic disease type, comorbidities, or treatments [3]. Similarly, an analysis of a Japanese COVID-19 registry showed a progressive improvement in COVID-19 prognosis among patients with rheumatic disease over time, spanning different periods of onset and dominant SARS-CoV-2 strains [21]. Hypoxemia rates decreased from 34.9% in the earliest period until June 2021 to 6.1% in the Omicron BA.5 period from July to December 2022. Mortality rates also decreased from 5.6% to 0% during the same period.

Overall, these findings suggest progressive improvement in COVID-19 prognosis among patients with rheumatic diseases, potentially due to higher vaccination rates and the milder Omicron variant [3]. However, COVID-19 risks remained elevated for patients with IMIDs compared to the general population due to reduced immune responses to the SARS-CoV-2 vaccine. Their risks of poor COVID-19 outcomes are further influenced by comorbidities and background therapies [3,10,17].

Understanding the Effects of DMARDs on COVID-19 Outcomes in Patients with IMIDs

In patients with IMIDs, the use of immunomodulatory and immunosuppressive therapies is known to increase their vulnerability to viral and bacterial infections [22]. Therapies like glucocorticoids have broad immunosuppressive effects that can impair innate and adaptive immunity against various pathogens [23,24]. Studies consistently show that patients on these therapies, particularly those on methotrexate, anti-CD20 antibody rituximab and mycophenolate mofetil (MMF), exhibit impaired vaccine response to COVID-19 vaccination [24,25,26]. However, certain therapies used in the treatment of IMIDs target proinflammatory cytokines that are induced in COVID-19 [24]. Cytokine inhibitors, as well as b/tsDMARDs targeting interleukin-6 (IL-6) and IL-1, tumor necrosis factor-inhibitors (TNFis) and Janus kinase inhibitors (JAKis) (Figure 2) [16,27,28,29] have shown efficacy in controlling disease activity of IMIDs such as RA [1,12,24]. The impact of b/tsDMARDs on COVID-19 outcomes has received particular interest given the potential of these medications in fighting the cytokine storm syndrome associated with severe COVID-19 [12,30]. While evidence suggests that certain b/tsDMARDs can lower the risk of severe COVID-19 by modulating the immune response, the baseline use of specific b/tsDMARDs like rituximab or abatacept may be associated with worse COVID-19 outcomes due to impaired viral immune defenses [30].

Figure 2. Overview of immunosuppressive and immunomodulatory therapies indicated for IMIDs.

Figure 2. Overview of immunosuppressive and immunomodulatory therapies indicated for IMIDs.

DMARD classes have diverse effects on COVID-19 outcomes: The available evidence highlights the variability in the effects of different DMARD classes on COVID-19 outcomes (Table 1). Studies have shown that, in general, the use of tsDMARDs does not increase the risk of severe COVID-19, with the exceptions of rituximab or JAKis [13], while therapies such as TNFis were found to decrease the risk of severe COVID-19 [1,10,13]. The C19-GRA registry reported that patients receiving JAKis or rituximab prior to COVID-19 had higher odds of poor outcomes compared to those on TNFi therapy [30]. Analysis of the UK OpenSAFELY database, which included over 1 million people with IMIDs, demonstrated that the use of various b/tsDMARDs including TNFis, IL-12/IL-23is, IL-17is, IL-6is, or JAKis did not increase the risk of COVID-19 related death compared to standard systemic therapy [13]. However, rituximab was associated with an increased risk of critical care admission or death.

A real-world study from Taiwan compared outcomes among patients with RA on various b/tsDMARDs, including JAKi, TNFi, and IL-6i, using data from the US Collaborative Network in TriNetX between January 2018 and December 2022 [1]. Compared to TNFi, RA patients on JAKi had a significantly higher risk of hospitalization (HR: 1.194, 95% CI: 1.003 to 1.423), mortality (HR: 1.440, 95% CI: 1.049 to 1.976) and composite adverse outcomes (HR: 1.242, 95% CI: 1.051 to 1.468) [1]. These findings were largely consistent with the C19-GRA registry studies, despite differences in the study period and different dominant variants of concern. Importantly, the study highlighted that the mortality risk tended to be significantly higher in the JAKi group among patients who were not vaccinated against COVID-19 (HR: 1.511, 95% CI: 1.077 to 2.121) [1]. The findings also suggest that the effects of JAKis on COVID-19 outcomes appear to be inconsistent, and there is a possibility that, like glucocorticoids, they may have divergent effects based on the underlying disease, although further confirmation is needed [10].

Table 1. Summary of findings from large cohort studies comparing effects of DMARD classes on COVID-19 outcomes

Table 1. Summary of findings from large cohort studies comparing effects of DMARD classes on COVID-19 outcomes

Baseline glucocorticoids negatively impact COVID-19 outcomes: While glucocorticoids have shown benefits when initiated for the treatment of moderate-to-severe COVID-19, they have been associated with worse outcomes among those who are already on baseline glucocorticoids at the time of infection [13,24,30,31]. Notably, patients with SLE on glucocorticoids experienced severe outcomes when infected with COVID-19 [14]. Studies from the C19-GRA registry found that higher dosages of glucocorticoids (≥10 mg/day of prednisolone equivalent) were linked to an increased risk of hospitalization in patients with rheumatic diseases [30,31]. Even doses below 10 mg/day have been associated with an elevated risk of worse outcomes [9,14]. Consensus guidelines by the British Society for Rheumatology identified a corticosteroid dose of ≥20 mg (0.5 mg/kg) prednisolone (or equivalent) per day for more than 4 weeks as posing a very high risk for COVID-19, providing a valuable principle for risk stratification [32]. The existing literature strongly supports our expert group’s real-world observations and experiences regarding the impact of glucocorticoids on COVID-19 outcomes, underscoring the importance of controlling disease activity to reduce baseline glucocorticoid dosage and mitigate the risk of severe COVID-19 [33]. This is particularly crucial for patients with SLE who frequently use glucocorticoids [14].

Impact of rituximab therapy in the context of evolving COVID-19 variants: Rituximab, an anti-CD20 therapy, has been associated with increased susceptibility to other viral infections and poor COVID-19 outcomes in conditions other than rheumatic diseases [10,24]. Given its impact on humoral immunity as a B cell-depleting agent, concerns were raised about the safe use of rituximab during the pandemic [10]. Multiple studies have indicated an increased risk of poor COVID-19-related outcomes, including deaths, in patients with rheumatic diseases treated with rituximab compared to the general population or those on other DMARDs [7,13,34].

Studies conducted during later stages of the pandemic continue to demonstrate the susceptibility of rituximab-treated patients to COVID-19 [34]. Despite high vaccination rates, approximately a third of patients experienced breakthrough SARS-CoV-2 infections while receiving rituximab therapy, but the majority had mild outcomes.[34] The incidence rates of moderate-to-severe COVID-19 were comparable across different SARS-CoV-2 variants (wild-type or Alpha, Delta and Omicron) [34]. Predictors of moderate-to-severe outcomes included an increasing number of comorbidities and hypogammaglobulinemia, while the risk of severe outcomes substantially decreased with each vaccine dose received [34].

These findings suggest that breakthrough SARS-CoV-2 infections were common but mostly mild among rituximab-treated patients during the Omicron phase [34]. Considering the emergence of less severe SARS-CoV-2 variants, increased vaccination rates, reduced social restrictions, and the availability of new therapies, careful consideration is needed when balancing the risks of rituximab treatment against under-treating patients with severe disease, especially when alternative treatment options are limited [34]. Increased vigilance is necessary for patients with comorbidities and low immunoglobulin concentrations [34].

Response to COVID-19 Vaccination in Patients with IMID on DMARDs

The available data indicate that patients with IMIDs, despite generally tolerating SARS-CoV-2 vaccination, are at risk of losing humoral immune protection due to their lower and less enduring response to SARS-CoV-2 vaccination [24,35,36,37]. Research has shown that patients with IMID experienced delayed and reduced responses to SARS-CoV-2 vaccination that appears to be a disease-related effect [11]. Compared to immunocompetent individuals, significantly more patients with IMID failed to develop neutralizing antibodies after vaccination [11]. Furthermore, there is ample evidence indicating that immunosuppressive treatments including cytokine inhibitors can dampen the adaptive immune response to SARS-CoV-2 vaccines [35].

While prioritization for vaccination is crucial for mitigating COVID-19 risks in patients with IMID, the complexity of treatment in this patient group and suboptimal immune responses following vaccination remain a challenge for healthcare professionals. The following sections provide an overview of the current literature related to immunogenicity of patients with IMIDs following COVID-19 vaccination, focusing on different classes of DMARDs and specific indications such as RA, PsA, axial spondyloarthritis (axSpA) and SLE. Understanding the various factors influencing vaccine responses in IMID patients is crucial for guiding clinical practice.

Impaired COVID-19 vaccine response observed in IMID patients: It is well established that individuals with IMIDs respond less favorably to routine vaccinations than healthy adults [38]. Although initial COVID-19 vaccine trials excluded patients with IMIDs, it quickly became evident that following the recommended 2-dose primary series of COVID-19 vaccination, serologic response rates were lower among patients with IMID compared to immunocompetent individuals [38]. A systematic review and meta-analysis reported a pooled seroresponse rate of 83% among all patients with IMIDs and 80% among the subgroup of patients with rheumatic diseases [38]. Patients with rheumatic diseases had lower odds of seroconversion compared to healthy controls (OR, 0.068; 95% CI, 0.016–0.29) [38]. Additional prospective studies also showed reduced seroconversion rates among IMID populations (range, 63%–91%) compared with healthy controls (range, 98%–100%) [38]. Another study assessing humoral, CD4 and CD8 responses after a 2-dose SARS-CoV-2 vaccination demonstrated significantly lower seroconversion rates and cellular immune responses in IMID patients compared to healthy individuals [29]. The diminished vaccine immunogenicity observed in IMID patients may be attributed to intrinsic dysregulation of the immune response associated with the underlying IMRD and/or immunosuppressive therapies.

DMARD class impacts COVID-19 antibody response in IMID patients: Studies have indicated that DMARDs reduced the immune response following COVID-19 vaccination after six weeks [39]. A study investigating the effectiveness of SARS-CoV-2 vaccination in patients with RA on DMARDs reported the lowest seroconversion rates in patients treated with abatacept, rituximab (<6 months from infusion) and those on concomitant methotrexate [40]. These findings align with previous data for rituximab, which showed impaired antibody responses to influenza and pneumococcal vaccines [40]. The impact of abatacept on vaccine response remains uncertain. In the study, no patients treated with abatacept achieved seroconversion after the first dose, but 50% achieved seroconversion after the second dose, likely due to abatacept’s effects on both T and B cells and its known ability to inhibit antibodies [40]. Substantially better seroconversion rates were observed with TNFis versus rituximab and with age ≤50. In terms of T cell responses, individual drugs had limited impact except for a potential effect associated with corticosteroids [40].

Another study involving patients with RA, SpA and inflammatory bowel disease showed that patients receiving b/tsDMARDs had significantly reduced antibody levels and neutralizing antibody titres six months after SARS-CoV-2 vaccination [41]. This reduction was attributed to a faster decline in antibody levels, indicating a significantly reduced duration of vaccination-induced immunity compared with healthy controls or patients receiving csDMARDs [41].Furthermore, there was a reduced response to booster vaccination, highlighting the need for earlier booster vaccination strategies based on specific antibody levels in patients under b/tsDMARD therapy [41]. These findings were supported by data from a Chinese cohort study involving RA patients, which showed that patients treated with bDMARDs, JAKis and prednisone had significantly lower neutralizing antibody titers when compared with healthy controls [42]. However, no significant decrease was observed in RA patients treated with csDMARDs [42].

Altogether, these findings indicate that patients treated with a combination of csDMARD and bDMARD face a higher disease risk than those exclusively on conventional drugs. Moreover, compared to patients not on DMARD treatment, patients treated with any type of DMARD or glucocorticoid at any dose exhibit substantially lower responses to SARS-CoV-2 vaccines [39]. Specifically, glucocorticoids, methotrexate, MMF, TNFis, and B cell-depleting therapy have been identified as posing a risk in attenuating serological responses [43]. However, it is important to note that some data suggest that even in patients on different medications who experienced insufficient seroconversion for neutralizing antibodies and SARS-CoV-2 immunoglobulin G, a second vaccination covered almost all patients, regardless of DMARD therapy [40].

Durability of vaccine response and hybrid immunity during Omicron: In the context of the Omicron wave, it becomes increasingly crucial to understand vaccine response, waning immunity, and the concept of hybrid immunity. Recent data reported that patients with IMID including RA, axSpA and psoriatic disease treated with biologics experienced greater waning of antibody and T cell responses to SARS-CoV-2 three months after the second dose of SARS-CoV-2 vaccine compared to healthy controls [43]. Notably, those receiving TNFi had substantially lower antibody levels and neutralization efficacy against variants of concern, with undetectable levels against Omicron three months after the second dose [43]. Based on these findings, it was concluded that administering a third vaccine dose of SARS-CoV-2 vaccine and continuously monitoring immune responses are critical for patients with IMIDs [43].

In a study involving patients with autoimmune rheumatic diseases who had completed primary series of vaccination, 17.4% experienced an Omicron infection [44]. Those with hybrid immunity (vaccinated individuals with a history of COVID-19 infection) had better protection against breakthrough infections during the Omicron wave compared to those who were only vaccinated [44]. Age and time since the last event (second dose of vaccination or past COVID-19 infection, whichever was later) did not significantly correlate with breakthrough infections. In the hybrid group, the order of infection and vaccination did not affect the risk of breakthrough infections [44]. These real-world findings suggest that hybrid immunity may potentially protect patients with IMIDs against breakthrough infections [44].

Discussion

Conclusions and Clinical Implications

References

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