Immunosuppressants More Common Among Autoimmune Patients with Severe COVID-19

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Therapies including biologics and corticosteroids were more frequently used among patients with rheumatoid arthritis and lupus who developed severe COVID-19.

Patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) or myositis hospitalized due to COVID-19 are more likely to have a history of biologic, immunosuppressant or corticosteroid treatment for their autoimmune disease.

In a new study presented during the Congress of Clinical Rheumatology (CCR) East 2023 Annual Meeting in Destin, FL, this week, a team of US-based investigators observed findings that may indicate an association between severe autoimmune disease treatment and risk of severe COVID-19 progression. The research, funded by AstraZeneca, provides further context into the links between rheumatic disease status and risks from the pandemic virus.

Led by Cassandra Calabrese, DO, assistant professor in the department of rheumatologic and immunologic disease at the Cleveland Clinic Lerner College of Medicine, investigators sought to compare the use of therapy for autoimmune diseases between patients with and without severe COVID-19, stratified by diagnoses for SLE, RA or myositis.

The team used data from the IBM Market Scan Commercial Database to identify adults aged ≥18 years old with a confirmed diagnosis of either disease between January 2013 and April 2020. Assessment of eligible patients began from that month until enrollment end, patient death or conclusion of December 2021.

Severe COVID-19 was defined by ICD-10 diagnosis coding in the database. Calabrese and colleagues assessed patient use of antimalarials, biologic therapies and immunosuppressants in the 6 months prior to their earliest COVID-19 diagnosis; corticosteroid use was assessed in the patients’ 30 days prior to COVID-19.

The team assessed patients without severe COVID-19 by their medication use in the time prior to a proxy date assigned based on the matched distribution of the earliest diagnosis data of patients with severe COVID-19, for comparison.

The final assessment included 18,665 patients with SLE, 52,406 patients with RA, and 1833 patients with myositis who met eligibility criteria. Investigators observed severe COVID-19 among 1.5%, 1.4% and 2.2% of the patient populations, respectively. Patients with severe COVID-19 had an older mean age in all 3 cohorts; patients with SLE or RA and severe COVID-19 were more frequently male.

Investigators observed significantly more comorbidities among patients with any of the 3 autoimmune diseases and severe COVID-19; a significant majority of the same patients had used biologic, immunosuppressant or corticosteroid treatment (79 – 83%), while just 62 – 75% of patients with an autoimmune disease and no severe COVID-19 had used such treatments.

The team additionally observed a significantly more prevalent use of any biologic, immunosuppressant or corticosteroid among patients in each cohort with severe COVID-19; antimalarial use was more common among patients with RA and severe COVID-19, and rituximab (7 – 20%) or mycophenolate (3 – 40%) use was more common among each cohort with severe COVID-19 versus those without severe COVID-19.

Another 12% of patients with SLE and severe COVID-19 used belimumab, versus 8% of patients with SLE and without severe COVID-19; the rate of patients with SLE or RA and severe COVID-19 who used leflunomide or tacrolimus were approximately doubled from those with either autoimmune disease and no severe COVID-19.

The study authors concluded that common autoimmune disease therapies—especially corticosteroids—were more frequently used by patients with SLE, RA and myositis who developed severe COVID-19 versus those who did not.

“These treatments may be indicative of autoimmune disease severity, or independently associated with the occurrence of severe COVID,” Calabrese and colleagues wrote. “The potential impact on patients’ COVID risk should be carefully considered when selecting or adjusting autoimmune treatment regimens.”


  1. Calabrese C, Atefi G, Evans KA, Moynihan M, et al. Prior Use of Autoimmune Disease Treatments Among Patients with Systemic Lupus Erythematosus, Rheumatoid Arthritis, or Myositis Hospitalized with COVID-19. Paper presented at: Congress of Clinical Rheumatology (CCR) East 2023 Annual Meeting. Destin, FL. May 4 – 7, 2023.