OP0283 DOES TNF-INHIBITION DECREASE THE RISK OF SEVERE COVID-19 IN RMD-PATIENTS?
Authors: R. Hasseli, B. F. Hoyer, A. Krause, H. M. Lorenz, A. Pfeil, A. Regierer, J. Richter, T. Schmeiser, A. Strangfeld, H. Schulze-Koops, R. Voll, C. Specker, U. Müller-Ladner
Journal: Annals of the Rheumatic Diseases (2021)

Background: Patients with rheumatic and musculoskeletal diseases (RMD) might have an increased risk for infection due to their immunomodulatory treatment, secondary to their disease and comorbidities. Recent studies suggest a decreased risk of severe COVID-19 in RMD-patients treated with biologics. Objectives: The aim of this study was to assess courses of RMD patients treated with TNF-inhibitors (TNF-I) included in the German COVID-19 registry. Methods: In the German physician-reported COVID-19-RMD registry, patients with an RMD and confirmed SARS-CoV-2-infection were documented (data entered between March 30, 2020 and January 30, 2021). We analysed TNF-I treated patients, their course and outcome of the infection. Data were compared to RMD-patients treated with other immunomodulatory drugs (OID) than TNF-I. Results: A total of 269 patients were treated with a TNF-I (57% female) compared to 874 patients who were treated with OID (68% female). Median age was 52 years (range: 19-87) in the TNF-I-group versus 58 years (range: 18-91) in the OID-group. Rheumatoid arthritis was the most common diagnosis (38% in TNF-I-group vs. 52% in the OID-group), followed by ankylosing spondylitis (32% vs. 6%), psoriatic arthritis (22% vs. 11%) and other RMD (9% vs. 31%). Adalimumab (35%) and etanercept (35%) were the most frequently used TNF-I (tab. 1). Glucocorticoids (GC) were used in 22% of TNF-I-treated patients and in 42% of the OID-group. Under TNF-I, stable disease was reported prior to the SARS-CoV-2-infection in 53% of the patients (OID-group: 47%), followed by low disease activity in 35% (OID: 34%), moderate disease activity in 6% (OID: 12%) and high disease activity in 4% (OID: 3%). Most frequent comorbidities were arterial hypertension (29% under TNF-I vs. 35% under OID), diabetes (8% vs. 11%) and cardiovascular diseases (7% vs. 12%). The most common reported COVID-19 symptoms were dry cough (57% vs. 55%), fever (53% vs. 61%) and fatigue (50% vs. 49%). Hospitalization due to SARS-CoV infection was required in only 12% of the TNF-I-treated cases vs. in 29% in the OID-group. Oxygen treatment was necessary in 5% of the patients under TNF-I compared to 22% under OID and invasive ventilation in 2% in the TNF-I-group compared to 6% under OID. Most notably, no fatal courses of COVID-19 were reported among the 269 RMD-patients treated with TNF-I versus 49 deaths in the 874 cases (5.6%) treated with OID. Focussing on the hospitalizated TNF-I patients, the rate of concomitant GC use (p&lt;0.001) and higher disease activity (p=0.005) was significant higher (tab.1). Conclusion: High or moderate RMD-disease activity is an important factor associated with severity of COVID-19 including mortality. In this large cohort RMD patients treated with TNF-I show a low hospitalisation rate and no fatal course. This is reassuring for patients and treating rheumatologists to use TNF-I to control RMD disease activity. The use of glucocorticoids and high disease activity seem to counteract possible protective effects of TNF-I. Table 1. TNF inhibition (269 ) Other immunomodulation (874 ) Total patients Rate (% ) Total patients Rate (% ) Disease activity stable 141 53 408 47 low 93 35 299 34 Moderate 15 6 108 12 High 10 4 29 3 Comorbidities cardiovascular diseases 18 7 104 12 arterial hypertension 77 29 303 35 bronchial asthma 12 4 65 7 COPD/interstitial lung disease 11 4 86 10 chronic renal failure 9 3 77 9 Osteoporosis 13 5 67 8 Diabetes 22 8 92 11 COVID-19 related symptoms Fever 142 53 478 55 dry cough 152 57 530 61 Expectoration 31 12 83 9 muscular pain 97 36 280 32 Fatigue 135 50 424 49 Headache 101 38 237 27 shortness of breath 49 18 245 28 no symptoms 23 9 56 6 COVID-19 outcome Outpatients 237 88 619 71 Inpatients 32 12 255 29 need of oxygen treatment 18 7 189 22 invasive ventilation 5 2 49 6 fatal course 0 0 49 6 TNF inhibitors Adalimumab 95 35 Infliximab 23 9 Certolizumab 33 12 Golimumab 24 9 Etanercept 94 35 GC and disease activity in TNF-I treated patients TNF-I inpatients treated with GC 18/32 56 p&lt; 0.001 TNF-I outpatients treated with GC 42/237 18 TNF-I inpatients with high disease activity 4/32 13 TNF-I outpatients with high disease activity 6/237 6 p= 0.005 Acknowledgements: The authors would like to thank all physicians and personnel involved in the documentation of the cases in our registry. Disclosure of Interests: None declared