TNF inhibitors may help COVID patients with IMIDs
COVID-19 patients with immune-mediated inflammatory diseases (IMIDs) may benefit from tumor necrosis factor (TNF) inhibitors, according to a study published yesterday in JAMA Network Open. TNF inhibitors are already first- or second-line treatments for IMIDs, but debate has centered on whether they would help mitigate COVID-19 severity because of their ability to inhibit cytokines or if they would hurt it due to associated increased infection vulnerability.
The researchers pooled three international COVID-19 registries (GRA, SECURE-IBD, and PsoProtect) from Mar 12, 2020, to Feb 1, 2021, and looked at 6,077 adults with rheumatic diseases, inflammatory bowel disease, or psoriasis. Most patients (58.6%) were women, the mean age was 48.8 years, and most people were from Europe (52.9%) or North America (33.2%), although the study included 74 countries.
Three subgroups received a TNF inhibitor, either as monotherapy (46.8%) or in combination with methotrexate (11.0%) or azathioprine/6-mercaptopurine (5.5%). Three other subgroups didn't receive TNF inhibitors at all, but rather methotrexate monotherapy (25.4%), azathioprine/6-mercaptopurine monotherapy (6.5%), or Jak inhibitor monotherapy (4.7%).
Compared with patients who received TNF inhibitor monotherapy, all of the other groups had a higher risk of hospitalization or death, with odd ratios (ORs) ranging from 1.82 to 2.00. The only exception was those who received a TNF inhibitor in combination with methotrexate therapy, which had an OR of 1.18 but a p-value of 0.33.
Overall, 21.3% were hospitalized, and 3.1% died. Previously associated factors such as obesity, diabetes, and cardiovascular disease were also associated with hospitalization or death.
"The finding that maintenance of TNF inhibitor monotherapy is associated with reductions in the risk of severe COVID-19 among patients with IMIDs offers new perspective that may guide health care professionals in the difficult decisions regarding therapeutic approaches among this specific group of patients," concludes Licio A. Velloso, MD, PhD, in a related commentary.
Oct 18 JAMA Netw Open study and commentary
Lit review looks at factors in severe pediatric COVID-19
A 56-study literature review of pre-Delta (B1617.2) variants found that multisystem inflammatory syndrome in children (MIS-C), acute respiratory distress syndrome (ARDS), and acute kidney injury were among some of the factors that increased the risk of severe COVID-19.
The findings, published yesterday in The Lancet's EClinical Medicine, included 79,104 children 18 years or younger. About 37.5% of studies were in the United States, and while 51.8% had no reported follow-up time, those that did had a range of 2 weeks to 7 months. On a scale from 0 to 9, with 7 being medium quality and 6 and below being low to very low quality, the 22 cohort studies had a median score of 6, the 9 case-control studies had a median score of 5, and the 25 case series had a median score of 9.
While some studies had low-quality data, strong associations were found across all measured outcomes. Mortality was higher in patients with MIS-C (OR, 58.00; 95% confidence interval [CI], 6.39 to 526.79) and those admitted to an intensive care unit (ICU) (OR, 12.64; 95% CI, 3.42 to 46.68), although the researchers note that the sample size for MIS-C was small. ARDS and acute kidney injury were linked to higher ICU admission odds (ORs, 29.54 and 55.02; 95% CIs, 12.69 to 68.78 and 6.26 to 483.35, respectively).
Shortness of breath was associated with respiratory support need (OR, 16.96; 95% CI, 7.66 to 37.51). And, progression to severe or critical disease was linked to high C-reactive protein levels (80 milligrams per liter or higher; OR, 11.70; 95% CI, 4.37 to 31.37), neurological disease (OR, 5.16; 95% CI, 2.30 to 11.60), or high D-dimer levels (0.5 micrograms per milliliter or higher; OR, 20.40; 95% CI, 1.76 to 236.44).
"Altogether, we cannot be sure whether age and gender affects the prognosis of COVID-19, and the use of male sex to identify those who are in the greatest need of protection may be problematic," say the researchers.
Oct 18 EClinical Medicine study