Factors Associated with COVID-19-related Death in People with Rheumatic Diseases: Results from the COVID-19 Global Rheumatology Alliance physician-reported registry

Objectives To determine factors associated with COVID-19-related death in people with rheumatic diseases. Methods Physician-reported registry of adults with rheumatic disease and confirmed or presumptive COVID-19 (March 24 to July 1, 2020). The primary outcome was COVID-19-related death. Age, sex, smoking status, comorbidities, rheumatic disease diagnosis, disease activity, and medications were included as covariates in multivariable logistic regression models. Analyses were further stratified according to rheumatic disease category. Results Of 3729 patients (mean age 57 years, 68% women), 390 (10.5%) died. Independent factors associated with COVID-19-related death were: age (66-75 years: OR 3.00, 95% CI 2.13-4.22; >75 years: 6.18, 4.47-8.53; both vs ≤65 years), male sex (1.46, 1.11-1.91), hypertension combined with cardiovascular disease (1.89, 1.31-2.73), chronic lung disease (1.68, 1.26-2.25) and prednisolone-equivalent dosage >10mg/day (1.69, 1.18-2.41; vs. no glucocorticoid intake). Moderate/high disease activity (vs remission/low disease activity) was associated with higher odds of death (1.87, 1.27-2.77). Rituximab (4.04, 2.32-7.03), sulfasalazine (3.60, 1.66-7.78), immunosuppressants (azathioprine, cyclophosphamide, cyclosporine, mycophenolate or tacrolimus: 2.22, 1.43-3.46) and not receiving any disease-modifying anti-rheumatic drug (DMARD) (2.11, 1.48-3.01) were associated with higher odds of death, compared with methotrexate monotherapy. Other synthetic/biological DMARDs were not associated with COVID-19-related death. Conclusion Among people with rheumatic disease, COVID-19-related death was associated with known general factors (older age, male sex and specific comorbidities) and disease-specific factors (disease activity and specific medications). The association with moderate/high disease activity highlights the importance of adequate disease control with DMARDs, preferably without increasing glucocorticoid dosages. Caution may be required with rituximab, sulfasalazine and some immunosuppressants.