COVID-19 and immunosuppressants: new data

Since COVID-19 is so new, there’s a shortage of important information on how it affects people with autoimmune disease. Many of us have asked our doctors for guidance with our conditions and medications, but in the end, no one really knows how COVID-19, autoimmune diseases, and immunosuppressants interact. We need data and cases to truly understand how we should proceed.

We don’t yet have any large-scale studies, but a small study from New York was released this week in the New England Journal of Medicine. It can give us some much-needed insight into how coronavirus impacts those of us who have autoimmune diseases and take immunosuppressants. Where my last article summarized expert advice based on speculation, here we have real (but limited) data. Hopefully, larger studies will follow.

Before getting into the data, it’s important to remember that having your autoimmune condition under control keeps your body in better condition to fight off a virus. If you stop a medication, it could cause a disease flare, leaving you more vulnerable to infection as your body wastes resources on autoimmunity. Always talk to your doctor about your concerns before changing your medication.

The New York case series

The New York case series report follows a group of 86 patients who contracted COVID-19 and had autoimmune disease according to records at New York University Langone Health. These people had conditions including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, psoriasis, ulcerative colitis, and Crohn’s disease. The study only included those on immunosuppressant treatment, such as biologics (Humira, Enbrel, Remicade, Cosentyx, etc.), methotrexate, hydroxychloroquine, and oral steroids.

Unfortunately, it’s a small group to work with, but it does offer some reassurances about taking biologics during the COVID pandemic. It also offers a potential warning about taking oral steroids, methotrexate, and hydroxychloroquine.

Ultimately, 14 of the 86 patients were hospitalized. Among people who were not hospitalized, a higher percentage were taking biologics. Among people who were hospitalized, a higher percentage were taking oral steroids, hydroxychloroquine, or methotrexate. Two cases were categorized by the researchers as “more severe,” and neither of them were on biologics.

Some additional data

The New York case series offers a small amount of data with some important (but cautious) conclusions. Another awesome resource we can look at is the SECURE-IBD database, although it doesn’t include analysis by experts.

The SECURE-IBD database is a database of coronavirus patients who have inflammatory bowel disease such as Crohn’s disease and ulcerative colitis. Doctors report on the outcomes of their IBD patients who contract COVID, including the medications they take and the state of their autoimmune disease. It has a hefty 877 reported cases all over the world as of 4/30/20.

What we can see by looking at the numbers are some similar trends to what the doctors in New York noticed. Patients taking oral steroids are at the highest risk by far for severe coronavirus. While just 32% of all reported cases resulted in hospitalization, 68% of those taking oral steroids were hospitalized. Further, 26% of those on oral steroids had more severe symptoms resulting in ICU time, ventilator use, or death.

Encouragingly, patients taking only anti-TNF biologics (Humira, Remicade) were hospitalized at a rate of just 17% and had more severe symptoms at a rate of just 3%. Patients taking anti-IL-12/23 biologics (Stelara) were hospitalized at a rate of just 10% and had more severe symptoms at a rate of just 2%.

Unfortunately, SECURE-IBD doesn’t offer much data about methotrexate or hydroxychloroquine, as they aren’t popular IBD drugs. Sulfasalazine and mesalamine showed indications of worse outcome, but without proper analysis, it’s hard to say if it represents a significant difference from baseline.

About oral steroids, methotrexate, and hydroxychloroquine

I’ve seen doctors warning about oral steroids (like prednisone) from the beginning, and with good reason. They’re well-known to suppress the immune system, making you more vulnerable to infection.

Steroids, methotrexate, and hydryoxychloroquine are all older autoimmune medications, and they were initially developed to treat something else. It was only later that we realized they could be used as immunosuppressants to treat autoimmune diseases. Because of this, they aren’t very targeted. They often suppress the immune system as a side effect of whatever else they were meant to do, and it’s not very elegant. It’s also why people see so many side effects when they take them.

Hydroxychloroquine has been hailed as a cure for COVID-19, but as more and more studies are done, there’s no evidence it’s effective.

Why might biologics be safer?

In contrast to older autoimmune treatments, biologics are specially developed to inhibit a very specific part of the inflammatory process. They target select molecules involved in the inflammatory process: TNF-alpha, in the case of Humira, Enbrel, and Remicade; IL-17, in the case of Cosentyx and Taltz; and IL-12/23, in the case of Stelara. This leaves the rest of the immune system intact to fight infections.

Because each class of biologic inhibits different parts of the immune system, you have different vulnerabilities depending on which you’re taking. Luckily, none of the common vulnerabilities are coronavirus, that we know of right now.

The important conclusions

While we still don’t have great data, both sources indicate that biologics don’t worsen outcome with COVID-19. The sources also show that oral steroids do worsen outcome. It’s not particularly clear about other treatments like methotrexate, hydroxychloroquine, sulfasalazine, and mesalamine, which were only reported by one source each but showed indications that they could worsen outcome.

Most importantly, talk to your doctor before making any medication change. It’s very important to avoid an autoimmune flare, because that can also leave you vulnerable.

Stay safe, everyone!

-Bri

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