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COVID-19 Outcomes Among Users of CD20 Inhibitors for Immune-Mediated Diseases: A Comparative Cohort Study
Naomi J Patel1, Kristin M D'Silva1,2, Tiffany Y-T Hsu3
1Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA.
Insights
Patients treated with CD20 inhibitors for immune-mediated diseases had a significantly higher risk of death from COVID-19 compared to matched controls. This highlights the need for risk mitigation strategies for these vulnerable patients.
Area of Science:
- Immunology
- Infectious Diseases
- Rheumatology
- Neurology
Background:
- Patients with immune-mediated diseases (IMDs) on CD20 inhibitors may face worse COVID-19 outcomes.
- Previous studies compared CD20 inhibitor users to other immunomodulatory drug users, but not the general population.
Approach:
- A retrospective cohort study identified patients with IMDs treated with CD20 inhibitors and diagnosed with COVID-19.
- Matched comparators from the general population with COVID-19 were selected based on age, sex, and diagnosis date.
- Cox regression analysis estimated hazard ratios for hospitalization, mechanical ventilation, and mortality.
Key Points:
- CD20 inhibitor-treated patients with COVID-19 exhibited a significantly higher mortality risk (aHR 2.16) compared to matched general population controls.
- Risks for hospitalization (aHR 0.88) and mechanical ventilation (aHR 0.82) were comparable between the groups.
- These findings held true across various indications, treatment durations, and after excluding specific comorbidities.
Conclusions:
- CD20 inhibitor treatment for IMDs is associated with increased mortality following COVID-19.
- Urgent risk mitigation strategies, like monoclonal antibodies or booster vaccinations, are needed for this population.
- These findings underscore the importance of protecting immunocompromised patients during pandemics.
Objective:
Patients with immune-mediated diseases treated with CD20 inhibitors may have worse COVID-19 outcomes due to impaired humoral immunity, but differences versus the general population are unknown.
Methods:
We identified patients with immune-mediated diseases who received CD20 inhibitors within one year prior to the index date of PCR-confirmed COVID-19 between January 31, 2020, and January 31, 2021. Comparators with COVID-19 were matched up to 5:1 by age, sex, and PCR date. Hazard ratios (HRs) and 95% confidence intervals (CIs) for hospitalization, mechanical ventilation, and death in CD20 inhibitor users versus comparators were estimated using Cox regression.
Results:
We identified 114 cases with COVID-19 who had received CD20 inhibitors for immune-mediated diseases (mean age 55 years, 70% female) and 559 matched comparators with COVID-19 (mean age 54 years, 70% female). CD20 inhibitor-treated cases had higher mortality (aHR 2.16; 95% CI: 1.03 to 4.54) than matched comparators. Risks of hospitalization (aHR 0.88; 95% CI: 0.62 to 1.26) and mechanical ventilation (aHR 0.82; 95% CI: 0.36 to 1.87) were similar. Similar trends were seen in analyses according to type of indication (e.g., rheumatic or neurologic disease) and duration of CD20 inhibitor use (<1 or ≥1 year), and after excluding patients with interstitial lung disease, cancer, and those on glucocorticoids prior to COVID-19 diagnosis.
Conclusions:
Patients who received CD20 inhibitors for immune-mediated diseases prior to COVID-19 had higher mortality following COVID-19 than matched comparators, highlighting the urgent need to mitigate excess risks in CD20 inhibitor users during the ongoing pandemic.
Key Messages:
What is already known about this subject?: Patients with immune-mediated diseases treated with CD20 inhibitors may have worse COVID-19 outcomes than those treated with other immunomodulatory medications, but differences compared to the general population are unknown.What does this study add?: CD20 inhibitor-treated cases had over two-fold higher risk of mortality than matched general population comparators, although risks of hospitalization and mechanical ventilation were similar.How might this impact on clinical practice or future developments?: There is an urgent need for risk mitigation strategies, such as SARS-CoV-2 monoclonal antibodies or booster vaccinations, for patients with immune-mediated diseases treated with CD20 inhibitors during the ongoing COVID-19 pandemic.
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