COVID-19 and patients with immune-mediated inflammatory diseases undergoing pharmacological treatments: a rapid living systematic review

Rocha, Aline Pereira da; Atallah, Álvaro Nagib; Pinto, Ana Carolina Pereira Nunes; Rocha-Filho, César Ramos; Milby, Keilla Martins; Civile, Vinicius Tassoni; Carvas Junior, Nelson; Reis, Felipe Sebastião de Assis; Ferla, Laura Jantsch; Ramalho, Gabriel Sodré; Trevisani, Giulia Fernandes Moça; Puga, Maria Eduarda dos Santos; Trevisani, Virgínia Fernandes Moça

doi:10.1590/1516-3180.2020.0421.R2.10092020

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Sao Paulo Medical Journal

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Original Article • Sao Paulo Med. J. 138 (6) • Nov-Dec 2020 • https://doi.org/10.1590/1516-3180.2020.0421.R2.10092020 copy

COVID-19 and patients with immune-mediated inflammatory diseases undergoing pharmacological treatments: a rapid living systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Patients with immune-mediated inflammatory diseases (IMID) are at increased risk of infection.

OBJECTIVE:

To assess whether patients undergoing pharmacological treatment for IMID present higher risk of worse outcomes when diagnosed with COVID-19.

DESIGN AND SETTING:

Rapid systematic review conducted in the medical school of the Federal University of São Paulo (SP), Brazil.

METHODS:

We searched CENTRAL, MEDLINE, EMBASE, LILACS, SCOPUS, Web of Science, L·OVE, ClinicalTrials.gov and WHO-ICTRP for studies evaluating patients diagnosed with COVID-19 who were undergoing pharmacological treatment for IMID. Two authors selected studies, extracted data and assessed risk of bias and certainty of evidence, following the Cochrane recommendations.

RESULTS:

We identified 1,498 references, from which one cohort study was included. This compared patients with and without rheumatic diseases (RD) who all had been diagnosed with COVID-19. Those with RD seemed to have higher chances of hospitalization and mortality, but no statistical difference was detected between the groups: hospitalization: odds ratio (OR) 1.17; 95% confidence interval (CI) 0.6 to 2.29; mortality rate: OR 1.53; 95% CI 0.33 to 7.11 (very low certainty of evidence). Patients with RD were three times more likely to require admission to intensive care units (ICUs), with invasive mechanical ventilation (IMV), than those without RD: OR 3.72; 95% CI 1.35 to 10.26 (for both outcomes; very low certainty of evidence).

CONCLUSION:

Patients undergoing pharmacological treatment for IMID seem to present higher chances of requiring admission to ICUs, with IMV. Additional high-quality studies are needed to analyze the effects of different treatments for IMID.

KEY WORDS (MeSH terms):
Immunosuppressive agents; Antirheumatic agents; Coronavirus infections; Systematic review [publication type]; Rheumatic diseases

AUTHORS' KEY WORDS:
Immune-mediated inflammatory diseases; Immune-modulating therapies; Evidence-based health

Rheumatic patients undergoing treatments with immunosuppressants, immunobiological agents, synthetic DMARDs or targeted synthetic DMARDs, compared with participants without rheumatic diseases; both groups diagnosed with COVID-19

Patient or population: Rheumatic patients using DMARDs, immunobiological agents, immunosuppressants or corticosteroid who were then diagnosed with COVID-19.

Comparison: Participants without rheumatic diseases and not undergoing no drug treatment, who had been diagnosed with COVID-19.

Setting: Tertiary-level care and community hospitals; and primary and specialty outpatient centers.

Outcomes	Relative effect (95% CI)	No. of participants (no. of studies)	Certainty of the evidence (GRADE)
Hospitalization	OR 1.1 (0.6 to 2.29)	156 (1 observational study)	VERY LOW ^a a Downgraded by one level due to serious study limitations (risk of bias). ^b b Downgraded by one level due to serious indirectness. Important differences in the severity of different rheumatic diseases. ^c c Downgraded by one level due to serious imprecision. The 95% CI crossed the line of no effect and was also a wide interval around the estimate of the effect. Therefore, it was clinically irrelevant.
Length of hospital stay	Mean difference in length of hospital stay between the groups was 1.3 (-4.85 to 7.34) days	65 (1 observational study)	VERY LOW ^a a Downgraded by one level due to serious study limitations (risk of bias). ^b b Downgraded by one level due to serious indirectness. Important differences in the severity of different rheumatic diseases. ^c c Downgraded by one level due to serious imprecision. The 95% CI crossed the line of no effect and was also a wide interval around the estimate of the effect. Therefore, it was clinically irrelevant.
ICU admission	OR 3.72 (1.35 to 10.26)	156 (1 observational study)	VERY LOW ^a a Downgraded by one level due to serious study limitations (risk of bias). ^b b Downgraded by one level due to serious indirectness. Important differences in the severity of different rheumatic diseases. ^c c Downgraded by one level due to serious imprecision. The 95% CI crossed the line of no effect and was also a wide interval around the estimate of the effect. Therefore, it was clinically irrelevant.
Mechanical ventilation	OR 3.72 (1.35 to 10.26)	156 (1 observational study)	VERY LOW ^a a Downgraded by one level due to serious study limitations (risk of bias). ^b b Downgraded by one level due to serious indirectness. Important differences in the severity of different rheumatic diseases. ^c c Downgraded by one level due to serious imprecision. The 95% CI crossed the line of no effect and was also a wide interval around the estimate of the effect. Therefore, it was clinically irrelevant.
Mortality	OR 1.53 (0.33 to 7.11)	156 (1 observational study)	VERY LOW ^a a Downgraded by one level due to serious study limitations (risk of bias). ^b b Downgraded by one level due to serious indirectness. Important differences in the severity of different rheumatic diseases. ^c c Downgraded by one level due to serious imprecision. The 95% CI crossed the line of no effect and was also a wide interval around the estimate of the effect. Therefore, it was clinically irrelevant.

DMARDs = disease-modifying antirheumatic drugs; CI = confidence interval; OR = odds ratio; ICU: intensive care unit; length of hospital stay is expressed as the mean number of days (with standard deviation).

GRADE Working Group grades of evidence

High certainty: Further research is very unlikely to change our confidence in the estimate of effect.

Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate

Very low certainty: We are very uncertain about the estimate.

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[1] Address for correspondence: Maria Eduarda dos Santos Puga, Programa de Saúde Baseada em Evidências, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), Rua Botucatu, 740 – 3° andar São Paulo (SP) — Brasil. CEP 04023-900 Tel. (+55 11) 5575-2970 E-mail: mespuga@yahoo.com.br