016 - Risk for Hospitalization, Intensive Care Unit Admission, and Mortality Among COVID-19 Patients Receiving Immunosuppressive Medications: A Population-Based Study

Background: Patients taking immunosuppressive or immunomodulatory agents (IIAs) have been thought to be at greater risk for severe COVID-19-related health outcomes. These IIAs, such as conventional disease-modifying antirheumatic drugs (DMARDs), anti-tumor necrosis factor (TNF) biologics, non-anti-TNF biologics, and glucocorticoids, are often prescribed for disease management in patients with autoimmune rheumatic diseases, transplantations, and cancer.

Objective: to assess the risk for severe outcomes (hospitalization, intensive care unit (ICU) admission, and 60-day mortality) in patients prescribed IIAs.

Methods: A retrospective cohort analysis was conducted using administrative health data from British Columbia (BC), Canada. Cohort eligibility included all BC adults who tested positive on SARS-CoV-2 PCR tests from the provincial public health agency, between February 6, 2020 and August 15, 2021. Current IIA use was defined as use within the last 3 months. IIA exposure was divided into 8 medication classes: 1) antimalarials, 2) methotrexate, 3) leflunomide, 4) immunosuppressants (azathioprine, mycophenolate mofetil (MMF), cyclosporine, cyclophosphamide), 5) anti-TNF biologics (adalimumab, certolizumab, etanercept, golimumab, infliximab), 6) non-anti-TNF biologics (abatacept, anakinra, secukinumab, tocilizumab), 7) rituximab, and 8) glucocorticoids. Certain IIAs were assessed individually due to distinct mechanisms of action relative to their particular medication class. Hospitalization and ICU admission data were obtained from hospital discharge abstracts, and mortality within 60 days of a positive SARS-CoV-2 test from vital statistics. We used overlap weighted logistic regression models, with age, socioeconomic status, Romano modification of the Charlson comorbidity index, hypertension, rurality, and number of previous SARS-CoV-2 PCR tests as variables.

Results: Among 147,301 adults who tested COVID-19-positive, we included 307 patients prescribed antimalarials (mean age 57.4 years, 27.4% male), 373 prescribed methotrexate (mean age 55.2 years, 40.4% male), 60 prescribed leflunomide (mean age 60.3 years, 36.5% male), 409 prescribed immunosuppressants (mean age 54.3 years, 48.1% male), 282 prescribed anti-TNF biologics (mean age 45.0 years, 15.9% male), 110 prescribed non-anti-TNF biologics (mean age 50.3 years, 42.0% male), 43 prescribed rituximab (mean age 57.1 years, 33.6% male), and 1237 prescribed glucocorticoids (mean age 58.5 years, 49.2% male, median dose 250.0 mg), each with an equal number of comparators. Risk of hospitalization and ICU admission were increased in patients using immunosuppressants (any one of azathioprine, MMF, cyclosporine, or cyclophosphamide) (adjusted odds ratio (aOR): 2.08 and 2.88, respectively), MMF (aOR: 2.82 and 2.52, respectively), or glucocorticoids (aOR: 1.63 and 1.86, respectively), compared to non-users. Risk for ICU admission or 60-day mortality combined also increased for these groups (62% greater risk for immunosuppressants users, 93% greater risk for MMF users, and 69% greater risk for glucocorticoid users) compared to non-users. Only glucocorticoid users exhibited increased risk for 60-day mortality (aOR: 1.58) compared to non-users.

Conclusion: Public health data analysis demonstrated that, while patients exposed to immunosuppressants and glucocorticoids have significant increases in risk for severe COVID-19 outcomes, patients exposed to most other IIAs, including biologics, did not. These findings may inform patients, healthcare providers, and policymakers on the need and priority of personal infection-prevention measures, prescription alterations, or public health programs like booster vaccination campaigns.

Immunosuppressant

COVID-19

Administrative Health Data

Disease-modifying antirheumatic drugs

Immunosuppressive or Immunomodulatory Agents

Immunomodulator 

Mid-Level

Influence

International Conference on Health Policy Statistics 2023